Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00227559 Renewal 07/11/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(g)Individual #1's psychiatric medication review, completed 2/1/23 did not include reasons for prescribing the medications or need the continue the medications. (Repeated Violation 7/14/22, et al).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.During the inspection the psychiatric evaluation was present; however, the summary had pages missing. The entire summary and psychiatric form were submitted to ODP first thing the following morning. As a result of 6400.165(g), the 90-day psychiatric appt was scheduled and attended by the participant on February 1, 2023. The completed psychiatric summary and appointment form was emailed to ODP on July 13, 2023. 07/13/2023 Implemented
SIN-00203644 Unannounced Monitoring 04/14/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)The carpet was removed from the top five of the eleven steps between the first and second floors and the three foot by three foot landing of the second floor of the home. However, frayed strips of carpet and carpet padding were left protruding from under the bedroom and staff office doors posing a tripping hazard. In addition, the steps that where the carpet was removed do not have an anti-skid surface. Floors, walls, ceilings and other surfaces shall be free of hazards.As a result of 6400.67(b), the CEO or designee shall ensure that transition strips have been installed in both doorway thresholds, and anti-skid pads are installed on stairs on 4/28/2022. 04/28/2022 Implemented
6400.68(a)The cold water bathtub faucet handle in the bathroom on the first floor of the home is detached and on the side of the bathtub.A home shall have hot and cold running water under pressure. As a result of 6400.68(a), new hardware will be installed on 5/13/2022, and faucet handles are in working order. 05/13/2022 Implemented
6400.101There is a padlock on the outside of the staff office door on the second floor of the home posing a possible obstructed egress.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. As a result of 6400.101, a key lock has been installed on the staff office door on 4/28/2022, and 3 sets are accessible to staff at the home at all times. 04/28/2022 Not Implemented
6400.111(e)The fire extinguisher on the second floor of the home was locked in the staff office. This is the only fire extinguisher on the second floor. A fire extinguisher shall be accessible to staff persons and individuals. As a result of 6400.111(e), the fire extinguisher was removed from the locked staff office and has been positioned in a designated and accessible place in the individual¿s bathroom on 4/14/2022. 04/14/2022 Implemented
6400.163(a)Individual #1's medication, Night Cold and Flu capsules, did not have the label issued by the pharmacy. There were several blister packs of pills and there were also loose capsules in the plastic storage bag. [Repeat Violation, 10/12/2021]Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.Personnel change will take effect 7/31/22 to safeguard a complete transition of the site Supervisor staff member, and to ensure that the required trainings take place and the individuals progress is not interrupted. 07/31/2022 Not Implemented
SIN-00202084 Unannounced Monitoring 03/09/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(b)Tamsulosin 0.4 MG capsule, take 1 capsule by mouth every evening at 5:00PM after dinner, prescribed to Individual #1 was documented as discontinued on Individual #1's February 2022 Medication Administration Record on 2/18/2022. Direct Service Worker #1 initialed this medication as administered from 2/18/2022 to 2/28/2022.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.As a result of 6400.066(b), the Director of Programs and Services shall direct the Regional Program Director to conduct a refresher training on proper medication administration documentation to the staff who made the incorrect documentation. Upon hire, staff are given a thorough training on medication administration and documentation. 03/24/2022 Implemented
SIN-00197232 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
6400.169(b)(2)Several Direct Service Workers administered Basaglar Kwikpen injections from 11/1/2021 through 12/7/2021 to Individual #1 without successfully completing the Department-approved diabetes education course.A staff person may administer insulin injections following successful completion of both: A Department-approved diabetes patient education program within the past 12 months.As a result of violation 6400.16, AIMED will ensure that a medical professional with the required credentials to train staff by 1/14/22, on injections for individuals diabetic. Staff will be educated on the protocol to follow per doctor's instructions. Additionally, staff will be trained by a medical professional on a yearly basis (current employees and new employees) to ensure the health and safety of the participant is maintained. The CEO, Director of Training and Compliance or the agency designee will be responsible for scheduling the training with the medical professional as well as tracking all staff training in AIMED Bamboo Software under the Training Folder. 01/14/2022 Not Implemented
