Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00290073 Renewal 07/06/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.111(f)The fire extinguishers in the home were inspected on 04/03/25 and not again until 04/09/26. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. Why is the regulation important? It's important that each home has a fully operational fire extinguisher. A current inspection assures each fire extinguisher is operational. What happened? The former Director went on medical leave and failed to place the inspection renewal date on the shared calendar. This caused the training compliance facilitator to miss the deadline. Why did it happen? The renewal date wasn't placed on the shared calendar, causing the training compliance facilitator to miss the deadline. What do we do right now? Once it was discovered the fire extinguishers were not inspected, the training and compliance facilitator scheduled the inspection. The renewal date is now on the shared calendar. 07/21/2026 Implemented
6400.112(h)The 05/18/26 Fire Drill Record does not indicate if the Individual in the home was able to successfully make it to the designated meeting spot. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Why is the regulation important? This regulation is important because it ensures the individual knows the actions to take during a real fire emergency including successfully making it to the designated meeting spot so that staff may verify the individual is safe from harm at the meeting spot. What happened? The Site Supervisor failed to adequately document on the fire drill record that the individual made it safely to the designated meeting spot as required to be in compliance with regulation 6400.112(h) Why did it happen? Prior to submitting the monthly fire drill, The Site Supervisor did not consistently follow the fire drill procedure and identify whether the individual made it safely to the evacuation spot on the fire drill record. The Program Team did not adequately review the form during the review of fire drill records to ensure all elements were complete, including regulation 6400.112(h) What do we do right now? Upon identification of the documentation concern, the 05/18/26 Fire Drill Record was reviewed to determine the details of the fire drill and verify whether the individual successfully evacuated to the designated meeting place, which the SIte Supervisor stated successful evacuation of individual#1 to the meeting spot but failure to accurately document this information in the Fire drill record. Staff were reminded of the requirement to document all required information on fire drill records, including whether each individual successfully evacuated to the designated meeting spot or fire-safe area. On 7/21/2026, there was an unannounced fire drill for individual#1 indicating that they were able to successfully make it to the designated meeting spot. 07/20/2026 Implemented
6400.144Individual #1 has two PRN medications for constipation to be given if Individual #1 has fewer than three Bowel Movements per week. There is no record of tracking of Bowel Movements, so there is no way to know when it is appropriate to administer the medications.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Why is the regulation important? This regulation is important because it ensures that the individual receives the health services needed and any concerns are addressed promptly so that the health and well-being of the individual is maintained. What happened? During inspection on 7/07/2026, individual #1 has two PRN medications for constipation. I is prescribed to be given if individual #1 has fewer than three bowel movements per week; however, AIMED failed to track individual #1 bowel movements on a daily basis, which would provide vital data to indicate when the individual's PRN constipation medication may be administered. Why did it happen? The AIMED staff were not aware of the bowel tracker and the necessity to track bowel movements daily, which resulted in the staff not tracking to determine the necessity of administering PRN constipation medication for individual #1. What do we do right now? On 7/17/2026, the Chief Program Officer trained DSP staff on the intake and elimination tracker in Therap to begin tracking bowel movement of individual #1 immediately. Tracking bowel movement began on 7/17/2026, which includes administering PRN bowel medication if individual #1 has fewer than 3 bowel movements weekly. The Site Supervisor will review the tracker on a daily basis to ensure staff are documenting bowel movements on the tracker. 07/17/2026 Implemented
6400.181(e)(3)(i)Individual #1's 03/25/26 Annual Assessment does not address the progress in "Acquisition of functional skills".The assessment must include the following information: The individual's current level of performance and progress in the following areas: Acquisition of functional skills. Why is the regulation important? It is important to assess progress toward functional skills that are essential to greater independence, quality of life, and the individual achieving their identified personal goals. Additionally, noting progress or regression of skills over the past year ensures the individual has been involved in the decision making process and making choices that impact them on a daily basis. What happened? During inspection on 7/07/2026, it was found that Individual #1's Annual Assessment completed on 03/25/26 by AIMED did not include documentation of the individual's progress in the area of acquisition of functional skills. Because this information was missing, the assessment did not meet the requirements of 55 Pa. Code 6400.181(e)(3)(i). Why did it happen? During completion of the Annual Assessment that was completed on 3/25/2026, the documentation of the individual's progress in the acquisition of functional skills was overlooked. The assessment was not reviewed to ensure all elements were completed, hence, it was finalized without this required information. What do we do right now? On 7/17/2026, The Chief Program Officer reviewed and updated the Annual Assessment to include documentation of the individual's progress in the acquisition of functional skills. The corrected assessment was completed to ensure compliance with 55 Pa. Code 6400.181(e)(3)(i). Additionally, AIMED conducted an audit of all assessments to ensure all elements were included and are in compliance. 07/17/2026 Implemented
