| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | The agency failed to provide needed supervision for Individual #1 between 11/30/2023 and 2/23/2024. Per Individual #1's most current Individual Support Plan, last updated 2/9/2024, Individual #1 should be supported at a one-to-one staff to individual ratio. This is indicated in the Supervision Care Needs section of the plan that states "[Individual #1] receives 1:1 supervision in the home" and the Behavioral Support Plan section which states, "the plan includes that [Individual #1] has a staffing ratio of 1:1 24-hour staff supervision". Individual #1's current assessment, last updated 7/15/2023, also indicates in the Restrictive Procedure Plan section that, "[Individual #1] continues to receive one-to-one therapeutic supports to monitor his progress." According to staff schedules as well as interviews with Individual #1, Individual #2, Direct Support Staff #2, and Regional Program Manager #3 conducted on 2/23/2024, Individual #1 and Individual #2 have been supported at a one-to-two staff to individual ratio since Individual #2's admission into the home on 11/30/2023. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Due to an emergency with another participant, AIMED needed to make a quick decision to protect the health and safety of two individual¿s living in the same home. Individual #2 was supported 1:2 in the previous home. The threats of harm to the housemate #1 by individual #2, created a very hostile environment. AIMED made a decision to move individual #2 to another home with an individual that is 1:1. The move was to only be a few days because the plan was always to move him to his home in York. However, the central region backtracked on the plan to expedite the license process and PROMISe enrollment. This put AIMED behind for weeks and out of ratio. However, both SC¿s were aware of the emergent need to move individual #2 to the single person home to protect the health and safety of the individual in the home where individual #2 was living. Individual #1 no longer has individual #2 living in his home, he has been transitioned to the central region in York, as planned. The health and safety of both individuals were maintained under the 1:2 supervision, although a violation of rights occured under ODP regulations.
As a result of 6400.16, AIMED¿s Regional Program Director (RPD) scheduled a critical revision meeting with the team and SC for individual #2 on March 1, 2024. However, she failed to show or call to notify the team she would not be available. She reported that she had an emergency and apologized. The CEO emailed the SC on March 5th and rescheduled the critical meeting for March 7th, to change Daniel B ratio from 1:1 to 24-hour staffing . The team meeting occured and the critical revision of 24-hour staffing was agreed upon by the entire team. |
02/22/2024
| Implemented |
| 6400.43(b)(3) | Chief Executive Officer #1 failed to ensure the safety and protection of the individuals residing within the agency. Chief Executive Officer #1 failed to ensure Individual #1 was provided with necessary supervision as outlined in the individual plan, violated Individual #1's rights by failing to allow individual #1 to participate in the implementation of the individual plan, failed to inform the proper entities of the changes to Individual #1's living arrangements upon the admission of a roommate, failed to inform the proper entities of Individual #2's current address, and failed to report incidents in a timely manner. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | The CEO was informed both Individual #1 and #1 SC and family were aware of the emergency move. The team had agreed the move was necessary and OK to move forward. Both individual #1 and #2 met prior to the move to be introduced to one another and the introduction went well. However, the fact remains that individual #1 was a 1:1 ratio and the ISP was not carried out as written. The failure to review the ISP prior to the move has created the need to refresher training on the topic of ISP supervision and individual rights. The incident point person, Sr. Clinical & Admission Officer, completed the training: ISP-Supervisor, Individual Needs and Grievances which was completed on 2/29/24.
As a result of 6400.43(b)(3), the CEO has created a new transition process effective 2/22/23. The process involved a step-by-step procedure and checklist for transitioning individuals internally and externally. The CEO reviewed this process with the team on 2/22/24, and implemented it immediately. The plan will further avoid mishap and/or steps in the transition process. |
02/22/2024
| Implemented |
| 6400.66 | On 2/23/2024 at 12:32pm, the rear basement egress was observed without sufficient lighting. A light fixture was observed near this egress; however, the fixture was inoperable. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The lighting in the rear of the home does have lighting. However, the home is older and the light switch is located further away from the exit. This caused the inspector to walk across the room to the light switch, which indicated safety hazard in the event of an emergency.
As a result of 6400.66, a maintenance request was submitted on 2/26/24, to install a motion light in the rear basement egress. The new motion light detector has been installed as of 2/27/2024. |
02/27/2024
| Implemented |
| 6400.214(b) | On 2/23/2024 at 12:00pm, Individual #1's most current assessment was not available in the residential home. The most current assessment for individual #1 that was available in the home was completed on 7/15/2022. On 2/23/2024 at 12:05pm, the most current assessment for Individual #2 was not available in the residential home. There was no assessment for individual #2 on site at the residential home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| AIMED is in the process of converting to an electronic records system. AIMED failed to have the most current assessment uploaded into Therap for review by the ODP inspector, creating a violation of the regulation, which states the most current documents must be on site.
