| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Staff interviews revealed that the provider agency's previous Co-owner/Chief previously opened a joint bank with Individual #1's funds. The provider agency did not maintain an up-to-date financial ledger of funds received by or deposited into the account. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | 1. Understanding the Regulation 6400.22(d)(1) and Why It Is Important
Purpose: This regulation protects individuals by ensuring full transparency, accountability, and safeguards when a provider handles or has access to an individual's funds.
Importance:
Prevents financial exploitation or misuse of funds
Ensures individuals' money is tracked, protected, and accessible
Provides clear documentation for audits, oversight, and individual rights
2. Review of the Violation
What happened:
A joint bank account was previously opened involving Individual #1's funds.
The agency did not maintain a current financial ledger documenting deposits, withdrawals, and balances.
This resulted in incomplete financial records and noncompliance with 6400.22(d)(1).
3. Why the Violation Happened
Inadequate financial policies regarding individual funds management
Lack of oversight during prior ownership/administrative structure
No standardized ledger or review process in place
4. Immediate Corrective Action (What Was Done Right Away)
The joint account involving Individual #1's funds was closed.
The individual financial ledger was returned by former co-owner o reflect all known transactions and current balances.
Management conducted a review of the financial ledger related to Individual #1's funds.
Documentation was secured in the individual's record. |
12/18/2025
| Implemented |
| 6400.22(d)(2) | Staff interviews revealed that the provider agency's previous Co-owner/Chief previously opened a joint bank with Individual #1's funds. The provider agency did not maintain an up-to-date financial ledger of disbursements made to or for the individual. | (2) Disbursements made to or for the individual.
| 1. Understanding the Regulation 6400.22(d)(1) and Why It Is Important
Purpose: This regulation ensures full accountability and transparency for how an individual's money is spent.
Importance:
Protects individuals from financial exploitation or misuse
Ensures individuals and designated persons can review how funds are used
Provides clear documentation for audits, investigations, and rights protection
2. Review of the Violation
What happened:
A joint bank account existed involving Individual #1's funds.
The agency did not maintain a current ledger of expenditures or disbursements made on behalf of the individual.
This resulted in incomplete financial documentation and noncompliance with 6400.22(b)(2).
3. Why the Violation Happened
Prior leadership did not implement proper individual fund management procedures
No standardized ledger or tracking system for disbursements
Lack of supervisory oversight of financial documentation
4. Immediate Corrective Action (What Was Done Right Away)
The account was close. The individual financial ledger was returned by former co-owner to reflect all known transactions and current balances.
An individual disbursement ledger for Individual #1 was created and updated using available financial records.
Management reviewed disbursement activity to the extent possible and documented findings.
Financial documentation was organized and secured in the individual's record.
Oversight of individual funds was restructured under current management. |
12/18/2025
| Implemented |
| 6400.22(f) | Staff interviews revealed that the provider agency's previous Co-owner/Chief previously opened a joint bank with Individual #1's funds. This provider agency is not Individual #1's Representative Payee and these funds were not monitored and an up-to-date financial ledger has not been maintained. | There may be no commingling of the individual's personal funds with the home or staff person's funds. | 1. Understanding the Regulation 6400.22(f) and Why It Is Important
Purpose: This regulation ensures that providers do not control or manage individual funds without legal authority and that all funds are safeguarded, monitored, and documented.
Importance:
Protects individuals from unauthorized financial control or exploitation
Ensures funds are managed only by a legally authorized payee
Maintains transparency and accountability for all financial activity
2. Review of the Violation
What happened:
A joint bank account existed involving Individual #1's funds.
The provider agency was not the Representative Payee for the individual.
Funds were not monitored by the agency in accordance with regulatory requirements.
An up-to-date financial ledger was not maintained.
This resulted in noncompliance with 6400.22(f).
3. Why the Violation Happened
Financial practices under prior leadership did not align with regulatory requirements
Lack of clarity regarding Representative Payee authority
Absence of formal policies governing individual funds management
4. Immediate Corrective Action (What Was Done Right Away)
The provider agency ceased any involvement in managing or accessing Individual #1's funds.
The joint account was closed. The individual financial ledger was returned by former co-owner o reflect all known transactions and current balances.
Management confirmed and documented that the agency is not the Representative Payee.
An individual financial ledger was created to document any historical information available.
Safeguards were implemented to ensure no agency access to individual funds without authorization. |
12/18/2025
| Implemented |
| 6400.63(a) | On 12/3/2025 at 3:10PM, the hot water temperature measured 127.9°F at the sink in the kitchen of the home. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | Individuals from coming in contact with the heat source.
1. Understanding the Regulation 6400.63(a) and Why It Is Important
Purpose: Protects individuals from burns or scalds when accessing or using heat sources in the home.