6400.181(e)(12)Individual #1's 03/25/26 Annual Assessment does not list specific recommendations for training, programming, and services.The assessment must include the following information: Recommendations for specific areas of training, programming and services. Why is the regulation important? This regulation is important because all individuals supported by AIMED have the right to choose their schedule and control the activities attended. The regulation allows for the support provided to be meaningful and a reflection of the individual's interests and choices. It ensures recommendations for additional support are made when necessary. What happened? During inspection on 7/07/2026, it was found that Individual #1's Annual Assessment completed on 03/25/26 did not document the individual's specific recommendations for training, programming, and services.The assessment was finalized without identifying this required element. Because this information was missing, the assessment did not meet the requirements of 55 Pa. Code 6400.181(e)(12). Why did it happen? During completion of the Annual Assessment, recommendations for specific areas of training, programming, and services were inadvertently omitted. The staff who completed the assessment did not review the assessment in its entirety to ensure all elements were included prior to finalizing the assessment, which What do we do right now? On 7/17/2026, Individual #1's Annual Assessment was reviewed and updated to include recommendations for specific areas of training, programming, and services based on the individual's assessed needs. The corrected assessment was completed to ensure all required information was included. 07/17/2026 Implemented
6400.211(b)(3)Individual #1's record does not identify the name, address, and telephone number of the person able to give consent for emergency medical treatment.Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. Why is the regulation important? It is important to have critical health information available in the event of a medical emergency. What happened? The parent's contact information wasn't present on the form. Their name was listed as the emergency contact. AIMED is listed as an emergency contact as well. Why did it happen? The mother is listed on the admission packet as the emergency contact; however, it was brought to AIMED attention that mom's full contact information should be listed on the emergency contact information if she's the primary contact. What do we do right now? AIMED has revised the Emergency information form in the EHR to reflect the current emergency contact, phone and address. 07/24/2026 Implemented
6400.34(a)(repeat from 09/29/25 inspection) Individual #1 was not informed of rights 31a-g, 32i, 33 a-b on their 01/01/26 individual rights form.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Why is the regulation important? Regulation 6400.34 (a-g), (32i), (33a-b) is important because it ensures that individuals and the people they designate understand their rights and know how to report concerns if they believe those rights have been violated. Additionally, this regulation ensures that all individuals are informed of all of their rights and individuals are able to make informed choices, advocate for themselves, and understand the protections available to them. Failure to review and provide complete information on individual rights may prevent an individual from fully understanding and exercising their rights. What happened? During an inspection on 7/7/2026, it was discovered that on the individual rights form completed by AIMED on 01/01/26 rights 31(a-g), 32(i), and 33(a-b) were not included on the individual rights form that was reviewed with the individual, consequently, the above rights were not documented as reviewed and explained to the individual on 1/1/2026. As a result, the Individual Rights Form did not include verification that all required rights had been communicated. Why did it happen? The Regional Program Director who worked at AIMED prior, failed to update the Individual Rights form to include rights 31 a-g, 32i, and 33 a-b. Additionally, The process for completing and reviewing Individual Rights Forms did not ensure that all required rights were verified as reviewed and explained before the form was finalized and marked as completed. As a result, rights 31(a-g), 32(i), and 33(a-b) were not documented for Individual #1. What do we do right now? By 7/24/2026, Individual #1's Individual Rights Form will be reviewed and updated to include rights 31(a-g), 32(i), and 33(a-b). By 7/24/2026, the Chief Program Officer will inform the individual and/or their designated representative of the omitted rights, and the form will be reviewed for completion of all required documentation. Going forward, the Chief Program Officer and the Chief Administrative Officer will review all individual rights completed to ensure all rights are reviewed with the individual in compliance with regulation 6400.34a, 31a-g, 32i, 33a-b. 07/24/2026 Implemented
6400.52(c)(6)Staff #4 administered medication to individual #1 in May 2026 per the Medication Administration Record; there is no record of Staff #4 receiving training on Individual #1 Individual Support Plan (ISP).The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Why is the regulation important? It's necessary for staff to receive job skills and knowledge prior to working with individuals. The training should reflect person-centered practices, community integration, individual choices and support individuals to develop and maintain relationships.Recognize and report incidents, safe and appropriate use of behavior supports and implement the ISP working directly with an individual. What happened? The fairly new supervisor failed to review the ISP with the newly hired staff. The new hire was training at a different site than hired to work and there was a breakdown in communication. Why did it happen? There was a breakdown in communication between the administrative personnel (former Director) and the Residential Supervisor. The Residential Supervisor was unaware that she needed to train the new hire on the ISP for that home since she was only training there. What do we do right now? Complete training on 7/21/26, with Residential Supervisor and the staff on regulation 52c1-6 and the ISP training. 07/21/2026 Implemented