As a result of 6400.21(b), the most current assessment for both individual #1 and #2, was immediately uploaded to ODP the same day. |
02/23/2024
| Implemented |
| 6400.18(a)(5) | Incident #9370012, Neglect (failure to provide needed supervision) for Individual #1, was entered into the Department's information management system on 2/23/2024 at 4:19:59pm for an incident that was initiated on 11/30/2023. | 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.
| AIMED wasn¿t aware that this would be an incident until the county made us aware and the incident was entered into EIM. immediately. According to incident regulation of ¿neglect¿ the incident must be entered within 24-hours, thus, causing AIMED to miss the deadline due not knowing it was considered an incident of neglect.
As a result of 6400.18(a)(5), the incident #9370012, was immediately entered upon notice from the county. |
02/29/2024
| Implemented |
| 6400.18(a)(13) | Incident #9365832, a violation of individual rights for Individual #1, was entered with a discovery date of 2/16/2024; however, the incident first section was not submitted into the Department's information management system until 2/23/2024 at 6:36:28pm. | 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:
A violation of individual rights. | AIMED wasn¿t aware that this would be an incident until the county made us aware and the incident was entered into EIM. immediately. According to incident regulation of ¿neglect¿ the incident must be entered within 24-hours, thus, causing AIMED to miss the deadline due not knowing it was considered an incident for a violation of rights.
As a result of 6400.18(a)(13), the incident #9365832, was immediately entered upon notice from the county. |
02/29/2024
| Implemented |
| 6400.166(a)(13) | On 2/23/2024 at 12:15pm, it was discovered that Direct Support Staff #4 did not sign and initial backs of Individual #1 and Individual #2's February 2024 Medication Administration records. Direct Support Staff #4 administered all medications to both individual #1 and Individual #2 on 2/3/2024, 2/4/2024, 2/10/2024, and 2/11/2024. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | AIMED staff and supervisor failed to catch that the staff #4 failed to sign and initial the back of the MAR. This is a clear violation of AIMED policy and violation of ODP medication MAR protocol.
As a result of 6400.166(a)(13). The MAR was immediately corrected by staff #4, by signing and initialing the back of the MAR. |
03/25/2024
| Implemented |
| 6400.182(c) | Individual #2's most current individual support plan, last updated 2/8/2024, indicates that individual #2 resides at a different agency home then the one they are currently living in. According to staff schedules as well as interviews with Individual #1, Individual #2, Direct Support Staff #2, and Regional Program Manager #3, Individual #2 moved into the current home on 11/30/2023. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The initial assessment was completed, however, individual #2, was moved due to an emergency and the plan was to stay for a few days. However, due to ODP (central region) retracting on an expedite requests, individual #2 stayed well beyond the plan. However, the Program Administrator should have changed the home address on the assessment.
As a result of 6400.182(c), the assessments for individual #2, the home address reflected his previous address. This oversight occurred within our agency¿s documentation process concerning the ISP.
The inconsistency was noted after the ISP was last updated on Feb. 8, 2024, although the actual move occurred on November 30, 2023. The correction to the assessment was made immediately upon notice and uploaded to ODP the same day. |
02/22/2024
| Implemented |
| 6400.186 | According to Individual #1's most current ISP, last updated 2/9/2024, Individual #1 should be supported at a one-to-one staff to individual ratio. This is indicated in the Supervision Care Needs section of the plan that states "[Individual #1] receives 1:1 supervision in the home" and the Behavioral Support Plan section which states, "the plan includes that [Individual #1] has a staffing ratio of 1:1 24-hour staff supervision". Individual #1's current plan also indicates in the Service Details section that his plan has been approved for a single-individual household. According to staff schedules as well as interviews with Individual #1, Individual #2, Direct Support Staff #1, and Regional Program Manager #2, Individual #1 has been supported at a one-to-two staff to individual ratio since Individual #2's admission into the home on 11/30/2023. | The home shall implement the individual plan, including revisions. | The incident involves individual #1, whose ISP specifies a 1:1 staffing ratio, and has been affected by the introduction of Individual #2 into the household. The non-implementation of the directed 1:1 staffing ratio for individual #1 as outlined in their most current ISP.
The oversight occurred in the operational procedures of our home, impacting the delivery of stated support to Individual #1. This discrepancy has been ongoing since November 30, 2023, the date Individual #2¿s into the home.
As a result of 6400.186. The team met with SC on March 7, 2024 to make a critical revision to individual #1 ISP. The critical revision changed from 1:1, to 24-hour supervision. The change reflects ODP bulletin Announcement 24-010 regarding ISP staff ratio. |
02/24/2024
| Implemented |