Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00209030 Renewal 07/14/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The agency's self-assessment results, completed 6/27/2022, identifies violations, but a written summary of corrections was not kept.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. The incorrect self assessment was retrieved and used the ODP website, however, the form was outdated. The corrections were documented on a separate sheet of paper. As a result of 6400.15(c), the Dr. of Prog and Srvs immediately downloaded the current form dated 2/2022 and saved to the shared drive on 7/18/22, for future use and the summary will be included on the current form. 07/18/2022 Implemented
6400.142(a)Individual #1, date of admission 9/2/2016, had a dental examination on 5/10/2022. There were not any previous dental examinations for Individual #1; therefore, compliance could not be measured.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. Individual #1¿s annual dental appointments were completed on 5/2/19 and 12/11/19. Accessible dental offices distributed communication stating they will be closing March 13, 2020 due to Covid-19 As a result of 6400.142(a),. The program Specialist scheduled the next available appointment on 5/10/22 when the offices reopened for in person visits. (Uploaded form) 07/25/2022 Implemented
6400.142(g)Individual #1 is not independent regarding dental hygiene. Individual #1 had a dental hygiene plan completed 5/10/22. There were not any previous dental hygiene plans for Individual #1; therefore, compliance could not be measured..A dental hygiene plan shall be rewritten at least annually. Individual #1¿s annual dental appointments were completed on 5/2/19 and 12/11/19. Accessible dental offices distributed communication stating they will be closing March 13, 2020 due to Covid-19. As a result of 6400.142(a), Individual #1 completed his annual dental on 5/10/22. (Uploaded form). 07/25/2022 Implemented
6400.181(e)(4)Individual #1's assessment, completed 9/3/21 does not include the individual's need for supervision. The assessment must include the following information: The individual's need for supervision. The individual ISP had revisions made on 6/21/22. The annual assessment was not due until 9/8/22. The update to the assessment was planned at the time when it was in September. As a result of 6400.181(e)(4) individual #1¿s assigned Program Specialist included the individual's need for supervision into his assessment on 8/10/22. It was reviewed by the Regional Program Director which included the significant change. 09/30/2022 Implemented
6400.181(e)(11)Individual #1's assessment, completed 9/3/21 does not include a psychological evaluation.The assessment must include the following information: Psychological evaluations, if applicable. The forms were mistakenly placed in purge when the chart was purged of documents older than 2 years. The document was retrieved and placed back into the chart. As a result of 6400.181(e)(11) individual #1 physiological assessment was located and filed in their chart by the Regional Program Director on 8/10/22. (Uploaded form) 08/10/2022 Implemented
6400.211(b)(2)Individual #1's emergency information does not include the name, address and telephone number of the physician or source of health care. Emergency information for each individual shall include the following: The name, address and telephone number of the individual's physician or source of health care.Documentation on lifetime medical and vial of life was seen at the site but not requested. As a result of 6400.211(b)(2)Individual #1's emergency information including the name, address and telephone number of the physician or source of health care were listed on the lifetime medical and vial of life forms that were viewed on inspection at the site. Both forms are filed in the administrative office and available to measure compliance. (Uploaded form) 07/25/2022 Implemented
6400.15(b)The agency completed a self-assessment of the home on 06/27/22; however, the agency did not use the Department's most current licensing inspection instrument (reflecting regulatory changes promulgated in February 2020) to measure and record compliance for this chapter.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.AIMED used the DHS-ODP website to download the self-assessment to complete prior to licensing, it is not dated. We were informed after inspection that the form used was incorrect. It is our thought that ODP would have up-to-date forms on the website. CLS does point you to the website to obtain forms and information. As a result of 6400.16(b), the self-assessment form obtained from DHS-ODP website on 7/18/22, has been replaced with the revised form 2/2022. The old form has been deleted from our drive. 07/18/2022 Implemented
