Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00209034 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 6/28/2022, 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 The incorrect self assessment was retrieved and used the ODP website, however, the form was outdated.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 om 7/1822, and saved to the shared drive for future use and the summary will be included on the current form. 07/18/2022 Implemented
6400.101There was key lock on the basement side of the door leading in to the garage; that would obstruct egress from the garage when engaged. There is not a man door in the garage. [Repeat Violation, 4/14/2022]Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The POC to replace the basement doors has been an ongoing process with the agency, our maintenance department has been working though getting the locks changed and a few were still in the process of being switched out. The lock was changed on the spot the day of inspection. As a result of 6400.101, all the locks with obstructed egress have been replaced to meet regulations effective 8/5/22. 08/05/2022 Implemented
6400.110(e)On 7/15/2022 at 1:05PM, the smoke detector on the first floor was not interconnected with the smoke detectors in the basement and on the second floor of the home. [Repeat Violation, 6/13/2022]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. Tested on 8/7/22 and all batteries replaced. Interconnected and working properly. The smoke detector was tested and operable during the blitz on 7/14/22 by the Operations Manager. The smoke detector was working again the following day. As a result of 6400.110(e), the Operations Manager entered a maintenance order to have the maintenance dept check the smoke detectors inter connectivity. The maintenance dept checked the smoke detectors on 8/7/22, and replaced the batteries in all the units as a precaution, the smoke detectors are interconnected and working. The supervisor verified the smoke detectors were operating during the normal smoke detector daily check. 08/07/2022 Implemented
6400.112(c)The written fire drill record for the fire drill held on 5/11/2022 does not address whether the fire alarm was operable. This section was left blank. [Repeat Violation, 12/7/2021]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 fire drill record was completed by the supervisor of the home on 7/15/22. (Uploaded form). 07/15/2022 Implemented
6400.15(b)The agency completed a self-assessment of the home on 6/28/22; 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
SIN-00202083 Unannounced Monitoring 03/09/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.18(a)(5)An alleged of neglect that occurred on 10/21/2021 involving Individual #1 was reported to the agency by Individual #1's family member on 10/22/2021. This incident was not entered into the Enterprise Incident Management System, the Department's information management system until 2/23/2022 at 3:10PM.The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person: Neglect. The CEO or designee shall ensure that the point person enters incidents are entered into EIM within 24 hours. The incident shall be reviewed by the Regional Program Director (RPD) and the Director of Program and Services. The incident shall be brought before the executive team during the daily briefing. At this time the incident shall be entered into the tracking system and assigned a CI, the investigation shall be initiated pursuant to ODP guidelines. 04/08/2022 Implemented
SIN-00197235 Renewal 12/07/2021 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)At 12:00PM on 12/8/2021, a spray bottle of Spic N Span cleaner was unlocked and accessible in the cabinet under the bathroom sink. Individual #1's current assessment, completed 4/7/2021 states, "[Individual #1] can use materials, but would need to be supervised, and then locked up after use to ensure health and safety is maintained." Individual #2's current assessment, completed 8/30/2021 states, "[Individual #2] does not come in contact with poisonous materials around the house. Staff handles dangerous chemicals."Poisonous materials shall be kept locked or made inaccessible to individuals. As a result of 6400.62(a), the Director of Programs and Services shall direct the Regional Program director to conduct refresher training regarding proper handling and storage of poisonous materials. During new hire, staff are trained on the storage protocol for poisonous materials. The CEO or designees shall conduct poisonous materials refresher training and review the ISP during the monthly site lunch and learn to ensure staff are aware of which cleaning products the participant is permitted to use. The Director of Program and Services shall ensure that the Regional Program Director conducts the training with the team by 1/14/22, to ensure the ISP is reflective of which materials are permissible for use. 01/14/2022 Implemented
6400.141(c)(3)Individual #1's most recent Tetanus immunization was completed on 2/5/2010. [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 Implemented
6400.141(c)(14)Individual #2's most recent physical examination, dated 11/30/2021, did not include medical information pertinent to diagnosis and treatment in case of an emergency. [Repeat Violation, 1/5/2021]The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Upon new hire training, the PS and Supervisor are trained on the proper protocol for completing physical examination documentation. As a result of 6400.141(c)(114), the Director of Programs and Services shall meet with the Regional Program Director to ensure a refresher training is conducted with Program Specialist by 1/14/22, and Residential Supervisor shall receive intensive training regarding proper completion of the annual physical form based on ODP regulations and AIMED Policy and Procedure. 01/14/2022 Not Implemented
6400.214(b)Individual #1's most current copy of the physical examination and individual assessment were not present at the home at the time of inspection. Individual #2's most current copy of the 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
6400.181(f)The program specialist provided Individual #1's assessment, completed 4/27/2021, to the individual plan team members on 5/4/2021 for an individual plan meeting on 5/4/2021. The program specialist provided Individual #2's assessment, completed 8/30/2021 to the individual plan team members on 11/5/2021 for a individual plan meeting on 10/19/2021. [Repeat Violation, 1/5/2021]The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.As a result of 6400.(181)(f), the Director of Programs and Services shall meet with the Regional Program and plan for a refresher training by 1/14/22. Upon hire the P.S. are given a thorough training on documentation, assessments, quarterly and monthly documentation by the Regional Program Director. During their new hire orientation, the Director of Training and Compliance reviews program regulations and agency protocol and expectations. The Director Director of Programs and Services shall ensure the Regional Program Director gives refresher training to the Program Specialists regarding assessment and documentation regulation. The team shall continue to use a calendar tracking method and invite the Regional Program Director and Director of Programs and Services for accountability purposes. The Director of Programs and Services shall enforce a quality chart check on a monthly basis immediately after the 1/14/22 refresher training. 01/14/2022 Implemented
SIN-00212925 Unannounced Monitoring 09/21/2022 Compliant - Finalized