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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | On 12/3/2025 at 11:06AM, there was a plastic spray bottle with a piece of paper taped to it with the word, "stove" hand-written on it containing a yellow substance in a storage closet in the basement of the home. | Poisonous materials shall be stored in their original, labeled containers. | 1. Understanding the Regulation & Why It Is Important
This regulation requires that all poisonous or potentially hazardous substances be kept in their original manufacturer-labeled containers. The original label provides critical safety information, including the product name, intended use, hazard warnings, and instructions for safe handling.
This regulation is important because individuals with Intellectual and Developmental Disabilities (IDD) may have limited ability to recognize dangerous substances. Improperly labeled containers increase the risk of accidental ingestion, misuse, chemical exposure, or poisoning, which could result in serious injury or death.
2. Review of the Violation -- What Happened
During the annual inspection, a plastic spray bottle was found in a basement storage closet containing a yellow substance. The bottle was not the original container and had a piece of paper taped to it with the word "stove" handwritten on it. The substance was not properly identified by a manufacturer label.
3. Why the Violation Happened
The violation occurred because staff transferred a cleaning product from its original container into an unlabeled spray bottle for convenience and failed to follow agency procedures regarding the proper storage and labeling of hazardous materials. There was also a lack of consistent staff training reinforcement and supervisory oversight related to chemical safety requirements.
4. Immediate Correction -- What Was Done Right Away
The unlabeled spray bottle was immediately removed and disposed of properly.
All remaining cleaning and chemical supplies in the home were reviewed the same day to ensure they were stored in original manufacturer-labeled containers.
The basement storage area was reorganized to ensure all poisonous materials are stored safely and clearly labeled. |
12/04/2025
| Implemented |
| 6400.64(e) | On 12/3/2025 at 11:00AM, there was a trash receptacle over eighteen inches with no lid containing miscellaneous discarded items in the garage of the home. | Trash receptacles over 18 inches high shall have lids. | 1. Understanding the Regulation & Why It Is Important
This regulation requires that any trash receptacle over eighteen (18) inches in height must have a secure lid. Lids help prevent access to potentially hazardous waste, control odors, reduce pests, and maintain a safe and sanitary environment.
This requirement is especially important in homes serving individuals with Intellectual and Developmental Disabilities (IDD), to minimizes the risk of individual illness and rodent and insect infestations and provides dignified living conditions for the Individuals.
2. Review of the Violation -- What Happened
During the annual inspection, a trash receptacle exceeding 18 inches in height was observed in the garage of the home. The trash can did not have a lid and contained miscellaneous discarded items, which was not in compliance with regulation §6400.64(e).
3. Why the Violation Happened
The violation occurred due to staff oversight and a lack of awareness that trash receptacles located in non-living areas such as garages are also required to comply with lid requirements when over 18 inches tall. There was also insufficient routine environmental monitoring to identify and correct the issue prior to the inspection.
4. Immediate Correction -- What Was Done Right Away
The trash receptacle was removed and replaced with a covered trash can that meets regulatory requirements.
All trash receptacles throughout the home, including the garage, were checked the same day to ensure compliance with lid requirements.
Staff on duty were immediately reminded of sanitation and safety requirements related to trash storage. |
12/04/2025
| Implemented |
| 6400.66 | On 12/3/2025 at 10:50AM, there was no light source in the hallway leading to the individuals' bedroom on the first floor of the home. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| 1. Understanding the Regulation 6400.66 & Why It Is Important
This regulation requires that all interior and exterior areas of the home be adequately lit to ensure safety and prevent accidents. Proper lighting is essential to allow individuals and staff to safely move throughout the home, especially during evening and nighttime hours.
Adequate lighting is particularly important for individuals with Intellectual and Developmental Disabilities (IDD), it ensures a rapid evacuation in the event of an emergency and minimizes the risk of falls, or other injuries, due to inadequate illumination.
2. Review of the Violation -- What Happened
During the annual inspection, it was observed that there was no functioning light source in the hallway leading to an individual's bedroom on the first floor of the home. This hallway was not properly illuminated, creating a potential safety hazard and noncompliance with §6400.66.
3. Why the Violation Happened
The violation occurred due to maintenance oversight. The lighting issue was not identified and corrected in a timely manner, and routine environmental safety checks did not detect the absence of a functioning light source prior to the inspection.
4. Immediate Correction -- What Was Done Right Away
A light source was installed immediately to ensure the hallway is properly illuminated.
The other homes were checked the same day to ensure all hallways and common areas had adequate lighting. |
12/18/2025
| Implemented |
| 6400.67(a) | On 12/3/2025 at 10:45AM, the wooden, sliding door on the left side of the closet in Individual #2's bedroom was off the track and required great force to open. At 10:47AM, the wooden, sliding door on the right side of the closet in Individual #1's bedroom was off the track and unable to be opened. At 11:02AM, the wooden, sliding door on the right side of the closet in the basement was off the track and unable to be opened. | Floors, walls, ceilings and other surfaces shall be in good repair. | . Understanding the Regulation 6400.67(a) & Why It Is Important
This regulation requires that all areas of the home, including doors, fixtures, and equipment, be maintained in good working condition to ensure the health and safety of individuals residing in the home.
