Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00197236 Renewal 12/07/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(a)On 12/8/2021 at 10:45AM, there were not screens in the two windows in the bedroom at the end of the hallway to the right. There was not a screen in one window in the bedroom at the end of the hallway to the left.Windows, including windows in doors, shall be securely screened when windows or doors are open. AIMED was unable to secure screens due to shortage of supplies due to COVID. The screens are on order with the maintenance department. As a result of 6400.72(a), The Director of Compliance shall resume compliance checks immediately and ensure the home meets regulations. The Regional Program Director shall review home regulations with Residential Supervisor during training and site lunch and learn. The CEO or designee shall ensure that by 1/14/22, the Regional Program Director conducts a training on site regulations using the quarterly site inspection derived by the ODP self-assessment declaration tool. This mock inspection shall occur quarterly and again during annual inspection. 01/14/2022 Implemented
6400.82(f)On 12/8/2021 at 10:45AM, there was not wall mirror in the bathroom in the home.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. As a result of 6400.82(f), the CEO or designee shall ensure that by 1/14/22, the Regional Program Director conducts a training on site regulations using the quarterly site inspection derived by the ODP self-assessment declaration tool. This mock inspection shall occur quarterly and again during annual inspection. 01/14/2022 Implemented
6400.110(b)On 12/8/2021 at 10:45AM, the smoke detector in the dining room and closest to Individual #1's bedroom was sixteen feet from Individual #1's bedroom.There shall be an operable automatic smoke detector located within 15 feet of each individual and staff bedroom door. As a result of 6400.110(b), the CEO or designee shall ensure that by 1/14/22, the Regional Program Director conducts a training on site regulations using the quarterly site inspection derived by the ODP self-assessment declaration tool. This mock inspection shall resume quarterly and again during annual inspection. 01/14/2022 Implemented
6400.165(g)Individual #1, date of admission 7/15/2021, had an initial review of medications prescribed to treat symptoms of a psychiatric illness on 10/22/2021. [Repeat Violation, 1/5/2021]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.AIMED¿s participants were presented with challenges in getting scheduled psychiatric appointments in a timely fashion and did the very best in managing these appointments with delayed appointment and workforces shortage. As a result of 6400.165(g) the Director of Programs and Services shall direct the Regional Program Director to conduct a refresher training on documenting refusals and/or getting documentation from the doctor¿s office for delayed appointments. The Regional Program Director shall conduct a refresher training with the P.S. and Residential Supervisor. 01/14/2022 Implemented
6400.166(b)Quetiapine 300mg tablet, take 1 tablet by mouth at bedtime and Quetiapine 400mg tablet, take 1 tablet by mouth at bedtime, prescribed to Individual #1 were not initialed as administered at 9:00PM from 12/01/2021 to 12/7/2021.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 6400.166(b) the Director of Programs and Services shall direct the Regional Program Director to conduct a refresher training on proper medication administration documentation. The Regional Program Director shall conduct a refresher training with the P.S. and Residential Supervisor. Upon hire the P.S. are given a thorough training on medication admin, 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. 01/14/2022 Implemented
SIN-00227561 Renewal 07/11/2023 Compliant - Finalized