Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00209035 Renewal 07/14/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC 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
SIN-00195168 Unannounced Monitoring 10/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16On 7/23/21 Individual #1 obtained a large forehead hematoma and facial bruising from allegedly tripping and falling into a wall. Individual #1 was not seen by a medical professional until 7/24/21. During the overnight hours between 10/5/2021 and 10/6/2021 individual obtained another injury including a laceration on the forehead and facial bruising which was not discovered or reported until the morning of 10/6/2021 during staff shift change. Individual #1's individual service plan, last updated 6/28/21, states the individual does have alone time in her bedroom with staff checking on her at least every 15 minutes. . The agency failed to provide any documentation that 15-minute checks are being conducted when the individual is in her bedroom.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.The first injury on 7/23/21, occured in the evening. The policy is that every fall must be addressed by a medical professional. The individual was taken to Med Express but the facility was closed for the day and the staff returned home. During the night, the individual picked the injury and the bruising spread across the face, she was immediately taken to the ER to be seen. As a result of violation 6400.16,the Program Specialist and Regional Program Director or CEO designee will retrain staff by 12/17/21, on the ISP and protocol. The staff will be retrained on the agency policy and procedures and the medical emergency policy. The staff will be retrained on following the ISP stipulations for monitoring activity and document in the Wake/Sleep tracking in Therap. The CEO, Director of Training and Compliance or agency designee will be responsible for scheduling the training with all staff and document training in AIMED Bamboo Training Folder. 12/17/2021 Implemented
6400.166(a)(15)Individual #1's October 2021 medication record documented Hydrocortisone Val 0.2% cream, with instructions to apply to affected area twice a day for skin irritation. The agency is administering the cream as a pro re nata medication but the October 2021 medication record did not include the special precautions or instructions that the medication should be used as a pro re nata medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable.As a result of 6400.166 (a)(15) violation, staff will be trained on the medication administration process by 12/17/21, the CEO, or designee, shall train staff on medication PRN includes documenting in accordance with Federal and State statutes and regulations whenever prescription medications are prescribed as a PRN. AIMED has begun the recruitment of an RN or LPN to contract for at least 10 hours per month. The medical professional will review all medical prescriptions, instructions and train staff on the application and protocols of any necessary medical needs. The RN shall report to the CEO and complete monthly reports that detail training, implementation of protocols and any horizonal concerns. 12/17/2021 Implemented
6400.186Individual #1's individual service plan last updated 6/28/21 states that the individual does have time alone in her bedroom with staff checking in on her at least every 15 minutes. The sleep documentation provided from the agency does not document that the individual is being checked on every 15 minutes. Staff witness statement, referring to 10/06/21 incident #8915430, documents the individual was left alone for more than 15 minute intervals.The home shall implement the individual plan, including revisions.As a result of 6400.186 violation, staff will be trained on the ISP and wake/sleep activity by 12/17/21, the CEO, or designee, shall train staff on the proper monitoring and documentation in the record. The CEO, Regional Program Director or agency designee will be responsible for scheduling the training with all staff and document training in AIMED Bamboo Training Folder. 12/17/2021 Implemented
SIN-00212926 Unannounced Monitoring 09/21/2022 Compliant - Finalized
SIN-00197237 Renewal 12/07/2021 Compliant - Finalized