| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(3) | During the annual inspection the policy on onboarding /hiring staff and the polices they are to follow was requested. The agency was only able to provide a check list not a policy that the agency has for the hiring process. Staff person #6's criminal background check that was given to the inspectors during the annual licensing was altered. The date received had been changed from 4/19/23 to 4/17/23. Staff #6's date of hire was 4/17/23. Once it was pointed out to the AIMED Director, the HR Director was contacted for verification. The HR director is the person responsible for running the criminal background checks. The agency could not identify who altered the Pennsylvania Criminal background check. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | Why it happened:
The original criminal background check was completed on 4/19/23 and given to the license inspector upon request. The duplicate copy that was provided to the license inspector came from the HR Director. An internal investigation was completed, and the identified person was addressed. Disciplinary action was taken along with a corrective action plan.
Plan of Correction:
The CEO met with the HR Director immediately after discovering the document had been altered, which was during the license inspection. The altered document was removed from the employee file. The official criminal background check is in the employee HR records. Beginning immediately, the HR Director is required to run background checks (state, federal, child abuse and sexual molestation) prior to new hire orientation, which is prior to working with an individual. |
12/08/2023
| Implemented |
| 6400.103 | -REPEAT from Inspection held 10/17/22- The emergency evacuation plan for Individual #1's home does not include: Individual responsibilities. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The Emergency evacuation was updated during last year's inspection and was approved and accepted. AIMED followed the instructions at that time. It is important to have a written emergency evacuation plan to ensure the safe evacuation and to transport to the hospital of choice. The CEO updated the emergency evacuation plan with Uploaded to ODP on 10/26/23. |
11/30/2023
| Implemented |
| 6400.112(e) | A sleep drill was conducted in September 2022 and not again until April 2023. No additional sleep drill was conducted in September 2023. | A fire drill shall be held during sleeping hours at least every 6 months. | The RS staff mistakenly did the overnight fire drill too soon. It is important to conduct overnight fire drills to ensure the safe evacuation during sleep hours. The regulation was immediately reviewed with the RS and its importance. The PS will be responsible for oversight of the fire drill process to ensure timeliness and accuracy. |
11/30/2023
| Implemented |
| 6400.112(h) | The fire Drills for the year except for fire drills conducted on 11/23/22 & 1/2/23 do not indicate if Individual #1 went to the meeting place during the fire drills. The fire drill forms only indicate where the meeting place is located. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Why:
AIMED individual petty cash form contains all the information in the regulation. However, the specific requested information was not separately listed on the form.
This regulation is important because it confirms fire drills occurred and allows providers to correct issues with the evacuation.
POC: (plan, training by whom date and supportive documentation. The CEO updated the fire drill form on 10/18/2023 to include the meeting place and what kind of assistance was needed to evacuate: verbal prompt, physical assist, visual prompt, or none.
The staff conducting the fire drill will guide the participants to the meeting location and complete the form indicating the participant(s) reached the desired location. |
12/08/2023
| Implemented |
| 6400.113(a) | Individual #1 had fire safety training completed on 4/25/22 and not again until 5/24/23, outside of the annual timeframe. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Why: This regulation is important because it ensures people what to do during emergencies.
POC: (plan, training by whom date and supportive documentation. The due date for the training will be added to a shared calendar immediately to ensure this violation doesn't reoccur. |
12/08/2023
| Implemented |
| 6400.144 | -REPEAT-(Inspection 10/17/22) It appears that there have been some issues with the documentation and administration of medications for Individual #1, who is diagnosed with Chronic Constipation. The Bowel Chart for October 2023 was pre-populated with dates, and Metamucil, as prescribed by the physician in March 2023, was not documented on the Medication Administration Records (MARs). Additionally, it seems there is a concern regarding the administration of PRN Senokot-S in September 2023, as there are no staff initials indicating its administration, after the individual went three days with no bowel movement. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The plan of correction was that the bowel chart was eliminated, and the tracking was added into Therap. The plan also indicated that the program specialist will submit a weekly inspection report to the residential director. The bowel chart has been eliminated and replaced with Elimination tracking in Therap on 10/28/23. |
12/08/2023
| Implemented |
| 6400.181(e)(4) | The Annual assessment 2/1/23 for Individual #1 is missing the supervision section in the home or in the community. Individual #1 requires 1:1 supervision. | The assessment must include the following information: The individual's need for supervision.
| The assessment form is in a format that may cause the information to drop down below the box, thus hiding the next category. The supervision category dropped down and was missed. It is important to have the "supervision" needed for the Individual to protect their health and safety. By November 17, 2023, the RD will amend Individual #1's annual assessment to include his supervision needs and redistribute the assessment to Individual #1 and the team. The PS will use the Assessment/ISP crosswalk to ensure that information is consistent in both documents. |
11/30/2023
| Implemented |
| 6400.212(b) | The Behavioral Support Plan for Individual #1 written by Staff #7 was signed and dated for December 29, 2023. This is dated for in the future. | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| The BSP was completed on time but misdated. It is important to current dates and legible information in order to make updates and/or changes to the plan. The Director of Clinical Services & Admissions corrected the date on the Behavior Support Plan, and the updated plan was provided during the inspection. |
11/30/2023
| Implemented |
| 6400.34(a) | 31 & 33 Are missing from Individual #1's record. Individual #1 signed all of the 6400.32 Rights on 5/23/23. The agency was unable to locate the 2022 Individual Rights for Individual #1 during the annual inspection. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The misplaced form was located and uploaded to ODP on 10/26/2023.