Closet doors that are off their tracks or difficult or impossible to open present multiple safety concerns, including:
Risk of injury due to excessive force or falling door panels
Restricted access to personal belongings
Potential obstruction during emergencies
For individuals with Intellectual and Developmental Disabilities (IDD), defective doors may create confusion, frustration, or physical risk, especially if the individual has mobility, strength, or coordination limitations.
2. Review of the Violation -- What Happened
During the annual inspection, the following issues were observed:
The wooden sliding closet door on the left side in Individual #2's bedroom was off its track and required significant force to open.
The wooden sliding closet door on the right side in Individual #1's bedroom was off its track and could not be opened.
The wooden sliding closet door on the right side of the basement closet was off its track and could not be opened.
These conditions indicated that the doors were not in good repair, resulting in noncompliance with §6400.67(a).
3. Why the Violation Happened
The violation occurred due to normal wear and tear over time and insufficient preventive maintenance monitoring. The damaged closet doors were not reported or addressed promptly prior to the inspection, resulting in delayed repairs.
4. Immediate Correction -- What Was Done Right Away
Maintenance was contacted immediately following the inspection.
The affected closet doors were repaired and placed back on track or replaced as needed to ensure safe and proper operation.
Staff confirmed that all repaired doors open and close smoothly without force.
A walk-through of the home was conducted to identify any additional maintenance concerns. |
12/19/2025
| Implemented |
| 6400.101 | On 12/3/2025 at 10:40AM, there was a metal storm door with a slide locking mechanism on the basement side with no locking mechanism on the garage side of the door between the basement and the garage of the home This locking mechanism poses an obstructed egress from the garage when engaged. There is no swing door inside the garage. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| 1. Understanding the Regulation 6400.101 & Why It Is Important
This regulation requires that all exits used for emergency evacuation be unobstructed, operable, and accessible from both sides, allowing individuals and staff to exit the home quickly and safely during an emergency.
This is critically important in homes serving individuals with Intellectual and Developmental Disabilities (IDD), as it ensures that individuals can escape from the home in the event of a fire or other life safety emergency.
2. Review of the Violation -- What Happened
During the annual inspection, it was observed that:
A metal storm door between the basement and garage had a slide locking mechanism on the basement side,
There was no locking or release mechanism on the garage side,
When engaged, the locking mechanism prevented egress from the garage,
There was no swing door inside the garage providing an alternate exit.
This condition created an obstructed means of egress from the garage area, resulting in noncompliance with §6400.101.
3. Why the Violation Happened
The violation occurred due to lack of awareness that the existing door hardware created an egress hazard. The locking mechanism was not evaluated from an emergency evacuation standpoint, and routine safety inspections did not identify the risk prior to the licensing inspection.
4. Immediate Correction -- What Was Done Right Away
The locking mechanism was immediately disengaged and removed to eliminate the obstruction.
Staff were instructed that the door must remain unlocked at all times until a permanent correction was completed.
Management assessed the door to ensure unrestricted egress from both sides.
Temporary measures were implemented to ensure safe passage until final repairs/modifications were completed. |
12/04/2025
| Implemented |
| 6400.141(c)(11) | Individual #2's physical examination completed 4/07/2025 did not include health maintenance needs. This section was left blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | 1. Understanding the Regulation 6400.141(c)(11) & Why It Is Important
This regulation requires that each individual's annual physical examination include a documented assessment of:
Health maintenance needs (such as preventive care, screenings, diet, and exercise),
The individual's current medication regimen, and
The need for blood work or other diagnostic testing at recommended intervals.
This information is critical to ensure ongoing monitoring of the individual's overall health, early identification of medical concerns, and coordination of care among providers. ds, and incomplete physical examinations can result in missed preventive care, unmanaged health conditions, or medication-related risks.
2. Review of the Violation -- What Happened
During the inspection, it was identified that Individual #2's physical examination completed on 04/07/2025 did not include documentation of health maintenance needs. This section of the physical exam form was left blank, resulting in incomplete documentation and noncompliance with §6400.141(c)(11).
3. Why the Violation Happened
The violation occurred due to incomplete documentation by the medical provider and insufficient review of the physical examination upon receipt by agency staff. The missing section was not identified and corrected prior to the licensing inspection.
4. Immediate Correction -- What Was Done Right Away
The individual's primary care provider was contacted immediately to obtain completed and updated documentation regarding health maintenance needs.
A corrected physical examination form was requested, when the completed form is received , it will be placed in Individual #2's record.