6400.186Individual #1's 06/24/26 Individual Support Plan (ISP) states that sharps should be locked in the staff office, because Individual #1 has no "safety awareness"; a wooden knife block partially filled with sharp knives was on the kitchen countertop at the time of the 07/08/26 inspection.The home shall implement the individual plan, including revisions.Why is the regulation important? Regulation 6400.186 is important because implementation of the individual's plan ensures that all individuals who support the individual have a clear understanding of the expectations in meeting the needs of the individual as it is outlined in their Individual plan. Additionally, a complete understanding of the individualized plan ensures that the individual has control over their decisions, choices, and that AIMED is protecting the individual's health and safety. Additionally, Individual #1's ISP requires sharps to be secured in the staff office due to identified safety concerns. When AIMED fails to adhere to the ISP by leaving the sharps accessible, the individual's health and safety is at risk and the required ISP supports are not being implemented as written. What happened? During an inspection on 7/8/2026, despite Individual #1's 06/24/26 Individual Support Plan (ISP) stating that sharps should be locked in the staff office, because Individual #1 has no "safety awareness"; a wooden knife block partially filled with sharp knives was on the kitchen countertop. Why did it happen? Prior to the inspection, the wooden knife block was locked up in the staff office by the site supervisor, as per the ISP; however, On the day of the inspection, the Chief Program Officer misread the ISP and instructed the Supervisor of the site to unlock the wooden knife block, consequently violating Regulation 6400.186. AIMED staff did not effectively follow up or implement the ISP regarding sharps; therefore, staff were unable to adequately acknowledge that unlocked sharps in individual #1's home is a violation of code 6400.186. Additionally, the ISP requirement regarding secured sharps was not consistently monitored during routine household checks. What do we do right now? Upon discovery that AIMED was in violation of regulation 6400.186, the wooden knife block was removed from the kitchen and locked in the staff office as outlined in individual #1 ISP. The Chief Program Officer and Site Supervisor reviewed Individual #1's ISP safety requirement regarding secured sharps and were reminded of the need to implement all ISP supports as written. 07/08/2026 Implemented
SIN-00272750 Renewal 09/29/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)At the time of the inspection on 10/1/25, the water in the bathroom on the right side of the house was 126.5 degrees. Hot water temperatures in bathtubs and showers may not exceed 120°F. On 10/01/25, the maintenance staff adjusted the hot water heater to lower the temperature setting. The water temperature was rechecked on 10/02/25, and the reading was 118F degrees, which was within compliance. The maintenance staff lowered the thermostat setting on the hot water tank and verified water temperatures at all sinks, tubs, and showers throughout the home to ensure all sites were between 110F and 120F. 10/01/2025 Implemented
6400.144-For Individual #1, the individual was administered Lactase Enz 3000 unit on 6/20/25 which can be taken as needed for dairy containing meals. It was documented in the comments section on the back of the medication record that TUMS was administered on this day, which was incorrect. - For Individual #1, the order for MiraLAX was changed on 8/7/25 from 17gm to be taken daily at 8am to 17 gm to be taken as needed for constipation. This medication was not added to the PRN list for the remainder of the August 2025 medication record.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The Program Administrator immediately reviewed June and August 2025 MARs for individual #1 on 10/02/25. Corrections were made to properly document the PRN administration of Lactase enzyme and ensure Miralax was correctly added to the PRN section of the MAR. Completed on 10/06/25. The RS cross-checked all PRN and daily medications against the physicians current medication orders and pharmacy records. The corrected MARs were verified by the Program Administrator for accuracy and compliance. Staff involved in the documentation error received retraining on proper medication documentation on 10/07/25. 10/16/2025 Implemented
6400.171At the time of the inspection on 10/1/25, there was a carton of heavy whipping cream that had a best by date of 8/31/25 in the refrigerator.Food shall be protected from contamination while being stored, prepared, transported and served. Regional Director disposed of expired whipping cream. Who: RS oversees and ensures all food storage areas are checked for expired or contaminated items. DSPs responsible for performing daily and weekly food checks, cleaning the refrigerator and removing expired or questionable food items. 10/16/2025 Implemented
6400.181(c)Individual #1's 3/25/25 annual assessment does not include the language "the assessment shall be based on assessment instruments, interviews, progress notes, and observations. "The assessment shall be based on assessment instruments, interviews, progress notes and observations. During the recent revamping of the assessment document in the Therap system, the section containing the required regulatory statement was unintentionally omitted when the form was reformatted to align with the updated agency template. The focus was on improving the layout and clarity of the content, and the missed language was an oversight rather than a failure to complete the assessment process. The assessment itself was conducted appropriately however, the statement verifying those methods was not carried over into the new format. The PA will update the current assessment for Individual # 1 to include the required statement verifying that the assessment is based on assessment instruments, interviews, progress notes and observations. All active assessments in the Therap system will be reviewed by 10/20/25, by the PA to ensure the same language is included where needed. 10/20/2025 Implemented
6400.181(e)(2)Individual #1's 3/25/25 annual assessment does not identify the individual's dislikes.The assessment must include the following information: The likes, dislikes and interest of the individual. When the assessment was completed, the Regional Program Director focused on updating goals, strengths, and likes, but overlooked adding Individual #1 dislike section. This was an unintentional error during the review process. The PA will update the assessment for Individual #1 to include their known dislikes. All current assessments will be reviewed by 10/20/25, to make sure this section is properly filled out for every individual. 10/20/2025 Implemented
6400.34(a)Individual #1 was not informed of rights 31a-g, 32i, 33 a-b on their 1/1/25 individual rights form.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The CEO will immediately update the individual rights form to include all required sections. Individual #1 was re-informed of all rights on 10/08/25 and signed acknowledgement has been placed in their file. When revamping the Individual Rights document the said section was omitted in error, it was not cross-checked before making it a live document. The Regional Director and Program Administrator will now use the ODP RCG checklist to verify that all rights are included before issuing or revising Individual Rights forms. All individual rights will be reviewed in full with each person by the Program Adm. by 10/08/25 to ensure compliance. The CEO corrected the document and ensured all rights are included.This was done immediately 10/01/25. 10/01/2025 Implemented