6400.182(a)Individual #1's assessment completed, 9/3/21 indicates Individual #1 requires supervision and verbal cues to both identify and move away from dangerous heat sources. Individual #1's individual plan, completed 5/27/22 indicates that Individual #1 understand basic dangers with heat sources and will avoid them. Individual #1's assessment completed, 9/3/21 indicates Individual #1 require verbal prompting to safely evacuate during a fire drill. Individual #1's individual plan, completed 5/27/22 indicates Individual #1 participates in fire drills at the community home and knows where the designated meeting place is. Individual #1's assessment completed, 9/3/21 indicates Individual #1 can safely use and avoid poisonous materials with verbal prompting and supervision. Individual #1's individual plan, completed 5/27/22 indicates that Individual #1 require full physical assistance and supervision when using poisonous substances. The program Specialist has not coordinated the aforementioned revisions or discrepancies with Individual #1's individual plan team.The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team.As a result of 6400.182(a) individual #1¿s assigned Program Specialist included the individual's heat sources, fire drills and poisonous materials into his assessment on 8/10/22. It was reviewed by the Regional Program Director which included the significant change and it was sent to his Supports coordinator on 8/12/22. (Uploaded form) 08/12/2022 Implemented
6400.195(b)Individual #1's behavior support plan, completed 12/19/21 includes restrictive procedures. A review was conducted by the human rights team on 3/28/22. There were not any previous reviews; therefore, compliance could not be measured.The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews.Documentation of previous reviews was not requested. Aimed can provide. As a result of 6400.195(b), the previous Human Rights Team reviews are filed in the administrative office and available to measure compliance. (Uploaded form) 08/12/2022 Implemented
SIN-00197230 Renewal 12/07/2021 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The completed self-assessment was not dated so compliance was unable to be measured.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. AIMED completed the self-assessment on time according to the regulation, however, the date was inadvertently left of the form. As a result of 6400.15(a), the CEO or designated person shall review the self-assessment form prior to submission to ensure full compliance. 01/14/2022 Implemented
6400.111(f)The fire extinguisher located on the second floor in the bathroom of the home was last serviced in June of 2020 according to the tag attached to the fire extinguisher, verified during the physical site inspection on 12/08/21. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. AIMED had all the fire extinguishers inspected in a timely manner and within ODP guideline. The inspector failed to change the tags on a few. The company that provides the fire extinguisher inspections was immediately contacted and a serviceman came and tagged the fire extinguishers. All fire extinguishers are in compliance to date. As a result of 6400.111(f), the Director of Compliance shall check each fire extinguisher tag after a new inspection to ensure all extinguishers are properly tagged. 01/14/2022 Implemented
6400.112(d)The fire drill conducted on 07/28/21 had an evacuation time of 4 minutes. The home does not have an extended evacuation time. [Repeat Violation, 1/5/2021] Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. As a result of 6400.112(d), the Director of Program and Services shall direct the Regional Program Director to retrain all staff on the evacuation timeframe.During new hire training, the Director of Training and Compliance trains all new hires on fire drill protocol and ODP regulations. 01/14/2022 Implemented
6400.112(e)The most recent fire drill held during sleeping hours was on 12/24/20.A fire drill shall be held during sleeping hours at least every 6 months. As a result of 6400.112(e), the Director of Programs and Services shall direct the Regional Program Director to retrain all staff on ODP regulations and the expectations of conducting a fire drill. During new hire training, the Director of Training and Compliance trains all new hires on fire drill protocol and ODP regulations. The CEO or designee shall have the Regional Program Director conduct a training refresher by 1/14/22, to ensure that all staff conducting a fire drill understands that at least one overnight fire drill is required every 6 months. The Director of Training Compliance shall resume compliance checks January 2022, and shall review fire drill records during this time. 01/14/2022 Implemented
6400.141(c)(3)Individual #1's most recent immunization for Tetanus, Diphtheria, and Pertussis on 08/14/11. [Repeat Violation, 1/5/2021]The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. As a result of 6400.141(c)(3), The CEO or designee shall ensure that staff meet the minimum requirements for physical examinations. There shall be an quarterly HR file review to ensure that all staff meets ODP regulations. During new hire training for the HR Manager is trained on ODP requirements for employee physicals and bi-annual renewal. 01/14/2022 Not Implemented
