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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC 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 |
| 6400.144 | Individual #1 has a constipation protocol to take Senexon-S 8.6-50 mg take 1 tab in addition to current dosing to equal 2 tablets every day if needed for no bowel movement for 2 days.
There were 26 occurrences that the individual went more than 2 days without a bowel movement and the second dosing of Senexon-S 8.6-50mg was not administered. Individual did not have a bowel movement for the following time frames:
10/26-10/29/25, 10/29-11/1/25, 11/2-11/5/25, 11/9-11/15/25, 11/22-11/26/25, 11/30-12/5/25, 12/7-12/11/25, 12/14-12/20/25, 12/21-12/27/25, 12/31/25-1/3/26, 1/4-1/8/26, 1/18-1/22/26, 1/31-2/3/26, 2/11-2/14/26, 3/18-3/21/26, 4/7-4/11/26, 4/12-4/17/26, 4/19-4/22/26, 4/22-4/25/26, 5/20-5/23/26, 5/25-5/29/26, 6/2-6/6/26, 6/8-6/11/26, 6/14-6/17/26, 6/21-6/26/26, and 6/28-7/4/26.
Individual #1 did not have a bowel movement for 6 days between 11/9-11/15/25, 5 days between 11/30-12/5/25, 5 days between 4/12-4/17/26, 5 days between 6/21-6/26/26 and 6 days between 6/28-7/4/26. The bowel protocol fails to address what action should be taken during a prolonged time frame of not having a bowel movement.
Individual #1 is prescribed PRN Acetaminophen 500 mg, PRN Ibuprofen 600 mg, and PRN Senexon-S 8.6-50 mg. At the time of the inspection on 7/8/26, these PRN medications were not available in the house. | 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? Regulation 6400.144 is important because it ensures that an individual's health care needs are being met. This regulation promotes adequate care and ensures treatments that the medical providers prescribe are being followed, essentially protecting the health, care, and safety of the individual.
What happened? During the inspection conducted on 07/07/2026 and 07/08/2026, it was identified that Individual #1's constipation protocol directs staff to administer an additional Senexon-S 8.6-50 mg tablet, for a total of two tablets daily, when the individual has not had a bowel movement for two consecutive days. A review of documentation by the inspectors found 26 instances in which the individual went more than two days without a documented bowel movement, and the additional Senexon-S dose was not administered as required by the protocol. Also, the bowel protocol failed to inform staff what action to take if individual#1 does not have a bowel movement after a prolonged period of time.
In addition, Individual #1 was prescribed PRN Acetaminophen 500 mg, PRN Ibuprofen 600 mg, and PRN Senexon-S 8.6-50 mg. At the time of the inspection on 07/08/2026, these PRN medications were not available in the home as prescribed.
Why did it happen? Site Supervisor did not inform staff on the importance of consistently documenting on the intake and elimination tracker individual#1's bowel movement. Staff did not follow the bowel protocol as written when bowel movements were missed, and the additional Senexon-S dose was not given as required. Staff lacked awareness of actions to take if the PRN meds were ineffective due to the bowel protocol also did not inform staff of what to do if the individual continued to have no bowel movement after the increased dose. In addition, the Site Supervisor of individual #1's home was responsible for reordering PRN medication' however, they did not reorder the prescribed PRN acetaminophen, ibuprofen, and Senexon-S listed on the MAR. Additionally, the discontinued PRN medication was not removed from the Medication Administration Record (MAR) once the Physician discontinued the PRN pain medication; however, during a site inspection, the prior training and compliance facilitator removed the PRN medication from the site but not from individual #1's MAR. Management did not identify these issues through routine review of documentation and medication supplies.
What do we do right now? Following completion of the Licensing inspection on 7/08/2026, the Chief Program Officer and the Chief Administrative Officer completed a team meeting with staff concerning individual #1
bowel protocol and tracker. The staff were informed on the importance of consistently tracking bowel movements daily and administering PRN Senexon-S if no bowel movement after three days. The Site supervisor was reminded of the importance of having all PRN medications available on site for the continued health of individual #1.
On 7/7/2026, the physician sent over a discontinue letter for the Ibuprofen and Acetaminophen. The PRN Senexon-S was immediately reordered and arrived from the PDC Pharmacy and placed at the site on 7/8/2026. On 7/9/2026, the agency Registered Nurse (RN) discontinued both the Ibuprofen 600 mg and Acetaminophen 500 mg from the MAR. Additionally, on 7/17/2026, the Chief Program Officer instructed the Agency RN that the bowel protocol for individual #1 failed to address what action should be taken during a prolonged time frame of not having a bowel movement, which it is important to reach out to the prescribing physician for a more specific bowel protocol. The RN reached out to the prescribing physician on 7/17/2026 for an updated bowel protocol that is in compliance with regulation 6400.144. |
07/17/2026
| Implemented |
| 6400.181(e)(9) | Individual #1's 01/17/26 Annual Assessment does not include the individual's disabilities. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Why is the regulation important? Regulation 6400.181 (e)(9) is important because the information concerning an individual's disability, functional and medical limitations is vital to an agency supporting individuals with disabilities, as it allows for the provider agency to provide the necessary adaptive equipment and the support the individual requires based on identified disabilities. This regulation helps providers to understand the support needs and provide appropriate services and consistent care, which ensures the individual's health and safety.