SIN-00181242 Renewal 01/05/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Direct Service Worker #1 had a physical examination completed on 05/01/17, and then again on 08/05/19. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. 6400.151(a) AIMED has implemented Bamboo software, where employees physical/TB tracker feature is available to track all required bi-annual Physical/TB. The Training/Compliance and Development Director was trained by the HR Manager, effective 1/22/21 how to use the platform. The new feature has been implemented and Physical/TB tracking is now effective in Bamboo. [Immediately, the CEO, or designee, shall train all staff on the requirements on staff physical examinations, as indicated by 6400.151(a-c). Documentation of training shall be kept. Within 60 days, the CEO, or designee, shall conduct an audit of all staff files to ensure that staff physical examinations are complete, accurate, and filed appropriately. Documentation of audits shall be kept. The CEO, or designee, shall conduct an audit of 25% of staff physical examinations 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
6400.151(c)(2)Direct Service Worker #1 had a Tuberculin skin test on 11/16/16, and then again on 08/08/19. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. 6400.151(c)(2) AIMED has implemented Bamboo software, where employees physical/TB tracker feature is available to track all required bi-annual Physical/TB. The Training/Compliance and Development Director was trained by the HR Manager, effective 1/22/21 how to use the platform. The new feature has been implemented and Physical/TB tracking is now effective in Bamboo. [Immediately, the CEO, or designee, shall train all staff on the requirements on staff physical examinations, as indicated by 6400.151(a-c). Documentation of training shall be kept. Within 60 days, the CEO, or designee, shall conduct an audit of all staff files to ensure that staff physical examinations are complete, accurate, filed appropriately, and include a negative Tuberculin evaluation. Documentation of audits shall be kept. The CEO, or designee, shall conduct an audit of 25% of staff Tuberculin evaluations 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
6400.169(d)Medication administration observations were completed on 11/25/19 and 5/13/20 for Direct Service Worker #1. A record of medication administration reviews and completion of annual practicum certification was not provided to demonstrate that the annual medication administration course was successfully completed.A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed.6400.169(d) AIMED has implemented Bamboo software, where a training tracker feature is available to track all required annul training. The Training/Compliance and Development Director was trained by the HR Manager, effective 1/22/21 how to use the platform. The new feature has been implemented and training tracking is now effective in Bamboo. [Immediately, the CEO, or designee, shall train all staff responsible for documenting and filing medication administration training documents on the requirements of Medication Administration Observations and Medication Administration Record reviews for initial training and annual practicum training, to include timelines, as required by 6400.162 and 6400.169. Within 60 days, the CEO, or designee, shall complete an audit of all medication administration trained staff files to ensure that training is accurate, completed, and filed appropriately. Documentation of audit shall be kept. The CEO, or designee, shall conduct an audit of 25% of medication administration trained staff 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-00141967 Renewal 09/20/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(f)Direct Service Worker #1 had initial fire safety training 1/20/17 then again 2/21/18.Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. The direct care worker had fire safety training 1/20/17 and again on 2/21/18, it¿s required annually. The Training and Compliance Manager is responsible for training and manually tracking fire safety for new and existing staff. The Training and Compliance manager will be adding all required new and annual training into our new agency electronic records system (Therap) that includes training tracking. The new system will alert both staff and the training manager when training is due and whether it occurred or not. The tracking training program is set up to give a 60 day advance notice of the actual training due date. The Training and Compliance Manager, Residential Program Manager is responsible for training all staff how to review their training in Therap, the training will be conducted within the next 60 days. [At least quarterly for 1 year, the CEO or designee shall audit a 25% sample of staff persons fire safety training records to ensure completion, timely. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 10/11/18)] 10/02/2018 Implemented
6400.112(c)The written fire drill records for the fire drills held on 11/16/17, 1/14/18, 3/18/18, 4/8/18, 5/5/18, 6/8/18, 7/2/18, 8/6/18 and 9/18/18 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 trainings 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
6400.151(c)(2)Direct Service Worker #1's most recent Tuberculin skin testing by Mantoux method with negative results was completed 9/1/16. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. The direct care worker most recent Tuberculin skin testing by Mantoux with negative result was completed 9/1/16. The direct care worker had his annual physical completed within the 2 year time frame and had a chest x-ray one month prior; however, it didn¿t state the direct care worker had a negative test result. The newly hired H.R. Coordinator and Compliance Manager will be responsible for checking the TB test result section on the annual physical form for compliance and the Compliance Manager is responsible for tracking and checking the annual physical/TB form for accuracy upon submission. There will be a quarterly file review for training and physical compliance. [Documentation of the audits of staff records shall be kept. (DPOC by AES,HSLS on 10/11/18)] 10/02/2018 Implemented
SIN-00122335 Renewal 09/27/2017 Compliant - Finalized