6400.46(b)Direct Service Worker #1 had annual fire safety training on 04/13/20, and then again on 06/28/21.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).As a result of 6400.46(b), the Director of Training and Compliance shall ensure that the Program Specialist and Direct Care worker are properly trained annually on fire safety. The training shall be scheduled on the agency¿s fiscal training calendar. 01/14/2022 Implemented
SIN-00181240 Renewal 01/05/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(3)Individual #1's most recent immunization for Tetanus, Diphtheria, and Pertussis was completed 02/05/10.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. 6400.141(c)(3), AIMED will ensure that the annual physical form is completed in its entirety as well as getting the After Visit Summary (AVS) and a supplemental immunization documentation once the appointment has concluded. The Team Coordinator is responsible for ensuring the paperwork is completed before leaving the doctor¿s office along with getting the additional paperwork as discussed above. Program Manager will review paperwork for completeness and accuracy before submitting to Program Specialist who in turn will review the documentation for accuracy before filing. Any missing information will be addressed immediately and corrected within two weeks. The Regional Program Director (RPD) conducted a training refresher with Program Specialist, Program Manager and Team Coordinators on January 11th during the team meeting. [Immediately, the CEO, or designee, shall train all staff responsible for accompanying individuals to physical examinations on the required components of a physical examination, as indicated by 6400.141(a-d). Documentation of training shall be kept. The CEO, or designee, shall conduct an audit of 25% of individual physical examinations at least quarterly for a period of one year. Documentation of audits shall be kept. DPOC by HDKP, HSLS on 2/24/2021.] 01/27/2021 Implemented
6400.181(f)The program specialist provided assessment, completed 04/27/20 for Individual #1 the individual plan team members on 08/07/20 for an individual plan meeting on 04/16/20.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.6400.181 (f), AIMED will ensure that assessments are submitted within the specified timeframe per regulations to the individual¿s entire team. Program Specialist(s) will be responsible for submitting the assessment to the team at least 30 days prior to an individual plan meeting. AIMED Program Specialist(s) will discuss with individuals¿ team that ISP meetings will be scheduled at least 30 days after the individuals¿ anniversary dates. Regional Program Director (RDP) will oversee the entire process to ensure compliance is met. The assessment 30-day window will be placed on the RPD and Program Specialist calendar as reminder. The Regional Program Director (RPD) conducted a training refresher with Program Specialist on January 11th. [Immediately, the CEO, or designee, shall train all staff responsible for completing any portion of the individual assessment, coordinating the completion of any portion of the assessment, or ensuring the completion of the individual assessment on the required components of an individual assessment, including required content and timelines, as indicated by 6400.181(a-f). Documentation of training shall be kept. The CEO, or designee, shall conduct an audit of 25% of individual assessments at least quarterly for a period of one year. Documentation of audits shall be kept. DPOC by HDKP, HSLS on 2/24/2021.] 01/27/2021 Implemented
SIN-00141965 Renewal 09/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The hot water temperature measured 129.2F in shower of bathroom located on the first floor adjacent to the dining room at 11:20AM on 9/20/18. Hot water temperatures in bathtubs and showers may not exceed 120°F. The hot water temperature measured 129.2°F in shower of bathroom located on the first floor adjacent to the dining room at 11:20AM on 9/20/18. Upon discovery of the high water temperature in the bathroom shower, the supervisor immediately lowered the temperature on the hot water tank. At approximately 2:00PM on 9/20/2018 the water was tested throughout the house (including the bathroom shower the high temperature was detected) and was 117°F. A water temperature log has been created and will be posted at each site at the conclusion of staff training which will take place at October 2018¿s monthly team meeting at all sites. A refresher training will take place at future team meetings. The water temperature log will include the daily water temperature reading in the bathroom and kitchen sinks of each site. The water temperature will be taken daily by site supervisors and direct care staff and will include the staff¿s initials to indicate who recorded the water temperature and at what time. The Program Specialist will review the water temperature log during monthly team meetings and Training and Compliance Manager is responsible for reviewing the water temperature log during the weekly site compliance visit. Residential Program Manager will review the water temperature log during monthly visits to the site. 10/02/2018 Implemented