Importance:
Prevents injury from excessive water or surface temperatures
Ensures a safe environment for all residents, including children and individuals with limited mobility or sensory impairments
Supports compliance with ODP environmental health and safety standards
2. Review of the Violation
What happened:
The hot water at the kitchen sink exceeded safe levels (127.9°F).
Staff adjusted hot water settings prior to inspection and was not able to get the setting correct.
This created a risk of scalding or burns for anyone using the sink.
3. Why the Violation Happened
4. Immediate Corrective Action (What Was Done Right Away)
The hot water heater was adjusted to maintain safe temperatures 115°F at all accessible outlets.
The kitchen sink was tested to confirm water temperature is within safe limits. |
12/04/2025
| Implemented |
| 6400.68(b) | On 12/3/2025 at 2:05PM, the hot water temperature measured 122.7°F at the bathtub in the bathroom on the first floor of the home. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | 1. Understanding the Regulation 6400.68(b) and Why It Is Important
Purpose: Ensures water temperature is safe for all residents, including children and individuals with sensory or mobility impairments.
Importance:
Prevents burns and scald injuries
Ensures a safe and accessible environment
Supports compliance with ODP health and safety standards
2. Review of the Violation
What happened:
Water temperature at the bathtub exceeded recommended safe levels (120°F).
Individuals using the bathtub were at risk of scalding or burns.
No prior monitoring or adjustment was documented for the hot water system.
3. Why the Violation Happened
staff adjusted hot water settings prior to inspection and was not able to get the setting correct.
4. Immediate Corrective Action (What Was Done Right Away)
Hot water heater was adjusted to maintain safe temperatures around 115°F
A white line was made on the thermostat to point. Pictures were emailed.
Staff were informed of the correct safe water temperature.
The bathtub water was tested and confirmed to be within safe limits before further use. |
12/04/2025
| Implemented |
| 6400.181(a) | Individual #1 had an assessment completed 6/01/2024 and then again 8/25/2025. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | 1. Understanding the Regulation 6400-181(a) and Why It's Important
Purpose: This regulation ensures that each individual's care needs are formally assessed at admission and updated yearly. It ensures the staff and providers have current information about an individual's adaptive behavior, health, and support needs.
Importance: Without timely assessments:
Care plans may be outdated
Risk of unmet health or safety needs increases
Regulatory compliance is violated
2. Review of the Violation
What happened:
Individual #1 had an initial assessment on 6/01/2024.
The next assessment did not occur until 8/25/2025.
This is more than a year apart, so the annual update requirement was not met.
3. Why the Violation Happened
Staff oversight of the annual assessment schedule
No tracking system in place for assessment due dates
4. Immediate Fix / What We Do Right Now
Conduct an updated assessment immediately.
Ensure all sections of the assessment are fully completed (adaptive behavior, medical, social, and functional needs).
Review the individual's current support plan and make updates based on the assessment findings. |
12/18/2025
| Implemented |
| 6400.181(e)(12) | Individual #1's assessment completed 8/25/2025 did not include recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | 1. Understanding the Regulation 6400.181(e)(12) and Why It's Important
Purpose: This regulation ensures that the assessment not only identifies an individual's needs but also guides staff on specific actions, programs, and services required to support their development and well-being.
Importance: Without these recommendations:
Individualized supports may be incomplete or inconsistent
Staff may not have clear guidance for interventions or skill-building
Quality of care and progress toward personal goals can be compromised
2. Review of the Violation
What happened:
Individual #1's assessment on 8/25/2025 listed needs but did not provide specific recommendations for training, programming, or services.
This is a noncompliance because ODP requires the assessment to directly inform the Individualized Service Plan (ISP).
3. Why the Violation Happened
Staff conducting the assessment may have overlooked the requirement for specific recommendations
Lack of a standardized assessment template or checklist
4. Immediate Fix / What We Do Right Now
Update Individual #1's assessment to include specific, actionable recommendations for:
Training (e.g., social skills, adaptive behavior, daily living skills)
Programming (e.g., day program activities, therapeutic interventions)
Services (e.g., speech therapy, occupational therapy, behavioral support)
Review the individual's ISP and ensure it reflects these updated recommendations. |
12/18/2025
| Implemented |
| 6400.18(b)(2) | The agency completed a self assessment 12/02/2025, which documented Individual #1 had a psychiatric medication review completed 7/16/2025 and then again 11/18/2025. The plan of correction documented "[Individual #1] experienced an omission in her prescribed medication, Lorazepam 0.5 mg for 1-2 days in November of 2025, as psychiatric oversight and authorization were not updated in time." On 12/03/2025 the medication error was not reported in the Department's information 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 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | 1. Understanding the Regulation 6400.18(b)(2) and Why It Is Important
Purpose: This regulation ensures that medication errors are timely reported so ODP can monitor health and safety risks and ensure appropriate follow-up.
