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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(7) | Individual #1 had a gynecological examination completed 3/14/25 then again 4/17/26. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Why is this regulation important? It is important that AIMED ensures all women supported by the agency who are 18 years of age and older receive appropriate preventive healthcare and consistent monitoring of their health needs. This approach is both preventive and proactive in protecting the health, safety, and overall well-being of women supported in our residential homes.
What happened? During the June 17, 2026 Licensing inspection, it was discovered that Individual #1 had a gynecological examination on 3/14/2025 and the next exam was on 4/17/2026, which is approximately one month past the due date to remain in compliance. The Site Supervisor at the time and the Program Specialist did not efficiently track the upcoming due date for the gynecological exam, hence missing the deadline.
Why did it happen?At the time of the licensure inspection, there was no documentation supporting the interval between examinations, nor was there a clearly established tracking system in place to ensure that the examination was scheduled and completed within the expected timeframe.
What do we do right now? Upon identification of the citation, AIMED PS reviewed medical records and documentation of gynecological examinations was verified. AIMED will implement a tracking system by 7-02-2026 to monitor preventive gynecological care for all women 18 years of age and older, including documentation of physician recommendations regarding frequency of examinations. Staff responsible for medical tracking were retrained on regulatory requirements, and ongoing audits will be conducted by the Chief Program Officer to ensure compliance. |
07/02/2026
| Implemented |
| 6400.142(a) | Individual #1 had a dental examination completed 8/27/24 then again 10/9/25. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Why is this regulation important? It is important that AIMED remains consistent and proactive in ensuring that all individuals supported receive appropriate dental care. Routine dental services help prevent pain, illness, and more serious health complications, while also promoting overall quality of life. This approach supports the protection of health, safety, and well-being for all individuals served by AIMED.
What happened? During the June 17, 2026 licensing inspection, it was identified that Individual #1 received a dental examination on 8/27/2024 and again on 10/09/2025. The annual dental examination requirement under regulation 6400.142(a) was not completed within the required timeframe, resulting in a finding of non-compliance at the time of review.
Why did it happen? The Site Supervisor at the time did not ensure that the dental examination was scheduled within the required 12-month timeframe, which resulted in the examination being completed outside of the regulatory requirement. The Program Specialist did not have a system of tracking and monitoring the regulatory appointments to ensure compliance.
What do we do right now? Upon identification of non-compliance with 55 Pa. Code § 6400.142(a), AIMED reviewed Individual #1's dental record and current status verified. The Program specialist immediately scheduled the next dental exam for individual #1, which is scheduled on 9/30/2026 to ensure compliance with regulation 6400.142 (a). A tracking system was implemented to monitor annual dental examinations for all individuals supported. Staff responsible for medical coordination were retrained on regulatory requirements. |
06/17/2026
| Implemented |
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