6400.165(b)For Individual #1, the order for MiraLAX was changed on 8/7/25 from 17gm to be taken daily at 8am to 17 gm to be taken as needed for constipation. On the August 2025 medication record, the medication was not discontinued as a daily administration until 8/13/25, which is 6 days after the order was changed by the physician.A prescription order shall be kept current.The Residential Supervisor failed to ensure the medication record was immediately updated to reflect the physician's new order. The Program Administrator reviewed the medication record and corrected it on 08/13/25. The Residential Supervisor has been retrained 10/08/25 on promptly updating the MAR upon any physician order change. The Program Adm. will oversee and verify all medication order changes are updated the same day. Effective immediately all current and future medication changes will be reviewed within 24 hours of receipt. 10/08/2025 Implemented
SIN-00252473 Renewal 10/07/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)Self-Assessments are to be completed three to six months prior to the certificate expiring or six to nine months after the last annual inspection. This would place the self-assessments as being due from 4/18/24 through 8/30/24. The self-assessment was not completed until 9/4/24 to 9/27/24.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. The violation occurred due to a misunderstanding of the inspection notification letter. To avoid future violations, by October 31st, 2024, the Director of Programs will add the due date for the self-assessments to the calendar shared by the Director of Operations, the CEO, and the CAO. The CEO will ensure the information is entered on the calendar by 10/24/2024. This action will ensure a four-point checking system: The Director of Programs and the Director of Operations will complete the self-assessment, and the CEO will review it to ensure regulatory compliance. 10/24/2024 Implemented
6400.22(c)Individual #1's funds were spent on health and beauty products that are to be included with room and board on 2/28/24 and 4/20/24.Individual funds and property shall be used for the individual's benefit. The participants used their own personal funds to purchase health and beauty products. The violation occurred because staff may not have been fully aware of the rules that pertain to allowable purchases with personal funds as it relates to the regulatory obligation of the agency to provide personal care items for the participant. All staff will receive updated training on the correct use of individuals personal funds, outlining what is appropriate for purchase and what is not. The Program Director will provide the mentioned training by Oct. 31, 2024. Guidelines will be set so that staff and participants are clear on what the obligation is of the agency to provide health and beauty products. Monthly audits will be performed to ensure compliance is maintained, According to 55 PA Code Chapter 6400.22(c). An EIM was entered October 9th. The funds that are in discrepancy will be reimbursed by AIMED at the conclusion of the CI. 10/31/2024 Implemented
6400.22(d)(1)Individual #1's financial record is not current and up to date. Beginning in March 2024 there were mathematical errors that were never rectified. Additionally, there were two receipts that were not logged on the sheet. One was on 3/12/24 for $19.26 at Dollar General. The other was for $16.58 spent on 8/8/24.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. The participants' financial records were inaccurate since March 2024 and never properly audited and reconciled. We failed in keeping accurate documentation required by ODP regulations. Mathematical errors were identified but not corrected, proving to be a lack of oversight from the Residential Supervisor and Program Specialist who are to ensure accuracy and compliance. The two receipts that were missing and not properly logged, identified a weakness in the organization of financial tracking. The PS will update all financial records to the current date ensuring that the participant ledgers balances are accurately reflected. This task will be completed by 10/31/24. Reimbursements will be made as needed. 10/31/2024 Implemented
6400.22(e)(3)The following receipts were missing from Individual #1's record: 2/4/24-$20 given to Individual #1, 3/9/24-$21.13 spent at Wal-Mart, 3-18-24-$23.49 spent at Rutters or Dollar General, 6/23/24-$32 spent at Papa's John, 6/25/24-$28 spent at Hair Cuttery, and 7/31/24-$60 given to Individual #1. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. Several purchases made with the participant were not properly documented with receipts as 6400.regulations require. Any purchase over $15.00 made by or for the participant must have a receipt or a record of the expense. This procedure did not happen, which put the site in non-compliance status with regulation 6400.22 (e)(3). Due to the staff not following proper procedures for collecting receipts caused this violation. Immediate staff training on the importance of collecting and submitting receipts for all purchases over $15.00, by the Regional Program Director on 10/17/2024. The Program Director will create a receipt submission policy that explains procedures to follow in the event of a lost receipt. Residential Supervisor will conduct a daily D at the change of shift to ensure that going into the new day that all ledgers are accurat 10/17/2024 Implemented
6400.82(f)At the time of the inspection, there were no paper towels or individual hand towels available at the sink used for the bathroom in the basement.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. At the time of inspection, there were no paper towels at the sink in the basement. This happened because that toilet is not a toilet that is regularly used and the sink is a mop sink that is not regularly monitored for said supplies Staff immediately stocked the sink with towels. We will also place a reminder to check the sink area for supplies daily to ensure that this violation does not re-occur. 10/16/2024 Implemented
6400.111(f)The fire extinguishers were inspected on 4/6/23 and not again until 4/10/24, outside of the annual timeframe. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. The fire extinguisher service was scheduled by the company that completed the inspections. The due date was unknown by the staff responsible for operations The fire extinguisher service was scheduled by the company that completed the inspections. The due date was not placed on the calendar by VP of Operations. 10/16/2024 Implemented