The individual's medical file was reviewed to ensure that all required components of the physical examination are now present. |
12/31/2025
| Implemented |
| 6400.141(c)(14) | Individual #2's physical examination completed 4/07/2025 did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | 1. Understanding the Regulation 6400.151(c) & Why It Is Important
This regulation requires that each individual's physical examination include critical medical information needed during an emergency, such as diagnoses, chronic conditions, allergies, special precautions, or other information that would guide emergency medical personnel in providing appropriate care.
For individuals with Intellectual and Developmental Disabilities (IDD), emergency responders may rely heavily on written medical information if the individual is unable to communicate effectively. Missing or incomplete emergency medical information can result in delayed treatment, medication errors, or inappropriate medical interventions, posing a serious risk to the individual's health and safety.
2. Review of the Violation -- What Happened
During the inspection, it was identified that Individual #2's physical examination completed on 04/07/2025 did not include medical information pertinent to diagnosis and treatment in the event of an emergency. This required section of the physical examination form was left blank, resulting in noncompliance with §6400.141(c)(14).
3. Why the Violation Happened
The violation occurred due to incomplete documentation by the medical provider and failure of agency staff to verify completeness of the physical examination upon receipt. The omission was not identified and corrected prior to the licensing inspection.
4. Immediate Correction -- What Was Done Right Away
The individual's primary care provider was contacted immediately to request completion of the missing emergency medical information.
A corrected physical examination form was requested, when the completed form is received , it will be placed in Individual #2's record
The individual's emergency medical information was reviewed and updated to ensure it accurately reflects current diagnoses, conditions, and treatment considerations. |
12/31/2025
| Implemented |
| 6400.32(m) | On 12/4/2025 at 10:56AM, Individual #1 reported that their personal mail was opened by staff without permission prior to being given to them. | An individual has the right to unrestricted access to send and receive mail and other forms of communications, unopened and unread by others, including the right to share contact information with whom the individual chooses. | 1. Understanding the Regulation 6400.32(m) & Why It Is Important
This regulation protects an individual's right to privacy and dignity, specifically regarding personal mail and communications. Individuals residing in ODP-licensed homes must be able to send and receive mail without interference, unless there is a court order or specific, documented consent allowing staff involvement.
For individuals with Intellectual and Developmental Disabilities (IDD), this regulation affords individuals the same right to privacy when communicating with others as a person without a disability.
2. Review of the Violation -- What Happened
During the inspection, Individual #1 reported that their personal mail was opened by staff without their permission prior to being provided to them. The mail was not opened in the presence of the individual and no documented consent or authorization was in place, resulting in a violation of §6400.32(m).
3. Why the Violation Happened
The violation occurred due to staff misunderstanding of individual rights regarding mail handling and lack of reinforcement of agency policy. Staff accidentally opened mail for the individual without explicit permission.
4. Immediate Correction -- What Was Done Right Away
Staff was immediately instructed that personal mail must be delivered unopened and unread unless the individual provides documented consent.
Individual #1's rights were reviewed with them, and they were informed of their right to receive mail unopened.
Management addressed the issue directly with the involved staff member. |
12/18/2025
| Implemented |
| 6400.32(n) | On 12/3/2025 at 10:45AM, there were cameras in the common areas of the home. Individual #1 and Individual #2 did not sign consent forms to allow video surveillance in the home. | An individual has the right to unrestricted and private access to telecommunications. | 1. Understanding the Regulation 6400.32(n) & Why It Is Important
This regulation protects an individual's right to privacy, by requiring informed, written consent before video surveillance is used in the home. Individuals must fully understand what areas are monitored, the purpose of the monitoring, how recordings are used, and their right to refuse consent without retaliation.
For individuals with Intellectual and Developmental Disabilities (IDD), this regulation affords individuals the same right to privacy when communicating with others as a person without a disability.
2. Review of the Violation -- What Happened
During the inspection on 12/03/2025 at approximately 10:45 AM, cameras were observed in the common areas of the home. It was determined that Individual #1 and Individual #2 had not signed consent forms authorizing video surveillance in the home. As a result, video monitoring was in use without documented informed consent, in violation of §6422.62(n).
3. Why the Violation Happened
The violation occurred due to administrative oversight. While cameras were installed for general safety and monitoring purposes, the required written informed consent was not obtained and documented prior to implementation. Additionally, supervisory review did not confirm consent documentation before cameras were activated.
4. Immediate Correction -- What Was Done Right Away
Video surveillance was immediately discontinued in all common areas of the home.
Cameras were powered off pending proper consent.
Individuals #1 and #2 were informed of their rights related to video monitoring.
