| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The self-assessment results, completed 6/28/2022, 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| The incorrect self assessment was retrieved and used the ODP website, however, the form was outdated.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 on 7/18/22 and saved to the shared drive for future use and the summary will be included on the current form. |
07/18/2022
| Implemented |
| 6400.64(a) | Under the vent on the floor in the dining room of the home was a dense matting of dust and debris. [Repeat Violation, 6/13/2022] | Clean and sanitary conditions shall be maintained in the home. | The home has been vacant for 18 months due to extreme damage caused by the previous individual. The home was damaged by spraying the fire extinguisher all over the home, creating a build up on the walls, carpet and vents. The vent didn¿t have dust, it was residue from the fire extinguisher (per a professional restoration company). AIMED has been restoring the home back to a livable condition There was no intention to move anyone onto the home until all repairs are completed..
As a result of 6400.64(a), the exhaust vent will be cleaned on 08/18/2022 by a professional restoration company. |
08/18/2022
| Implemented |
| 6400.64(b) | There was an inordinate amount of deceased insects on the shelves and floor in the closet in the basement of the home. | There may not be evidence of infestation of insects or rodents in the home. | The home has been vacant for 18 months due to extreme damage caused by the previous individual. The living areas of the home were cleaned, however, the unused basement areas were not focused on because AIMED is seeking bids for a professional restoration and cleaning company due to the home being vacant for over a year. AIMED has been restoring the home back to a livable condition and it has been quite extensive. There was no intention to move anyone in until all repairs were completed.
As a result of 6400.64(b), the home will be cleaned on 8/18/22 by a professional restoration and cleaning company. |
08/18/2022
| Implemented |
| 6400.64(f) | On the back patio of the home, there was a discarded uncovered cardboard box from a 32 inch television overflowing with miscellaneous discarded items including additional cardboard boxes and plastic bags. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | The home has been vacant for 18 months due to extreme damage caused by the previous individual. The previous day a TV was purchased and theTV box was placed outside for trash. The box was stuffed with styrofoam, plastic and cardboard from the contents inside of the box. There may have been one item placed in the box from off the ground in the backyard as the team was leaving but no trash.
As a result of 6400.64(f), the box was removed from the premises by program staff on 8/9/22. |
08/09/2022
| Implemented |
| 6400.67(b) | There were eight screws protruding through several boards that were used to replace a 4-inch by 8-inch panel on the front door of the home. [Repeat Violation, 4/14/2022, 6/13/2022] | Floors, walls, ceilings and other surfaces shall be free of hazards. | The home has been vacant for 18 months due to extreme damage caused by the previous individual. The front door had extensive damage and had some repairs done but the maintenance dept hadn¿t completed all repairs. There were no intentions on moving anyone into the home until all repairs and restoration have been completed.
As a result of 6400.64(f), the repairs to the door were completed on 8/30/22 by the maintenance dept. |
08/30/2022
| Implemented |
| 6400.72(b) | The window above the sink in the kitchen of the home is broken with jagged pieces of glasses protruding from the window frame. The window has been covered with plexiglass on the inside and outside. | Screens, windows and doors shall be in good repair. | The home has been vacant for 18 months due to extreme damage caused by the previous individual. The window was broken with an object with the plexi glass over it. The home had extensive damage and some repairs were done, it has been an ongoing project restoring the home. There were no intentions to move anyone into the home until all repairs and restoration have been completed.
As a result of 6400.72(b), the glass for the window has been ordered by the maintenance dept on 8/12/22 and will be replaced 9/15/22, contingent upon the arrival of the glass. |
09/15/2022
| Implemented |
| 6400.76(a) | The front left burner on the gas stove did not have a cover and the spark electrode continued to click in an attempt to ignite when in the off position when the other burners were ignited and flaming. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The home has been vacant for 18 months due to extreme damage caused by the previous individual. The burner was damaged due to a destroyed burner. The home had extensive damage and some repairs were done but not completely, it has been an ongoing project to restore the home. There were no intentions to move anyone into the home until all repairs and restoration have been completed.
As a result of 6400.76(a), the burner plate was ordered by the maintenance dept on 8/30/22, and will be replaced once it arrives. |
08/30/2022
| Implemented |
| 6400.80(a) | The cement slabs of the walkway of the home are uneven posing a tripping and falling hazard. [Repeat Violation, 12/7/2021] | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The front walkway is not cracked, however, the left side walkway (kitchen exit walkway is).
The home has been vacant for 18 months due to extreme damage caused by the previous individual. The management company has been asked to repair the walkway several times. There were no intentions to move anyone into the home until all repairs and restoration have been completed. AIMED will absorb the cost to repair the crack if necessary.
As a result of 6400.80(a), the repair to the concrete crack was completed on 8/11/22. (Uploaded picture). |
08/11/2022
| 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 the ODP website would have up-to-date forms on the website and My ODP. 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 has been replaced effective immediately with the revised form dated 2/2022 on 7/18/22. The old form has been deleted from our drive. |
07/18/2022
| Implemented |