Importance:
Protects individuals from reoccurring medication errors
Ensures transparency and accountability
Allows for timely corrective oversight and systemic improvement
2. Review of the Violation
What happened:
A medication omission involving Lorazepam 0.5 mg occurred for 1--2 days.
The omission met the definition of a reportable medication error.
The error was not entered into the Department's information management system within 72 hours, resulting in noncompliance.
3. Why the Violation Happened
Staff did not recognize the medication omission as a reportable incident.
No secondary review process was in place to ensure all reportable incidents were submitted
4. Immediate Corrective Action (What Was Done Right Away)
The medication error was reviewed by management and corrective steps were taken to ensure psychiatric authorization was updated.
Staff were re-educated on what constitutes a reportable medication error and reporting timelines.
Documentation related to the medication error was updated and secured in the individual's record.
5. Prevention Plan (How This Will Not Happen Again)
Provide mandatory training to all staff on reportable incidents and 72-hour reporting requirements under 6400.18(b)(2)
Implement a medication error reporting checklist to ensure all required steps are completed.
Require supervisory review of all medication errors within 24 hours of discovery.
Assign a designated compliance staff member to verify all reportable incidents are entered into the Department's system.
Conduct monthly incident reporting audits to ensure compliance. |
12/18/2025
| Implemented |
| 6400.32(n) | On 12/3/2025 at 2:00M, 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 2:15PM, 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. Staff interviews also revealed that Individual #1 is not physically able to utilize a keyed locking mechanism. | 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 |
| 6400.32(r)(4) | On 12/3/2025 at 2:15PM, 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. Staff did not have labelled keys to access the bedrooms in case of an emergency. | The locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency. | 1. Understanding the Regulation 6400.32(r)(4) and Why It Is Important
Purpose: This regulation ensures that:
Individuals can exit their bedrooms independently at all times, and
Staff can immediately access bedrooms during emergencies without delay.
Importance:
Prevents delays in emergency response (fire, medical, behavioral crisis)
Protects individuals' health, safety, and rights
Ensures compliance with ODP life-safety standards
2. Review of the Violation
What happened:
Individual #1's bedroom door required a key to unlock from the outside.
Staff did not have labeled or readily accessible keys.
This configuration did not allow staff to unlock the door without a key, which is not permitted under 6400.32(r)(4).
3. Why the Violation Happened
The locking mechanism was installed without confirming ODP regulatory compliance
Staff and maintenance personnel were not fully trained on bedroom door safety requirements
No documented review process existed for approving door hardware changes
4. Immediate Corrective Action (What Was Done Right Away)
The keyed locking mechanism was removed and replaced with an ODP-compliant locking device that allows:
Individuals to unlock from the inside, and
Staff to unlock from the outside without a key.
All bedroom doors in the home were inspected to ensure compliance.
Staff were informed immediately of proper emergency access requirements. |
12/18/2025
| Implemented |
| 6400.34(a) | Individual #1 was informed of individual rights 7/03/2024 and then again 7/06/2025. | 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. | 1. Understanding the Regulation 6400.34(a) and Why It Is Important
Purpose: This regulation ensures individuals consistently understand their rights, protections, and reporting procedures.
Importance:
Supports self-advocacy and protection from abuse or neglect
Reinforces dignity, respect, and informed choice
Ensures ongoing compliance with rights education requirements
2. Review of the Violation
What happened:
Individual #1's rights review exceeded the 12-month annual requirement.
The delay resulted in noncompliance with 6400.34(a).
3. Why the Violation Happened
Annual rights reviews were not tracked using a date-specific monitoring system
Staff relied on approximate anniversary dates rather than exact due dates
Lack of supervisory oversight to verify timeliness
4. Immediate Corrective Action (What Was Done Right Away)
Individual #1 was re-informed and educated on individual rights and the process to report rights violations.
Documentation was completed and placed in the individual's record. |
12/18/2025
| Implemented |
| 6400.46(b) | Direct Service Worker #1, date of hire 9/1/2022, was trained in fire safety on 12/8/2024 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) and Why It Is Important
Purpose: This regulation ensures that staff receive hands-on, site-specific fire safety training from a qualified fire safety expert.
Importance:
Staff must understand this specific home's layout, exits, alarms, and fire-safe areas
In-person training improves staff readiness during emergencies
Reduces risk to individuals who may need physical assistance during evacuation
2. Review of the Violation
What happened:
DSW #1 completed an online fire safety training.