6400.112(c)The written fire drill records for the fire drills held on 10/14/17, 11/13/17, 12/13/17, 1/10/18, 2/13/18, 3/11/18, 4/13/18, 5/10/18, 5/13/18, 6/12/18, 7/14/18, 8/15/18 and 9/14/18 did not include if there were problems encountered or whether the fire alarm or smoke detector was operative.[Repeated Violation-9/28/17, et al]A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. As a result of last year¿s violation of 6400.112(c), AIMED revised the agency¿s fire drill form. This revision failed to include a section that indicated if there were any problems encountered during the fire drill as well as whether the fire alarm or smoke detector was operative at time of drill. Immediately upon the conclusion of this year¿s licensing visit (on September 21, 2018), AIMED revised the fire drill form to include the following: 1. Did you encounter problems during fire drill? ¿ Yes ¿ No 2. Was fire alarm operative during fire drill? ¿ Yes ¿ No 3. Designated meeting place AIMED Program Specialist will train all supervisors and direct care staff on how to properly complete the revised form to assure that drills are being conducted properly and the forms are being completed properly agency wide. This training will take place at each site during October¿s monthly team meeting with refresher training at future team meetings. Training and Compliance Manager is responsible for reviewing the fire drill record for accuracy during the weekly site compliance visit. Program Specialists will review fire drill records for accuracy during weekly site visits. Residential Program Manager will review the fire drill record for accuracy during monthly site visits.[Documentation of trainings and audits of fire drill records shall be kept. (DPOC by AES,HSLS on 10/11/18)] 10/02/2018 Implemented
SIN-00122331 Renewal 09/27/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment of the home was completed on 6/23/17. The agency's certificate of compliance expiration date was 8/20/17. [Repeated Violation-9/27/16, et al]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. AIMED completed the self inspection for each site and used the Inspection summary instructions for the timeline to complete, which it stated 3-6 months prior to inspection, opposed to license renewal. AIMED has since corrected the due date on our calendar and will issue notification at our Leadership team meeting on October 27, 2017. The Training and Compliance Manager is responsible for placing the due date on the calendar 6 months prior to the license renewal and share the date with site supervisors and the Director of Operations. The Director of Operations is responsible for making sure the inspection tool is completed no less than 4 months prior to license renewal. [Prior to 3 months before the expiration date of the certificate of compliance, the CEO or designated management staff person shall audit all completed self-inspections to ensure timely completion of the self-inspections to measure and record compliance with this chapter. Documentation of the audits shall be kept. (AS 11/28/17)] 10/27/2017 Implemented
6400.163(c)The psychiatric medication reviews completed 5/23/17 and 8/29/17 for Individual #1 did not include the reasons for prescribing the medications. [Repeated Violation-9/27/16, et al] If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.The reason for prescribing the medication by the psychiatrist was not completed on the form. The Program Specialist has revised the form to highlight the necessary information and retrained the supervisors on the proper completion and the necessary information needed on the form. The supervisor will review the form for proper completion and will submit the form to the Program Specialist for further review of accuracy. [Immediately, the CEO or designated management staff person shall develop and implement procedures to follow if during the aforementioned audits required information is not included and train all staff person responsible for ensuring that medication reviews are completed with all required information of the procedures. Documentation of all aforementioned audits shall be kept. (AS 11/28/17)] 10/27/2002 Implemented