Management initiated the process to obtain informed written consent, ensuring individuals fully understood their rights, including the right to refuse. |
01/07/2026
| Implemented |
| 6400.32(r)(1) | On 12/3/2025 at 10:48AM, there was a turn locking mechanism on the inside with a keyed locking mechanism on the outside of the door leading to Individual #1's bedroom. Individual #1 has not been provided with a key to lock and unlock the door independently. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | 1. Understanding the Regulation 6400.32(r)(1) & Why It Is Important
This regulation ensures an individual's right to privacy and personal space by allowing them to independently lock and unlock their bedroom door. The locking mechanism must be accessible to the individual, not controlled solely by staff.
For individuals with Intellectual and Developmental Disabilities (IDD), having control over their personal living space promotes dignity, independence, and emotional well-being. A locking system that staff can control but the individual cannot is considered a restriction of rights unless properly authorized and documented.
2. Review of the Violation -- What Happened
During the inspection on 12/03/2025 at approximately 10:48 AM, it was observed that the door leading to Individual #1's bedroom had:
A turn-style locking mechanism on the inside, and
A keyed locking mechanism on the outside of the door.
Individual #1 had not been provided with a key, preventing them from independently locking and unlocking their bedroom door. This condition resulted in noncompliance with §6400.32(r)(1).
3. Why the Violation Happened
The violation occurred due to staff and administrative oversight. The locking mechanism was installed without ensuring the individual had independent access to the locking device. There was also insufficient review of individual rights related to bedroom privacy during environmental and safety checks.
4. Immediate Correction -- What Was Done Right Away
Individual #1 was immediately provided with a key to allow independent access to lock and unlock their bedroom door.
Staff were instructed that no bedroom door may be locked by staff unless the individual has equal access or proper authorization is in place.
Management verified that the locking mechanism is operable and accessible to Individual #1. |
12/18/2025
| Implemented |
| 6400.46(b) | Chief Executive Officer/Program Specialist #1, date of hire 12/12/2017, was trained in fire safety on 1/10/2025 via an online training. This training did not include an in-person, site-specific component. Direct Service Worker #2, date of hire 8/7/2025, was trained in fire safety on 7/28/2025 via an online training. This training did not include an in-person, site-specific component. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | 1. Understanding the Regulation 6400.46(b) & Why It Is Important
This regulation requires that all staff receive fire safety training that includes an in-person, site-specific component, not solely online or classroom instruction. Site-specific training ensures staff are familiar with:
The layout of the home
Primary and secondary exits
Fire extinguishers and alarms
Individual evacuation needs
Emergency evacuation routes and procedures
For homes serving individuals with Intellectual and Developmental Disabilities (IDD), this training is critical because staff must be able to respond quickly, confidently, and correctly during emergencies. Online training alone does not sufficiently prepare staff to safely evacuate individuals from a specific home environment.
2. Review of the Violation -- What Happened
During the inspection, it was identified that:
The Chief Executive Officer/Program Specialist #1 (date of hire: 12/12/2017) completed fire safety training on 01/10/2025 via an online training only, with no documented in-person, site-specific component.
Direct Service Worker #2 (date of hire: 08/07/2025) completed fire safety training on 07/28/2025 via an online training only, with no documented in-person, site-specific component.
As a result, both staff members did not receive the required in-person, site-specific fire safety training, resulting in noncompliance with §6400.46(b).
3. Why the Violation Happened
The agency relied on the approved online fire safety training class from MyODP to meet annual requirements.
The Trainer is a qualified fire safety expert. The Certificates were not signed by the Trainer, instead they were signed by a nurse.
4. Immediate Corrective Action (What Was Done Right Away)
(a) We contacted milestones concerning the certificates and they reissued all staff new certificates signed by the trainer for the 2025 Fire Safety class. The certificates will be emailed
(b) The Agency contacted Monroeville Fire Dept. Station #4. And spoke to the Asst. Chief. He stated they can come out in January 2026 for an in-person, site-specific fire safety training conducted by a qualified fire safety expert. We will call in January to have the training set up at each house.
The training will include:
emergency exits and evacuation routes
Fire alarm and extinguisher locations
Designated meeting areas
Individual-specific evacuation needs |
01/15/2026
| Implemented |
| 6400.51(b)(1) | Direct Service Worker #2, date of hire 8/7/2025, completed orientation training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships on 7/26/2025. This training was completed via self-reading. | The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | 1. Understanding the Regulation 6400.51(b)(1) & Why It Is Important
This regulation requires that orientation training for staff include a clear explanation of person-centered practices, community integration, individual choice, and relationship building. This training must be interactive and instructional, not solely completed through self-reading, to ensure staff understand how to apply these principles in daily practice.
For individuals with Intellectual and Developmental Disabilities (IDD), This regulation ensures that all staff understand the laws and best practices relating to supporting individuals with an intellectual disability or autism and has the knowledge and skills necessary to assure the health and welfare of the individuals served. Self-reading alone does not ensure comprehension or proper application of these concepts.