The training did not include in-person instruction or a site-specific walkthrough of the home.
As a result, the annual fire safety training requirement under 6400.46(b) was not fully met.
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 |
| 6400.52(c)(5) | Direct Service Worker #1's annual training for calendar year 2024 did not include the safe and appropriate use of behavior supports for the individual he worked directly with. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | 1. Understanding the Regulation 6400.52(c)(5) and Why It Is Important
Purpose: This regulation ensures staff who work directly with individuals are properly trained to use behavior supports safely, ethically, and effectively.
Importance:
Protects individuals from unsafe or inappropriate interventions
Promotes consistency with approved behavior support plans
Reduces risk of injury, rights violations, and regulatory noncompliance
2. Review of the Violation
What happened:
DSW #1 completed annual training for 2024.
Required training on the safe and appropriate use of behavior supports was not included.
This resulted in noncompliance with 52.52(c)(5).
3. Why the Violation Happened
Training tracking system did not flag individual-specific training requirements
Annual training curriculum was not customized to staff assignments
Supervisory review of training content was incomplete
4. Immediate Corrective Action (What Was Done Right Away)
DSW #1 received immediate training on the safe and appropriate use of behavior supports specific to the individual supported.
Training completion was documented in the employee's personnel file. |
12/18/2025
| Implemented |
| 6400.52(c)(6) | Direct Service Worker #1's annual training for calendar year 2024 did not include implementation of the individual plan for the individual he worked directly with. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | 1. Understanding the Regulation 6400.52(c)96) and Why It Is Important
Purpose: This regulation ensures staff understand how to carry out each individual's plan, including goals, supports, health and safety needs, and daily routines.
Importance:
Promotes consistent, person-centered support
Reduces risk of unmet needs or plan deviations
Ensures staff actions align with approved ISP requirements
2. Review of the Violation
What happened:
DSW #1 completed annual training for 2024.
Required training on implementation of the individual's plan was not included.
This resulted in noncompliance with 6400.52(c)(6).
3. Why the Violation Happened
Annual training curriculum was not individualized based on staff assignments
Training tracking system did not identify missing individual-plan-specific topics
Supervisory review of training completeness was insufficient
4. Immediate Corrective Action (What Was Done Right Away)
DSW #1 received immediate training on the implementation of the individual's plan, including goals, supports, and health and safety requirements.
Training was documented in the employee's personnel file. |
12/18/2025
| Implemented |
| 6400.207(5)(II) | On 12/3/2025 at 2:13PM, there was a partial bedrail on the right side of the bed in Individual #1's bedroom. Individual #1's service plan, last updated 5/20/2025, reads, "[Individual #1] is diagnosed with cerebral palsy on [their] left side and requires staff to be in arm's length when walking...Requires assistance to maintain upright seated position. Assistance with sit to stand position with either hands or grab bar." Individual #1 is not prescribed the bedrails for post-surgical or wound care, balance or support to achieve functional body position and is unable to easily remove the bedrails and there is not a plan or procedures for the bedrails to be removed by staff persons immediately upon the request or indication by Individual #1, there is not a plan that includes periodic relief of the bedrails to allow freedom of movement. Individual #1's assessment, completed 8/25/2025 and Individual #1's Individual Plan, last updated 5/20/2025 were not updated regarding the use of bedrails on Individual #1's bed. | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Balance or support to achieve functional body position, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | 1. Understanding the Regulation 6400.207(5)(ll) and Why It Is Important
Purpose: This regulation ensures devices that restrict movement are not used as restraints unless medically necessary and safe.
Importance:
Protects individuals from unnecessary physical restriction
Ensures safety
Prevents use of undocumented or unauthorized mechanical restraints
2. Review of the Violation
What happened:
A partial bedrail was in place that restricted Individual #1's movement.
There was no documentation in the Individual Plan or assessment regarding its use.
There were no procedures for staff to remove it immediately or provide periodic relief.
This constitutes noncompliance with mechanical restraint regulations.
3. Why the Violation Happened
Bedrail was placed without updating the assessment or Individual Plan.
Staff were told to remove bedrails, instead of removing bedrails from both sides of bed, only one side was removed, leaving bedrail on one side of bed.
No policy or checklist existed to monitor mechanical restraint use in alignment with ODP requirements.
4. Immediate Corrective Action (What Was Done Right Away)
The bedrail was removed immediately from Individual #1's bed.
Picture was emailed.
The Individual Plan and assessment were updated to reflect the change and clarify that no mechanical restraint is used.
Staff were trained on mechanical restraint definitions, safe use, and documentation requirements.
Supervisory staff verified that Individual #1's freedom of movement is unrestricted. |
12/04/2025
| Implemented |