Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC 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 |