It is important to ensure people are aware of their rights.
The PS located the missing Rights form on 10/24/23. |
11/30/2023
| Implemented |
| 6400.163(h) | Individual #1's medication disposal records indicate that Melatonin and Risperidone were disposed of by flushing or placing them in the garbage, which is not a safe method of medication disposal as per Federal and State regulations. Staff #2 reported on 10/18/23 that they did not dispose of medication in this manner. However, there is no specific documentation indicating the correct method of disposal. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Why: The medication disposal form was outdated. The staff disposed of the medication properly but did not record it properly because the form was outdated.
It is important to dispose of medication properly to protect the environment and community.
POC: (plan, training by whom date and supportive documentation. The CEO updated the medication disposal form on 10/18/2023 and uploaded the form to ODP on 10/26/23, and the RD ensured the form was distributed to the homes. (see attached) |
12/08/2023
| Implemented |
| 6400.165(c) | Melatonin 5mg tablet was discontinued on 3/28/23. Staff #4 administered the medication at 8pm on 3/28 & 3/29. | A prescription medication shall be administered as prescribed. | The medication was not administered because it was not in the home; the RS staff brought it to the office for disposal. It is important to pass medication as prescribed to protect the health and safety of the individual The staff participated in a training about discontinuing medication and signing the MAR on November 3, 2023. The training was conducted by the AIMED Medication Administration Trainer, Adrienne Harrington. The RD has scheduled a staff med admin remediation class with the Medication Administration Trainer. The remediation class will be completed by December 8, 2023. |
11/30/2023
| Implemented |
| 6400.165(g) | The Quarterly Psych Med Review completed on 10/11/23 for Individual #1 does not include the reasons why the medications were prescribed. | 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. | The doctor completed the form, and the RS did not review it for accuracy before leaving the appointment. This regulation is important because it ensures accurate treatment information. The PS will contact the doctor to ensure a corrected form is signed by November 13, 2023. |
11/30/2023
| Implemented |
| 6400.166(a)(3) | -Individual #1's annual physical & PCP encounter forms lists an allergy to the medication Haldol. The MARs from Oct 2022- October 2023 do not list Haldol as an allergy. The ISP & emergency data form do not list Haldol as an allergy. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies. | Why: The RS and PS did not ensure the pharmacy included this information on the MAR. The Supports Coordinator did not include this information in the ISP, and the PS and RS did not notice the omission.
This regulation is important because it protects the person from being exposed to allergens.
POC: (plan, training by whom date and supportive documentation. On 10/19/23, the PS contacted the Supports Coordinator to request the ISP be updated. As of 11/9/23, an updated ISP is not available in HCSIS. The RD contacted the SC and the SC's supervisor on 11/9/23.
The pharmacy was contacted, and new MARs arrived on 10/20/23. |
12/08/2023
| Implemented |
| 6400.167(a)(1) | -March 15 & 17th at 8pm staff did not initial the MAR's as administrating Individual #1's Risperidone 2mg tablets. The date/time was left blank on the MAR's. MAR's- April 26, 2023, 8pm Benztropine Mesylate 0.5mg was not initialed by staff as being administered. This date/time was blank on the MAR's. | Medication errors include the following: Failure to administer a medication. | This regulation is important because it ensures med errors are handled efficiently and appropriately. The RS and PS failed to observe the error. The staff participated in a training about discontinuing medication and signing the MAR on November 3, 2023. The training was conducted by the AIMED Medication Administration Trainer, Adrienne Harrington. The RD has scheduled a staff med admin remediation class with the Medication Administration Trainer. The remediation class will be completed by December 8, 2023. |
11/30/2023
| Implemented |
| 6400.181(f) | The annual ISP was held 2/28/23 and the assessment was not completed until 2/9/23. This was not completed and sent 30 days prior to ISP meeting for Individual #1. In addition, there is not clarification that all team members received a copy. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | -During a time of staff shortage, the Director of Clinical Services & Admissions completed the assessment but sent it only to the mother/legal guardian and did not preserve evidence of sending the assessment It is important to complete an assessment and provide the team with a copy to ensure continuity of information. The PS will provide the assessment within the 30-day timeframe. The RD will review prior to the 30 days. The RD will provide a refresher training to the PS on November 17, 2023. |
11/30/2023
| Implemented |