| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC 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 |
| 6400.68(a) | On 12/8/2021 at 10:56AM, the hot water temperature measured 86.5 degrees Fahrenheit at the shower in the bathroom along the hallway in the home. | A home shall have hot and cold running water under pressure. | AIMED purchased the thermometer recommended by ODP over two years ago, it was a technical recommendation. AIMED has used the thermometer since the recommendation. The water temp was checked by AIMED and the inspector at the same time and the two were different, the inspector's reading was higher she stated her reading must be the documented reading for inspection. AIMED reading was within regulation,
As a result of 6400.68(a), the Director of Training and Compliance shall resume compliance checks and supervisory temp checks January 2022, they shall be reviewed during those compliance visits. There shall be refresher training conducted during the monthly site lunch and learn to ensure all staff are conducting temp checks accurately. |
01/14/2022
| Implemented |
| 6400.106 | The furnace was inspected and cleaned by a professional furnace cleaning company on 9/9/2020 and again on 9/29/21. | 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.
| AIMED made every attempt to get the furnaces inspected within the required timeframe but due to COVID and the company being short staffed, the deadline couldn¿t be met. As a result of 6400.106, the CEO or designate shall ensure that each home has a current furnace inspection. The Director of Compliance shall resume home compliance inspections by 1/14/22, at which time the furnace inspections will be included in compliance checks. |
01/14/2022
| Implemented |
| 6400.112(c) | The written fire drill record for the fire drills conducted from 4/29/2021 to 10/30/2021 do not include whether the fire alarm or smoke detector was operative and if any problems were encountered. | 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 6400.112(c), the Director of Program and Services shall direct the Regional Program Director to retrain all staff on the evacuation and documentation.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 fire drills understand the required evacuation timeframe and documentation and/or any problems encountered. There shall be a quarterly fire drill inspection to ensure that records are kept according to the ODP regulations. |
01/14/2022
| Implemented |
| 6400.112(d) | The fire drill conducted 3/30/2021 had an evacuation time of 4 minutes. [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 |
| 6400.214(b) | Individual #1's most current copy of individual assessment was not present at the home at the time of inspection. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| AIMED hasn¿t kept an individual assessment at the home since the start of the agency, and wasn¿t aware it was an ODP requirement.As a result of 6400.214(b), The Director of Programs and Services shall direct the Regional Program Director to complete a training refresher on documentation and which documents are required to be at the site.The CEO designee shall require the Regional Program Director to conduct a training refresher with the Program Specialist by 1/14/22. The training shall be documented in the Bamboo training record. |
01/14/2022
| Implemented |