6400.141(c)(11)Individual #1's most recent physical completed on 7/10/24 does not document their health maintenance needs, medication regiment, or bloodwork. These factors are not documented on the physical at all.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. The provider used a new physical form recommended by the Western Regions AE this licensing year, unfortunately, it did not have the regulated criteria on the new form which led to violations. The CEO plans to reinstate AIMEDs physical form that has been used in the past, which included the assessment of the individual's health maintenance need, medication regimen and the need for bloodwork at recommended intervals. 11/01/2024 Implemented
6400.141(c)(12)Individual #1's most recent physical completed on 7/10/24 does not document their physical limitations. This section is not on the physical form.The physical examination shall include: Physical limitations of the individual. The provider used a new physical form recommended by the Western Regions AE this licensing year, unfortunately, it did not have the regulated criteria on the new form which led to violations. The CEO plans to reinstate the physical form that has been used in the past, which included physical limitations of the individual. 11/01/2024 Implemented
6400.145(2)Individual #1's emergency medical plan does not document their method of transportation.The home shall have a written emergency medical plan listing the following: The method of transportation to be used. The omission of this information was due to an oversight during the creation and review of the plan. The plan unfortunately did not go through a thorough quality assurance process to ensure all regulatory elements were included. The plan for the participant will be immediately reviewed and updated to reflect the mode of transportation during an emergency situation. Staff will be retrained on the emergency plan for the participants by 10/31/24 by the Regional Program Director. 10/31/2024 Implemented
6400.181(a)The most recent assessment written on 8/7/24 cannot be accepted as a complete assessment. The following information was either missing or not thoroughly addressed: Preferences, Needs, Dislikes, Communication, Personal Adjustment, Personal Needs with or without Assistance, Ability to Evacuate in a Fire, Disability/Functional/Medical Limitations, Psychological, Recommendations, and Progress in any of the Categories. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. The recent assessment for the participant was found to be incomplete. Key areas that need to be addressed were either missing or very limited in detail. This violation occurred because the agency was trying to put together a very in depth and strong assessment to address all necessary information but failed to build the content out far enough. The CEO or designee is in the process of rebuilding the new template through THERAP that encompasses all the regulatory points outlined in regulation 6400.181(a). The target date for completion is November 1,2024. 11/01/2024 Implemented
6400.211(b)(1)Individual #1's demographic information does not document the name/address/phone of the emergency contact.Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. Incomplete documentation of the participants record. There was an oversight during the entering of the data into the record. There was no regular audit of the documentation which led to the missing information. Quarterly audits will be done by the Regional Program Director to review the charts to ensure all necessary data is put in the record. 10/16/2024 Implemented
6400.211(b)(3)Individual #1's demographic information does not document the name/address/phone of who to contact for medical consent.Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. The incorrect form was placed in the participants chart. The Regional Program director will update with the correct form and information in the individuals chart by 10/31/2024 10/31/2024 Implemented
6400.165(g)(Repeat Violation from 10/18/23) The quarterly psych med review appointment held on 5/31/24, 7/12/24 did not document whether Individual #1 is to continue all psych meds as previously prescribed. Individual #1's psych med appointment on 2/15/24, 5/3/24 did not document the reason for prescribing each of the psych meds.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The doctor's notes did not clearly state if the participant should continue all prescribed psychiatric medications, the physician also did not list the reason as to why the medications were prescribed. The attending staff person with the participant did not ensure that all pertinent information was documented per regulation. The Regional Program Director will conduct a training with all staff on Oct. 17, 2024, so that the staff understands the required documentation from the physician for a quarterly psychiatric medication review. The staff will use the medication review checklist during appointments to ensure all criteria pertaining to regulation 6400.165 (g) is met. Within 24 hours of the appointment staff will submit the documentation to the Program Director or review. 10/17/2024 Implemented
6400.195(a)Individual #1 has restrictive procedures identified in the Behavior Support Plan developed on 8/23/24 that are "allowed to be used." These restrictive procedures were not approved by HRT.For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures.The Senior Admissions & Clinical Officer was unaware that using a one-person or two-person guide is an approved restrictive procedure, which requires a Restrictive Procedure Plan to address the need for the holds. By December 31, 2024, the Senior Admissions & Clinical Officer shall develop an RPP for the one-person or two-person guide and present the plan to the Human Rights Committee for review and approval. When approved, the staff that work with the Individual shall be trained by The Senior Admissions & Clinical Officer, or designee, to ensure their comprehension of the holds and how and when to use them. 12/31/2024 Implemented
6400.213(1)(i)The individual prep list provided indicated Individual #1's DOA was 2/27/24. The individual rights in the record document the DOA as 8/7/23. An additional document lists the admission date as 7/1/23.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.The participant was asked to sign and date onboarding documents by the referring agency before the admission and dated the documents for 7/1/23. The actual admission was 8/7/23 all documents were dated for this date. The participant then relocated to the York Region upon which the new admission date of 2/27/24 was used. This error occurred due the fact that it was not clear to the administration that the admission date remains the same no matter if a transfer to a new region takes place. The Sr. Admission & Clinical Officer will provide clear onboarding/admissions instructions to the referring provider to leave all dates blank to avoid incorrect dates entered on the admissions form. dates on the form. The participant will sign and date in the presence of personnel. Before finalizing an admission, The PS will review all documents to make sure the admission date is the same on all forms. There will be a Quality Assurance review by the PD of the participants record after admission and or transfers to ensure that all dates match and regulatory information is in the admission packet. 10/16/2024 Implemented