SIN-00101275 Renewal 09/27/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(e)Direct Service Worker #1, date of hire 11/12/15, did not have training on the individual's rights within the 30 calendar days after initial employment or within the 12 months prior to initial employment.Program specialists and direct service workers shall have training in the areas of mental retardation, the principles of normalization, rights and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. No longer employed as of 9/28/16. A full-time Training and Compliance Manager was hired and trained. The TCM Manager will conduct new hire orientation and train new employees on Individual¿s Rights, ODP¿s Principals and Values training have been added to the agency orientation as of 09/26/2016. Employees complete orientation prior to working with individuals.[At least quarterly, the CEO shall review a 25% sample of completed staff training documents and staff training tracking document to ensure all required staff training is completed and documented as required. (AS 1/10/17)] 12/10/2016 Implemented
6400.46(h)There was not documentation showing that Direct Service Worker #1, date of hire 11/12/15 was trained before working with individuals in first aid techniques; therefore, compliance could not be measured.Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home, shall be trained before working with individuals in first aid techniques. No longer employed as of 9/28/16. New Training Manager was trained and will review all employees training record and document on orientation form if necessary. Trained on tracking form and reviewed 6400 regulations. The TCM Manager will conduct med certification, First Aid/CPR, and all professional development training. She will tract all staff training as well as provide all required and needed training to all staff on an ongoing basis. All training will be accurately documented in employee files and reviewed by the Director of Operations. [At least quarterly, the CEO shall review a 25% sample of completed staff training documents and staff training tracking document to ensure all required staff training is completed and documented as required. (AS 1/10/17)] 12/10/2016 Implemented
6400.46(i)Direct Service Worker #1's training in cardio-pulmonary resuscitation expired on 6-6-16.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. No longer employed as of 9/28/16. A full-time Training and Compliance Manager has was hired and trained. The TCM Manager will conduct med certification, First Aid/CPR, and all professional development training. She will tract all staff training as well as provide all required and needed training to all staff on an ongoing basis. All training will be accurately documented in employee files and reviewed by the Director of Operations. [At least quarterly, the CEO shall review a 25% sample of completed staff training documents and staff training tracking document to ensure all required staff training is completed and documented as required. (AS 1/10/17)] 12/10/2016 Implemented
6400.110(e)The home has three stories. The smoke detectors on each floor of the home, which include a basement, first floor and second floor were not interconnected.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. The Director of Operations purchased new smoke detectors in October and was installed by site supervisors. Wireless interactive connectable smoke alarms have been purchased for each level of the house (basement, first floor and second floor). [At least weekly for 1 month and continuing monthly thereafter, a designate staff person shall check all smoke detectors in all community homes to ensure they are operable, interconnected and audible as required. Documentation of checks shall be kept and reviewed by the director of operations at least quarterly. (AS 1/10/17)] 12/10/2016 Implemented
6400.111(a)The fire extinguishers located in basement and the attic of the home had 1-A 10 BC ratings.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. The Director of Operations purchased new fire extinguishers in October and they installed by site supervisors. A 2-A rating fire extinguisher has been purchased for the second floor and basement and is scheduled for delivery. Invoice is attached. [Immediately, and at least quarterly a designated management staff person shall check all fire extinguishers to ensure there is at least one operable fire extinguisher with a minimum 2-A rating on each floor of all community homes, including the basement and attic as required. Documentation of all checks shall be kept and reviewed by the director of operations at least quarterly. (AS 1/10/17)] 12/10/2016 Implemented
6400.141(c)(7)The physical examination, completed 8/3/16 for Individual #2 did not include a gynecological examination. 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. The participant attended an appt with her PCP on 11/1/16, and she is not required to have the exam. Staff was re-trained on annual appointment requirements 10/31/16. And, trained on what the doctor should document on the annual physical form if the participant doesn¿t medically need the exam.[Immediately, the CEO shall train Residential Coordinator and the Clinical Program Manager of the requirements of individual physical examinations as per 6400.141(c)(1)-(15) and that no required areas of physical examinations shall be left blank. Documentation of training shall be kept. Immediately and upon completion, the aforementioned reviews of physical examinations shall be completed and missing information shall be immediately obtained. Documentation of trainings and reviews shall be kept. (AS 1/10/17)] 12/10/2016 Implemented