2. Review of the Violation -- What Happened
During the inspection, it was identified that Direct Service Worker #2 (date of hire: 08/07/2025) completed orientation training related to:
Person-centered practices
Community integration
Individual choice
Supporting individuals to develop and maintain relationships
on 07/26/2025. This training was completed via self-reading only, without documented instructor-led explanation or interactive training, resulting in noncompliance with §6400.51(b)(1).
3. Why the Violation Happened
The violation occurred due to misinterpretation of orientation training requirements. Self-reading materials were incorrectly considered sufficient to meet the "explanation" requirement of the regulation. Supervisory oversight did not verify that the training included an instructional component.
4. Immediate Correction -- What Was Done Right Away
Direct Service Worker #2 completed in-person, instructor-led orientation training from MYODP covering:
Person-centered practices
Community integration
Individual choice
Supporting relationships
Completion of the training was documented in the employee's personnel file. |
12/18/2025
| Implemented |
| 6400.51(b)(2) | Direct Service Worker #2, date of hire 8/7/2025, completed orientation training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse on 7/26/2025. This training was completed via self-reading. | The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations. | 1. Understanding the Regulation 6400.52(b)(2) & Why It Is Important
This regulation requires that staff orientation include instructor-led training on the prevention, detection, and reporting of abuse, suspected abuse, and alleged abuse. The training must align with the following laws and regulations:
Older Adults Protective Services Act (35 P.S. §§ 10225.101--10225.5102)
Child Protective Services Law (23 Pa. C.S. §§ 6301--6386)
Adult Protective Services Act (35 P.S. §§ 10210.101--10210.704)
Applicable protective services regulations
This training is essential to ensure staff understand their mandated reporter responsibilities, can recognize signs of abuse, and know how to take immediate and appropriate action to protect individuals. Self-reading alone does not ensure comprehension of legal responsibilities or reporting timelines.
2. Review of the Violation -- What Happened
During the inspection, it was identified that Direct Service Worker #2 completed orientation training on the prevention, detection, and reporting of abuse. However, this training was completed via self-reading only, without documented instructor-led explanation or interactive training, resulting in noncompliance with §6400.51(b)(2).
3. Why the Violation Happened
The violation occurred due to misinterpretation of orientation training requirements. Self-reading materials were incorrectly considered sufficient to meet the regulatory requirement for abuse prevention training. Supervisory oversight did not verify that the training included an instructional component aligned with mandated reporting laws.
4. Immediate Correction -- What Was Done Right Away
Direct Service Worker #2 completed in-person, instructor-led training from myodp covering:
Prevention, detection, and reporting of abuse
Mandated reporter responsibilities
Applicable Pennsylvania protective services laws
Agency abuse reporting procedures
Completion of the training was documented in the employee's personnel file. |
12/18/2025
| Implemented |
| 6400.51(b)(3) | Direct Service Worker #2, date of hire 8/7/2025, completed orientation training on individual rights on 7/26/2025. This training was completed via self-reading. | The orientation must encompass the following areas: Individual rights. | 1. Understanding the Regulation 6400.52(b)(3) & Why It Is Important
This regulation requires that staff orientation include a clear, instructor-led explanation of individual rights, not solely self-directed reading. Staff must understand how individual rights apply in daily practice, including privacy, dignity, choice, communication, and freedom from restraint or retaliation.
For individuals with Intellectual and Developmental Disabilities (IDD), staff understanding of individual rights is essential to ensuring respect,protection from rights violations, and meaningful participation in decision-making. Self-reading alone does not ensure staff comprehension or proper implementation of these rights.
2. Review of the Violation -- What Happened
During the inspection, it was identified that Direct Service Worker #2 (date of hire: 08/07/2025) completed orientation training on individual rights on 07/26/2025. This training was completed via self-reading only, without documented instructor-led explanation, resulting in noncompliance with §6400.51(b)(3).
3. Why the Violation Happened
The violation occurred due to misinterpretation of orientation training requirements. Self-reading materials were incorrectly considered sufficient to meet the regulatory requirement for explanation of individual rights. Supervisory review did not verify that training included an interactive instructional component.
4. Immediate Correction -- What Was Done Right Away
Direct Service Worker #2 completed in-person, instructor-led training on individual rights from myodp.
Training included:
Review of rights under §6400.32
Training completion was documented in the employee's personnel file. |
12/18/2025
| Implemented |
| 6400.51(b)(4) | Direct Service Worker #2, date of hire 8/7/2025, completed orientation training on recognizing and reporting incidents on 7/26/2025. This training was completed via self-reading. | The orientation must encompass the following areas: recognizing and reporting incidents. | 1. Understanding the Regulation 6400.51(b)(4) & Why It Is Important
This regulation requires that staff orientation include instructional training on how to recognize and report incidents. This training must go beyond self-reading to ensure staff understand:
What constitutes an incident
Reporting timelines and procedures
The importance of accurate and timely reporting
The role incident reporting plays in protecting individuals' health, safety, and rights
For individuals with Intellectual and Developmental Disabilities (IDD), prompt and accurate incident reporting is critical to preventing harm, ensuring appropriate follow-up, and maintaining compliance with ODP requirements. Self-reading alone does not ensure staff can correctly identify or respond to incidents.