SIN-00235861 Renewal 10/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(3)During the annual inspection the policy on onboarding /hiring staff and the polices they are to follow was requested. The agency was only able to provide a check list not a policy that the agency has for the hiring process. Staff person #6's criminal background check that was given to the inspectors during the annual licensing was altered. The date received had been changed from 4/19/23 to 4/17/23. Staff #6's date of hire was 4/17/23. Once it was pointed out to the AIMED Director, the HR Director was contacted for verification. The HR director is the person responsible for running the criminal background checks. The agency could not identify who altered the Pennsylvania Criminal background check.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. Why it happened: The original criminal background check was completed on 4/19/23 and given to the license inspector upon request. The duplicate copy that was provided to the license inspector came from the HR Director. An internal investigation was completed, and the identified person was addressed. Disciplinary action was taken along with a corrective action plan. Plan of Correction: The CEO met with the HR Director immediately after discovering the document had been altered, which was during the license inspection. The altered document was removed from the employee file. The official criminal background check is in the employee HR records. Beginning immediately, the HR Director is required to run background checks (state, federal, child abuse and sexual molestation) prior to new hire orientation, which is prior to working with an individual. 12/08/2023 Implemented
6400.103-REPEAT from Inspection held 10/17/22- The emergency evacuation plan for Individual #1's home does not include: Individual responsibilities.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The Emergency evacuation was updated during last year's inspection and was approved and accepted. AIMED followed the instructions at that time. It is important to have a written emergency evacuation plan to ensure the safe evacuation and to transport to the hospital of choice. The CEO updated the emergency evacuation plan with Uploaded to ODP on 10/26/23. 11/30/2023 Implemented
6400.112(e)A sleep drill was conducted in September 2022 and not again until April 2023. No additional sleep drill was conducted in September 2023.A fire drill shall be held during sleeping hours at least every 6 months. The RS staff mistakenly did the overnight fire drill too soon. It is important to conduct overnight fire drills to ensure the safe evacuation during sleep hours. The regulation was immediately reviewed with the RS and its importance. The PS will be responsible for oversight of the fire drill process to ensure timeliness and accuracy. 11/30/2023 Implemented
6400.112(h)The fire Drills for the year except for fire drills conducted on 11/23/22 & 1/2/23 do not indicate if Individual #1 went to the meeting place during the fire drills. The fire drill forms only indicate where the meeting place is located. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.Why: AIMED individual petty cash form contains all the information in the regulation. However, the specific requested information was not separately listed on the form. This regulation is important because it confirms fire drills occurred and allows providers to correct issues with the evacuation. POC: (plan, training by whom date and supportive documentation. The CEO updated the fire drill form on 10/18/2023 to include the meeting place and what kind of assistance was needed to evacuate: verbal prompt, physical assist, visual prompt, or none. The staff conducting the fire drill will guide the participants to the meeting location and complete the form indicating the participant(s) reached the desired location. 12/08/2023 Implemented
6400.113(a)Individual #1 had fire safety training completed on 4/25/22 and not again until 5/24/23, outside of the annual timeframe. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. Why: This regulation is important because it ensures people what to do during emergencies. POC: (plan, training by whom date and supportive documentation. The due date for the training will be added to a shared calendar immediately to ensure this violation doesn't reoccur. 12/08/2023 Implemented
6400.144-REPEAT-(Inspection 10/17/22) It appears that there have been some issues with the documentation and administration of medications for Individual #1, who is diagnosed with Chronic Constipation. The Bowel Chart for October 2023 was pre-populated with dates, and Metamucil, as prescribed by the physician in March 2023, was not documented on the Medication Administration Records (MARs). Additionally, it seems there is a concern regarding the administration of PRN Senokot-S in September 2023, as there are no staff initials indicating its administration, after the individual went three days with no bowel movement.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The plan of correction was that the bowel chart was eliminated, and the tracking was added into Therap. The plan also indicated that the program specialist will submit a weekly inspection report to the residential director. The bowel chart has been eliminated and replaced with Elimination tracking in Therap on 10/28/23. 12/08/2023 Implemented
6400.181(e)(4)The Annual assessment 2/1/23 for Individual #1 is missing the supervision section in the home or in the community. Individual #1 requires 1:1 supervision. The assessment must include the following information: The individual's need for supervision. The assessment form is in a format that may cause the information to drop down below the box, thus hiding the next category. The supervision category dropped down and was missed. It is important to have the "supervision" needed for the Individual to protect their health and safety. By November 17, 2023, the RD will amend Individual #1's annual assessment to include his supervision needs and redistribute the assessment to Individual #1 and the team. The PS will use the Assessment/ISP crosswalk to ensure that information is consistent in both documents. 11/30/2023 Implemented