6400.141(c)(8)The physical examination, completed 8/3/16 for Individual #2 did not include a mammogram. The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. The participant attended an appt with her PCP on 11/1/16. She was referred to have a mammogram on 1/4/2017. An annual appt checklist is created and tracked on calendar by the Residential Coord. and Clinical Program Manager. Program Manager. Staff was re-trained on annual appointment requirements 10/31/16. Staff was trained on what the doctor should document on the annual physical form if the participant doesn¿t medically need the exam.[Immediately, the CEO shall train Residential Coordinator and the Clinical Program Manager of the requirements of individual physical examinations as per 6400.141(c)(1)-(15) and that no required areas of physical examinations shall be left blank. Documentation of training shall be kept. Immediately and upon completion, the aforementioned reviews of physical examinations shall be completed and missing information shall be immediately obtained. Documentation of trainings and reviews shall be kept. (AS 1/10/17)] 12/10/2016 Implemented
6400.142(a)Individual #2 did not have an annual dental examination.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. The participant attended an appt with her PCP on 11/2/16, her gums were examined. Prior to admission, each individual will have his/her regulatory medical appts reviewed by the Residential Coord. and followed up with the Clinical Program Manager to avoid overlooked regulatory exams. An annual appt checklist is created and tracked by Residential Coord., Clinical Program Manager to avoid missing all necessary annual appointments.[At least quarterly for 1 year, the CEO shall review individuals dental examination documentation and tracking system to ensure all individuals have dental examinations, timely. (AS 1/10/17)] 12/10/2016 Implemented
6400.164(a)Medications were initialed as administered to Individual #2 from 9/10/16 through 9/29/16 on Individual #2's medication log; although, the corresponding name was not included on the medication administration record. A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. A medication administration signature form has been created and placed in the medication binder (where the MAR is located) at each site. The initials and signatures of each staff who is certified with the agency to administer medication will initial and sign the form. This form will be updated by the Medication Administration Trainer on a regular basis. The Clinical Program Manager will visit all sites on a weekly basis using the weekly site visit form to assure that all staff who administered medication to individuals has signed the medication administration record.[Immediately and continuing at least weekly, program manager shall review all individuals' medications, MARs, and physicians orders to ensure all individuals are being administered medications as prescribed and documented as required. The program manager shall retrain staff qualified to administer medications as needed to ensure medications are administer and documented as required. Documentation of all trainings and reviews shall be kept.(AS 1/10/17)] 12/10/2016 Implemented
6400.181(e)(9)Individual #1's assessment completed 7/16/16 did not include documentation of the individual's disability, including functional medical limitations.The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. The assessment was revised and information was added in October. Re-training was done on 10/21 on the content of the assessment. The disability and functional medical limitations has been added to the assessment. The Residential Coord. (new position since inspection) and Clinical Program Manager will review for accuracy once assessment is completed.[Immediately, the CEO will educate the program specialist as to what must be included in individual assessments as per 6400.181.(e)(1)-(14). Immediately, and at least quarterly, the Program specialist shall review all individual assessments to ensure all required information is present and all individual are accurately assessed. Documentation of the reviews shall be kept. (AS 1/10/17)] 12/10/2016 Implemented
