Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.68(b) | At 11:52AM on 7/15/2022, the hot water temperature measured 122.3°F at the kitchen sink. At 12:02PM on 7/15/2022, the hot water temperature measured 122.3°F at the bathtub in the first floor bathroom. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The water temperature was tested and documented at the home by the supervisor. The temperature on 7/14/22 was 116 degrees. As a result of 6400.68(b) The hot water tank was turned down immediately on 7/15/22 and checked later for compliant temperature. |
07/15/2022
| Implemented |
6400.15(b) | The agency completed a self-assessment of the home on 06/28/22; 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 |
6400.18(a)(4) | On 4/4/22, it was documented on Individual #1's psychiatric diagnostic evaluation appointment report that "staff member at Aimed stating 'if you have these thoughts about babies you will go to hell'...supervisor to review". The agency failed to report the allegation of verbal abuse in the Department's information management system, Enterprise Incident Management System. | 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:
Abuse, including abuse to a individual by another client.
| Upon notification from ODP regarding the report by the individual, AIMED conducted an certified investigation. The results were unfounded. The individual has a history of making false accusations and perseverates going to heaven or hell as evidenced in her ISP and psychiatric documentation.
As a result of 6400.207(4)(I), AIMED conducted a certified investigation on 7/19/2022 and the administrative team met on 7/20/2022 and concluded the incident was unfounded. |
07/19/2022
| Implemented |
6400.207(4)(I) | Individual #1 is prescribed Chlorpromazine pro re nata with the following instructions: take 1 tablet by mouth twice a day as needed for agitation or psychosis. The specific reasons or symptoms specific to Individual #1 for administration of this medication is included. This medication was administered to Individual #1 on 7/1/2022. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | When the physician prescribed the Chlorpromazine medication the prescription order states, ¿give for agitation, as needed¿. Due to the individual's behaviors related to her disability, determining agitation behaviors due to anxiety are difficult to differentiate from her baseline disability behaviors.
As a result of 6400.144 Program Specialists requested written detailed instructions on 8/9/22 from the doctor on when and how to administer PRN diphenhydramine for agitation. The instructions include discontinuing both PRN Chlorpromazine and PRN Olanzapine medication. (Uploaded the document). |
08/09/2022
| Implemented |