What happened? During inspection on 7/07/2026, it was found that Individual #1's Annual Assessment completed on 01/17/2026 by AIMED did not include documentation of the individual's disability, including functional and medical limitations.
Because this information was missing, the assessment did not meet the requirements of 55 Pa. Code 6400.181(e)(9).
Why did it happen? During completion of the Annual Assessment that was completed on 1/17/2026 by AIMED staff, the documentation of the individual's disability, including functional and medical limitations was overlooked prior to finalizing, nor was an attachment with the disability, functional and medical limitations included. The assessment was not reviewed to ensure all elements were completed, hence, it was finalized without this required information. There was no checklist verifying that all elements were included in the assessment prior to finalizing, including elements pertaining to regulation 6400.181 (e)(9).
What do we do right now? On 7/17/2026, The Chief Program Officer reviewed and updated individual #1's Annual Assessment to include documentation of the individual's disability, including functional and medical limitations. The corrected assessment was completed to ensure compliance with 55 Pa. Code 6400.181(e)(9). Additionally, on 7/17/2026, AIMED Chief Program Officer conducted an audit of all AIMED assessments to ensure all elements were included and are in compliance. |
07/17/2026
| Implemented |
| 6400.181(e)(10) | Individual #1's 01/17/26 Annual Assessment does not include the individual's Lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Why is the regulation important? Regarding regulation 6400.181(e)(10), this regulation is important because a complete lifetime medical history helps staff understand the individual's past and current health needs. AIMED including the lifetime medical history in the assessment acknowledges all important medical information, including the individual's physical examination contents, which ensures comprehensive care and support can be provided to individuals supported. Additionally, this regulation is important since accurate medical information is vital because it allows staff and healthcare providers to make informed decisions, recognize potential health concerns, and provide safe and consistent care, which mitigates risk and protects the individuals health and safety.
What happened? During inspection on 7/07/2026, it was found that Individual #1's Annual Assessment completed on 01/17/2026 by AIMED did not include the individual's lifetime medical history. Because this information was missing, the assessment did not meet the requirements of 55 Pa. Code 6400.181(e)(10).
Why did it happen? During completion of the Annual Assessment that was completed on 1/17/2026 by AIMED staff, the lifetime medical history was not included in the assessment nor was it attached when emailed to the necessary parties. The assessment was not reviewed to ensure all elements were completed, hence, it was finalized without this required information. There was no checklist verifying that all elements were included in the assessment prior to finalizing, including elements pertaining to regulation 6400.181 (e)(10).
What do we do right now? On 7/17/2026, The Chief Program Officer reviewed and updated individual #1's Annual Assessment to include the lifetime medical history. The corrected assessment was completed to ensure compliance with 55 Pa. Code 6400.181(e)(9). Additionally, on 7/17/2026, AIMED Chief Program Officer conducted an audit of all AIMED assessments to ensure all elements were included and are in compliance. |
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. |
07/21/2026
| 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 |
| 6400.165(c) | On 12/26/25, Individual #1 was prescribed Amoxicillin 500 mg to take 1 pill every 6 hours until gone. The directions on the Medication Administration Record were to take 1 capsule four times daily at 8am, 12pm, 4pm and 8pm for 7 days, which was not written as the physician prescribed the medication. | A prescription medication shall be administered as prescribed. | Why is this regulation important? Regulation 6400.165(c) is important because it is vital that individuals receive their medication exactly as prescribed by their physician. Following the prescription as it is written helps protect the individual's health, supports safe effective treatment, and prevents unnecessary medication errors.
What happened? During an inspection on 7/7/2026 and 7/8/2026, it was discovered that individual #1 was prescribed Amoxicillin 500 mg to take 1 pill until gone; however, the AIMED Medication Administration Record (MAR) reflected directions to administer one capsule four times daily at 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM for 7 days. The instructions received from PDC Pharmacy did not accurately reflect the prescribing physician's order as it was written, resulting in AIMED Regional Program DIrector entering the medication directions on the MAR differently than prescribed which, is in violation of regulation 6400.165(6)
Why did it happen? The error occurred because the medication instructions received from PDC Pharmacy did not accurately reflect the prescribing physician's order. As a result, the AIMED Regional Program Director entered the medication directions onto the Medication Administration Record (MAR) based on the incorrect instructions provided, causing the MAR to reflect directions that differed from the physician's prescribed order. This resulted in noncompliance with regulation 6400.165(c), which requires prescription medications to be administered as prescribed.
What do we do right now? Upon discovery of the medication documentation discrepancy, the medication order and MAR were reviewed to determine what occurred. The physician's order and pharmacy instructions were compared to the MAR entry, and it was confirmed that the MAR did not accurately reflect the prescribed directions. Going forward, AIMED nurses will ensure the prescription from the provider reflects exactly what is documented on the MAR. The current MAR was reviewed and updated to ensure medication instructions match the prescribing provider's order. The Regional Program Director is no longer with AIMED; however, the Agency nurse was reminded of the importance of verifying medication orders prior to entering directions on the MAR. |
08/02/2026
| Implemented |
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