6400.181(e)(10)Individual #2's assessment completed 7/26/16 did not include lifetime medical history.The assessment must include the following information: A lifetime medical history. The assessment was revised and information was added in October. Re-training was done on 10/21 on the content of the assessment. Re-training was done on 10/21/16. The Clinical Program Manager is responsible for completing the assessment and the Residential Coord is responsible for assuring documents are in the chart and complete for avoid future incidents.[Immediately, the CEO will educate the program specialist as to what must be included in individual assessments as per 6400.181.(e)(1)-(14). Immediately, and at least quarterly, the Program specialist shall review all individual assessments to ensure all required information is present and all individual are accurately assessed. Documentation of the reviews shall be kept. (AS 1/10/17)] 12/10/2016 Implemented
6400.181(e)(13)(vii)Individual #1's assessment completed 7/16/16 and Individual #2's assessment completed 7/26/16 did not include current levels in the area of financial independence.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence. The assessment was revised and information was added in October. Re-training was done on 10/21 on the content of the assessment. The Residential Coord. and Clinical Program Manager will review final assessment for accuracy. [Immediately, the CEO will educate the program specialist as to what must be included in individual assessments as per 6400.181.(e)(1)-(14). Immediately, and at least quarterly, the Program specialist shall review all individual assessments to ensure all required information is present and all individual are accurately assessed. Documentation of the reviews shall be kept. (AS 1/10/17)] 12/10/2016 Implemented
6400.181(e)(14)Individual #1's assessment completed 7/16/16 and Individual #2's assessment completed 7/26/16 did not include knowledge of water safety and ability to swim.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. The assessment was revised and information was added in October. Re-training was done on 10/21 on the content of the assessment. The Clinical Program Manager is responsible for completing the assessment and the Residential Coord will assure that all forms are in the chart and completed accurately.[Immediately, the CEO will educate the program specialist as to what must be included in individual assessments as per 6400.181.(e)(1)-(14). Immediately, and at least quarterly, the Program specialist shall review all individual assessments to ensure all required information is present and all individual are accurately assessed. Documentation of the reviews shall be kept. (AS 1/10/17)] 12/10/2016 Implemented
6400.181(f)The program specialist did not provide Individual #1's assessment dated 11/12/15 to the plan team members including the supports coordinator.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). A signature form has been created on 10/21 and sent to the team. The Residential Coord. Is responsible for all team members getting a copy and Clinical Program Manager will review for accuracy. [Immediately, the CEO shall train the program specialist of the responsibilities of the program specialist position as per 6400.44(b)(1)-(19) and document the training. At least quarterly for 1 year the CEO or designated management shall review the documentation showing that the program specialist provided all individuals' assessments to the all the plan team members as required. Documentation of reviews shall be kept. (AS 1/10/16)] 12/10/2016 Implemented
6400.186(d)The program specialist did not provide Individual #1's ISP review documentation dated 9/21/16 to the plan team members including the supports coordinator. The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. A signature form has been created and signed by the team. The form will be filed with the reviews and reviewed by Residential Coord. and Clinical Program. [Immediately, the CEO shall train the program specialist of the responsibilities of the program specialist position as per 6400.44(b)(1)-(19) and document the training. At least quarterly for 1 year the CEO or designated management shall review the documentation showing that the program specialist provided all individuals' ISP reviews to the all the plan team members as required. Documentation of reviews shall be kept. (AS 1/10/16)] 12/10/2016 Implemented
6400.213(1)(i)Individual #2's record did not include the religious affiliation. Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.The Residential Coordinator was hired and trained on the admissions checklist and made the corrections 10/21/16. Upon admissions, each individual will have his/her religious affiliation identified on the admission application completed by the Residential Coord. (new positions since inspection) and reviewed by the Clinical Program Manager prior to actual admission.[Immediately, upon admission and at least quarterly, the program manager and residential coordinator shall review all individuals' records to ensure all required information is present as per 6400.213(1)-(14). Documentation of reviews shall be kept. (AS 1/10/17)] 12/10/2016 Implemented
SIN-00212917 Unannounced Monitoring 09/21/2022 Compliant - Finalized