2. Review of the Violation -- What Happened
During the inspection, it was identified that Direct Service Worker #2 (date of hire: 08/07/2025) completed orientation training on recognizing and reporting incidents on 07/26/2025. This training was completed via self-reading only, without documented instructor-led explanation, resulting in noncompliance with §6400.51(b)(4).
3. Why the Violation Happened
The violation occurred due to misinterpretation of orientation training requirements. Self-reading materials were incorrectly considered sufficient to meet the instructional requirement. Supervisory review did not verify that the training included an interactive component.
4. Immediate Correction -- What Was Done Right Away
Direct Service Worker #2 completed in-person, instructor-led training on myodp.
Recognizing reportable incidents
Incident reporting timelines
Agency reporting procedures
Documentation requirements
Completion of the training was documented in the employee's personnel file. |
12/18/2025
| Implemented |
| 6400.51(b)(5) | Direct Service Worker #2, date of hire 8/7/2025, completed orientation training on 7/28/2025. This orientation training did not include job-related knowledge and skills. | The orientation must encompass the following areas: Job-related knowledge and skills. | 1. Understanding the Regulation 6400.51(b)(5) & Why It Is Important
This regulation requires that staff orientation include instruction on job-related knowledge and skills specific to the staff person's duties. This ensures staff are competent to safely and effectively support individuals in accordance with their job responsibilities and individual support needs.
For individuals with Intellectual and Developmental Disabilities (IDD), staff competency is essential to ensuring health, safety, rights protection, and quality of care. Orientation that does not include job-specific instruction may result in unsafe practices, inconsistent support, or failure to follow individual plans.
2. Review of the Violation -- What Happened
During the inspection, it was identified that Direct Service Worker #2 (date of hire: 08/07/2025) completed orientation training on 07/28/2025. However, the orientation did not include job-related knowledge and skills, such as:
Individual-specific support needs
Daily responsibilities and expectations
Implementation of Individual Support Plans (ISPs)
Health and safety responsibilities
This resulted in noncompliance with §6400.51(b)(5).
3. Why the Violation Happened
The violation occurred due to incomplete orientation structure and documentation. Orientation focused on general required topics but did not sufficiently include or document job-specific training components. Supervisory review did not verify that all required elements of orientation were completed prior to the staff person working independently.
4. Immediate Correction -- What Was Done Right Away
Direct Service Worker #2 completed in-person, instructor-led job-specific training, which included:
Review of assigned job duties
Individual support needs and ISP implementation
Health, safety, and supervision responsibilities
Documentation expectations
Training was conducted by supervisory staff and documented in the personnel file. |
12/18/2025
| Implemented |
| 6400.163(h) | Individual #2's prescribed medication, L-Methylfolate Cal 15MG, was discontinued on 12/1/2025. On 12/3/2025 at 11:25AM, this medication was in Individual #2's medication box. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | 1. Understanding the Regulation 6400.163(h) & Why It Is Important
This regulation requires that any medication discontinued by a prescribing practitioner be promptly removed from the individual's medication storage area. Keeping discontinued medications accessible creates a serious risk of medication errors, including accidental administration of a medication that is no longer prescribed.
For individuals with Intellectual and Developmental Disabilities (IDD), this regulation prevents potential adverse reactions to expired or discontinued medications; reduces the chances of medication theft or misuse.
2. Review of the Violation -- What Happened
During the inspection, it was identified that Individual #2's prescribed medication, L-Methylfolate Calcium 15 mg, was discontinued on 12/01/2025. However, on 12/03/2025 at approximately 11:25 AM, this medication was still present in Individual #2's medication box, resulting in noncompliance with §6400.186(d).
3. Why the Violation Happened
The violation occurred due to failure to immediately remove discontinued medication after the prescriber's order. There was a breakdown in communication and follow-through regarding medication changes, and supervisory review of the medication box did not identify the discontinued medication prior to the inspection.
4. Immediate Correction -- What Was Done Right Away
The discontinued medication was immediately removed from Individual #2's medication box.
The medication was properly disposed of in accordance with agency policy and pharmacy guidance.
Individual #2's Medication Administration Record (MAR) was reviewed to ensure it accurately reflected the discontinuation.
All medication boxes in the home were checked the same day to ensure no other discontinued medications were present. |
12/04/2025
| Implemented |
| 6400.166(a)(2) | Individual #1's November 2025 Medication Administration Record did not include the prescriber for Escitalopram. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | 1. Understanding the Regulation 6400.166(a)(2) & Why It Is Important
This regulation requires that the Medication Administration Record (MAR) contain complete and accurate information, including the name of the prescribing practitioner. Complete MAR documentation ensures:
Medications are administered exactly as prescribed
Staff can quickly verify orders
Accurate communication with medical providers in emergencies
For individuals with IDD, accurate medication documentation is essential to prevent medication errors, ensure continuity of care, and support safe clinical decision-making.