6400.212(b)The Behavioral Support Plan for Individual #1 written by Staff #7 was signed and dated for December 29, 2023. This is dated for in the future. Entries in an individual's record shall be legible, dated and signed by the person making the entry. The BSP was completed on time but misdated. It is important to current dates and legible information in order to make updates and/or changes to the plan. The Director of Clinical Services & Admissions corrected the date on the Behavior Support Plan, and the updated plan was provided during the inspection. 11/30/2023 Implemented
6400.34(a)31 & 33 Are missing from Individual #1's record. Individual #1 signed all of the 6400.32 Rights on 5/23/23. The agency was unable to locate the 2022 Individual Rights for Individual #1 during the annual inspection.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The misplaced form was located and uploaded to ODP on 10/26/2023. It is important to ensure people are aware of their rights. The PS located the missing Rights form on 10/24/23. 11/30/2023 Implemented
6400.163(h)Individual #1's medication disposal records indicate that Melatonin and Risperidone were disposed of by flushing or placing them in the garbage, which is not a safe method of medication disposal as per Federal and State regulations. Staff #2 reported on 10/18/23 that they did not dispose of medication in this manner. However, there is no specific documentation indicating the correct method of disposal.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.Why: The medication disposal form was outdated. The staff disposed of the medication properly but did not record it properly because the form was outdated. It is important to dispose of medication properly to protect the environment and community. POC: (plan, training by whom date and supportive documentation. The CEO updated the medication disposal form on 10/18/2023 and uploaded the form to ODP on 10/26/23, and the RD ensured the form was distributed to the homes. (see attached) 12/08/2023 Implemented
6400.165(c)Melatonin 5mg tablet was discontinued on 3/28/23. Staff #4 administered the medication at 8pm on 3/28 & 3/29.A prescription medication shall be administered as prescribed.The medication was not administered because it was not in the home; the RS staff brought it to the office for disposal. It is important to pass medication as prescribed to protect the health and safety of the individual The staff participated in a training about discontinuing medication and signing the MAR on November 3, 2023. The training was conducted by the AIMED Medication Administration Trainer, Adrienne Harrington. The RD has scheduled a staff med admin remediation class with the Medication Administration Trainer. The remediation class will be completed by December 8, 2023. 11/30/2023 Implemented
6400.165(g)The Quarterly Psych Med Review completed on 10/11/23 for Individual #1 does not include the reasons why the medications were prescribed.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The doctor completed the form, and the RS did not review it for accuracy before leaving the appointment. This regulation is important because it ensures accurate treatment information. The PS will contact the doctor to ensure a corrected form is signed by November 13, 2023. 11/30/2023 Implemented
6400.166(a)(3)-Individual #1's annual physical & PCP encounter forms lists an allergy to the medication Haldol. The MARs from Oct 2022- October 2023 do not list Haldol as an allergy. The ISP & emergency data form do not list Haldol as an allergy.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies.Why: The RS and PS did not ensure the pharmacy included this information on the MAR. The Supports Coordinator did not include this information in the ISP, and the PS and RS did not notice the omission. This regulation is important because it protects the person from being exposed to allergens. POC: (plan, training by whom date and supportive documentation. On 10/19/23, the PS contacted the Supports Coordinator to request the ISP be updated. As of 11/9/23, an updated ISP is not available in HCSIS. The RD contacted the SC and the SC's supervisor on 11/9/23. The pharmacy was contacted, and new MARs arrived on 10/20/23. 12/08/2023 Implemented
6400.167(a)(1)-March 15 & 17th at 8pm staff did not initial the MAR's as administrating Individual #1's Risperidone 2mg tablets. The date/time was left blank on the MAR's. MAR's- April 26, 2023, 8pm Benztropine Mesylate 0.5mg was not initialed by staff as being administered. This date/time was blank on the MAR's.Medication errors include the following: Failure to administer a medication.This regulation is important because it ensures med errors are handled efficiently and appropriately. The RS and PS failed to observe the error. The staff participated in a training about discontinuing medication and signing the MAR on November 3, 2023. The training was conducted by the AIMED Medication Administration Trainer, Adrienne Harrington. The RD has scheduled a staff med admin remediation class with the Medication Administration Trainer. The remediation class will be completed by December 8, 2023. 11/30/2023 Implemented
6400.181(f)The annual ISP was held 2/28/23 and the assessment was not completed until 2/9/23. This was not completed and sent 30 days prior to ISP meeting for Individual #1. In addition, there is not clarification that all team members received a copy.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.-During a time of staff shortage, the Director of Clinical Services & Admissions completed the assessment but sent it only to the mother/legal guardian and did not preserve evidence of sending the assessment It is important to complete an assessment and provide the team with a copy to ensure continuity of information. The PS will provide the assessment within the 30-day timeframe. The RD will review prior to the 30 days. The RD will provide a refresher training to the PS on November 17, 2023. 11/30/2023 Implemented
SIN-00213583 Renewal 10/17/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency license expiration date is 11/30/22. The self-assessment for this home was completed 9/16/22 through 9/29/22, outside of the window required by regulation.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. There was some confusion around the time frame stated on the notice and the regulation. As a result of 6400.15(a), the Dr. of Program and Services will place the due date on the shared calendar and complete the self-assessment between 3 to 6 months of the license expiration date and according to the written regulations. 11/07/2022 Implemented
6400.81(k)(6)At the time of the 10/18/22 inspection, Individual #1's bedroom did not have a mirror.In bedrooms, each individual shall have the following: A mirror. The mirror was removed due to the health and safety of the individual and the mirror had to be replaced. As a result of 6400.81(k)(6), the Operations Manager purchased a plexiglass mirror on 10/18/22. The mirror was hung on the wall on 10/27/22. Picture of mirror on the wall was emailed to licensing 11/7/22 10/27/2022 Implemented
6400.103The emergency evacuation plan for the home does not include individual responsibilities, means of transportation, or an emergency shelter location.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. As a result of 6400.103, the CEO revised the emergency evacuation plan on 10/24/22, to clearly outline on-shift staff responsibilities, shelter location and transportation expectations. Revised version emailed to licensing on 11/7/22. 10/24/2022 Implemented
6400.106Individual #1 moved into the home on 4/25/22. The furnace was not inspected in this home until 5/11/22.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. As a result of 6400.106, the CEO or Dr. Prog and Serv shall ensure that each home has a current furnace inspection. The Dr. of Training and Compliance shall ensure that the Operations Manager has the furnace inspected prior to a new move-in and the RPD will provide a second check. The site preparation checklist has been updated to include "furnace inspection," 11/07/2022 Implemented
6400.144Individual #1 had a new patient appointment with their PCP on 12/16/21. The physician wanted a 2-month follow-up for this visit. This follow up appointment was not completed.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. There was a change in staff & management, and the information was not communicated from previous staff. As a result of 6400.144, the Program Specialist will ensure that all appt follow-ups are placed on the calendar and shared with the RPD. The portal login information is now shared on the drive for others to access. The RPD provided a refresher training to the Residential Supervisors on 11/2/22. 11/02/2022 Implemented
6400.145(1)The emergency medical plan for Individual #1 did not include a hospital or source of health care to be used in an emergency.The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. The correct Behavioral and Medical Emergency policy wasn't used for the annual licensing and has since been replaced with the correct form. As a result of 6400.145(1), the CEO has revised the Behavioral and Medical Emergency Plan to include the hospital and transportation used. The revised version was emailed to licensing on 11/7/22. 11/07/2022 Implemented
6400.145(2)The emergency medical plan for Individual #1 did not include a means of transportation.The home shall have a written emergency medical plan listing the following: The method of transportation to be used. The correct Behavioral and Medical Emergency policy wasn't used for the annual licensing and has since been replaced with the correct form. As a result of 6400.145(1), the CEO has revised the Behavioral and Medical Emergency Plan to include the hospital and transportation used. Revised version was emailed to licensing on 11/7/22. 11/07/2022 Implemented
6400.181(e)(4)Individual #1's 2/9/22 assessment does not include their current level of supervision. The assessment must include the following information: The individual's need for supervision. The level of supervision is within the body of the assessment and but not easily identified as a separate category. As a result of 6400.181(e), the CEO made revisions to the assessment on 10/24/22, to include a separate category for supervision that is easily identifiable. The revised assessment was emailed to licensing 11/7/22. 11/07/2022 Implemented
6400.165(b)Individual #1's physician increased their Risperidone dosage from 1.5mg twice daily to 2mg twice daily on 9/12/22. Individual #1 did not receive the increased dosage in the home until 9/22/22.A prescription order shall be kept current.The delivery of the medication had a two day delay due to delivery attempts and no one was home. There was a miscommunication between staff and the Dr. during the virtual appointment. When medications were received, the staff was not clear on the change and needed to confirm med change with the Dr. The change was not done until it was confirmed with Dr. There was a gap in between the time the staff contacted the Dr. and when they returned the call. As a result of 165(b), The RPD provided a refresher training on 11/2/2022, to review proper protocol for after appt visits. The staff will give the summary to the Program Specialist immediately after the appointment. 11/02/2022 Implemented
6400.165(g)Individual #1's 6/3/22, 7/8/22, and 9/12/22 medication reviews do not include the reason for prescribing the medication.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The outdated psychiatric form was being used by the residential supervisor, the form was missing the current medications, which are completed by the staff prior to the appointment. As a result of 6400.165(g), The correct form was sent to the Program Specialist on 10/21/22 and Residential Supervisor was to begin using the current form. The RPD provided a refresher training with the residential supervisor to review proper form completion and protocol on 11/2/22. 11/02/2022 Implemented
6400.166(a)(2)At the time of the 10/18/22 inspection, the October 2022 Medication Administration Record (MAR) did not include the name of the prescriber for all of the medications.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.The pharmacy that is being used, put the name of the prescriber on the bottom of MAR and did not include all prescribers' names. As a result of 6400(a)(2), The CEO had the RPD contact the pharmacy on 10/18/22 and instructed them to put the prescriber name in each medication row. The pharmacy complied and a copy of the MAR was emailed to licensing on 11/7/22. 11/07/2022 Implemented
6400.167(a)(1)Individual #1 did not receive their 8pm dose of Risperidone on 3/31/22.Medication errors include the following: Failure to administer a medication.Medication blister packs were reviewed at the end of the month and all medications had been given. There was a documentation error. As a result of 6400.167(a)(1), the RPD provided refresher training to the Residential Supervisor on 11/2/22. The RPD is responsible to ensure that the Residential Supervisor reviews the MAR daily and reports any error. A copy of the training form was emailed to licensing on 11/7/22. 11/02/2022 Implemented
6400.167(b)Individual #1's failure to receive their 8pm dose of Risperidone on 3/31/22 was not documented as a medication error.Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record.Medication blister packs were reviewed at the end of the month and all medications had been given. The PS failed to document as a documentation error on the MAR As a result of 6400.167(b), the RPD provided refresher training with Residential Supervisor on 11/2/22. The RPD is responsible to ensure that the Residential Supervisor reviews the MAR daily and reports any error. 11/02/2022 Implemented
SIN-00231420 Renewal 10/18/2023 Compliant - Finalized