2. Review of the Violation -- What Happened
During the inspection, it was identified that Individual #1's November 2025 MAR did not include the prescribing practitioner for Escitalopram. All other required medication information was present; however, the omission of the prescriber resulted in noncompliance with §6400.186(c).
3. Why the Violation Happened
The violation occurred due to a documentation oversight when the MAR was created or updated. There was no secondary review process in place to verify that all required MAR elements were completed before use.
4. Immediate Correction -- What Was Done Right Away
The prescribing practitioner for Escitalopram was verified using the physician's order and pharmacy label.
The MAR was immediately corrected to include the prescriber's name.
All current MARs for all individuals in the home were reviewed to ensure that prescriber information was present and accurate.
Staff responsible for MAR completion were notified of the documentation requirement. |
01/07/2026
| Implemented |
| 6400.166(a)(5) | Individual #2's November 2025 Medication Administration Record did not include the strength for Stomach Relief 525MG/30ML. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | 1. Understanding the Regulation 6400.166(a)(5) & Why It Is Important
This regulation requires that the Medication Administration Record (MAR) clearly and accurately document all required medication details, including the strength of the medication. Medication strength is critical to ensure that staff administer the correct amount and to prevent under-dosing or overdosing.
For individuals with IDD, clear medication documentation is essential to ensure safe administration, continuity of care, and effective medical treatment, particularly when multiple staff are involved in medication administration.
2. Review of the Violation -- What Happened
During the inspection, it was identified that Individual #2's November 2025 MAR did not include the medication strength for Stomach Relief (525 mg/30 mL). While the medication name and administration instructions were present, the omission of the strength resulted in noncompliance with §6400.186(c).
3. Why the Violation Happened
The violation occurred due to a documentation oversight when the MAR was created or updated. There was no secondary review in place to ensure that all required medication elements---including strength---were completed prior to use.
4. Immediate Correction -- What Was Done Right Away
The medication strength for Stomach Relief (525 mg/30 mL) was verified using the pharmacy label and prescriber's order.
The MAR was immediately corrected to include the medication strength.
All current MARs for all individuals in the home were reviewed to ensure medication strength information was complete and accurate.
Staff responsible for MAR completion were notified of the documentation requirement. |
12/04/2025
| Implemented |
| 6400.166(a)(7) | Individual #1's November 2025 Medication Administration Record did not include the dose of Escitalopram. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | 1. Understanding the Regulation 6400.166(a)(7) & Why It Is Important1. Understanding the Regulation & Why It Is Important
This regulation requires that the Medication Administration Record (MAR) include the exact dose of each prescribed medication. Accurate dose information ensures medications are administered correctly and consistently as ordered by the prescriber.
For individuals with IDD, missing dose information increases the risk of medication errors, including under-dosing, overdosing, or inconsistent treatment, which can negatively affect health, behavior, and overall well-being.
2. Review of the Violation -- What Happened
During the inspection, it was identified that Individual #1's November 2025 MAR did not include the dose of Escitalopram. While the medication name was listed, the omission of the dose resulted in noncompliance with §6400.186(c).
3. Why the Violation Happened
The violation occurred due to a documentation error during MAR preparation or transcription from the prescriber's order. There was insufficient supervisory review to verify that all required MAR elements were completed before the MAR was used.
4. Immediate Correction -- What Was Done Right Away
The prescribed dose of Escitalopram was verified using the physician's order and pharmacy label.
The MAR was immediately corrected to include the accurate dose.
All current MARs for all individuals in the home were reviewed to ensure that dose information was complete and accurate.
Staff responsible for MAR documentation were notified of the required elements. |
12/04/2025
| Implemented |
| 6400.166(a)(8) | Individual #1's November 2025 Medication Administration Record did not include the route for Escitalopram. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | 1. Understanding the Regulation 6400.166(a)(8) & Why It Is Important
This regulation requires the Medication Administration Record (MAR) to clearly document the route of administration (for example, oral, topical, injection). The route ensures medications are given in the manner prescribed and prevents serious medication errors.
For individuals with IDD, staff rely on the MAR to administer medications safely and consistently. Missing route information can lead to incorrect administration, delayed treatment, or potential harm.
2. Review of the Violation -- What Happened
During the inspection, it was identified that Individual #1's November 2025 MAR did not include the route of administration for Escitalopram. While the medication name was listed, the omission of the route resulted in noncompliance with §6400.186(c).
3. Why the Violation Happened
The violation occurred due to a documentation oversight during MAR preparation or transcription. A supervisory review process was not completed to ensure all required MAR elements were present prior to use.
4. Immediate Correction -- What Was Done Right Away
The route of administration for Escitalopram was verified using the prescriber's order and pharmacy label.
The MAR was immediately corrected to include the route (oral).
All current MARs for all individuals in the home were reviewed to ensure route information was complete and accurate.
Staff responsible for MAR documentation were informed of the required documentation standards. |
12/04/2025
| Implemented |
| 6400.166(a)(9) | Individual #1's November 2025 Medication Administration Record did not include the frequency for Escitalopram. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | 1. Understanding the Regulation 6400.166(a)(9) & Why It Is Important
This regulation ensures that the Medication Administration Record (MAR) clearly documents the frequency of medication administration (for example, once daily, twice daily). Frequency is critical so staff administer medications at the correct times and intervals.
For individuals with IDD, missing frequency information increases the risk of missed doses, duplicate doses, or inconsistent administration, which can negatively affect mental health stability, physical health, and overall safety.
2. Review of the Violation -- What Happened
During the inspection, it was identified that Individual #1's November 2025 MAR did not include the frequency for Escitalopram. Although the medication was listed, the omission of frequency resulted in noncompliance with §6400.186(c).
3. Why the Violation Happened
The violation occurred due to a MAR transcription and review oversight. The MAR was not fully verified against the prescriber's order, and a secondary supervisory review did not occur prior to the MAR being placed into use.
4. Immediate Correction -- What Was Done Right Away
The prescribed frequency for Escitalopram was verified using the physician's order and pharmacy label.
The MAR was immediately corrected to include the frequency.
All MARs for all individuals in the home were reviewed to ensure that frequency, dose, route, strength, and prescriber information were complete.
Staff responsible for MAR completion were notified of the missing element. |
12/04/2025
| Implemented |
| 6400.166(a)(11) | Individual #1's November 2025 Medication Administration Record did not include the diagnosis or purpose for Escitalopram. Individual #2's November 2025 Medication Administration Record did not include the diagnosis or purpose for Guanfesine. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | 1. Understanding the Regulation 6400.166(a)(11) & Why It Is Important
This regulation requires the Medication Administration Record (MAR) to clearly document the diagnosis or purpose for each prescribed medication. This information ensures that staff understand why the medication is prescribed, allowing for accurate monitoring of effectiveness, side effects, and changes in the individual's condition.
For individuals with IDD, documenting the purpose of medications supports:
Safe and informed medication administration
Effective communication with healthcare providers
Appropriate response in medical emergencies
2. Review of the Violation -- What Happened
During the inspection, it was identified that:
Individual #1's November 2025 MAR did not include the diagnosis or purpose for Escitalopram, and
Individual #2's November 2025 MAR did not include the diagnosis or purpose for Guanfacine.
All other medication information was present; however, the omission of the diagnosis/purpose resulted in noncompliance with §6400.186(c).
3. Why the Violation Happened
The violation occurred due to incomplete MAR documentation and lack of supervisory verification. When the MARs were created or updated, the diagnosis/purpose field was not completed, and a secondary review process did not identify the omission prior to use.
4. Immediate Correction -- What Was Done Right Away
The diagnosis/purpose for Escitalopram and Guanfacine was verified using prescriber orders and medical documentation.
The MARs were immediately corrected to include the diagnosis/purpose for each medication.
All current MARs for all individuals in the home were reviewed to ensure that diagnosis/purpose information was included for every medication.
Staff responsible for MAR documentation were notified of this requirement. |
12/04/2025
| Implemented |
| 6400.213(1)(i) | Individual #1's record did not include religious affiliation. On 12/03/2025 Individual #1's record did not include identifying marks. Individual #2's record did not include religious affiliation. On 12/03/2025 Individual #2's record did not include identifying marks. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | 1. Understanding the Regulation 6400.213(1)(i) & Why It Is Important
This regulation ensures that each individual's record contains complete personal information, which is essential for:
Proper identification of individuals in the home or in emergencies
Providing person-centered care that respects individual preferences and religious beliefs
Compliance with ODP standards and recordkeeping requirements
Incomplete records may result in misidentification, improper care, or failure to accommodate the individual's preferences and needs.
2. Review of the Violation -- What Happened
During the inspection on 12/03/2025, it was identified that:
Individual #1's record did not include religious affiliation or identifying marks
Individual #2's record did not include religious affiliation
This omission resulted in noncompliance with §6400.213(1).
3. Why the Violation Happened
The violation occurred due to incomplete documentation at intake or annual review. Staff did not verify that all required personal information fields were completed, and supervisory review did not catch the missing information.
4. Immediate Correction -- What Was Done Right Away
Staff updated Individual #1's and Individual #2's records to include:
Religious affiliation (as reported by the individual or guardian)
Identifying marks for Individual #1
Supervisors reviewed the updates and documented completion. |
12/18/2025
| Implemented |
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