| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Direct Service Worker #2, date of hire 2/04/2025, had a Pennsylvania criminal history record check submitted to the State Police on 1/27/2025. The disseminated report documented the staff had a criminal history. There is no documentation the agency reviewed the criminal history and the decision about why they chose to hire the staff. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| 1. Understanding the Regulation 6400.21(a) and Why It Is Important
Purpose: This regulation ensures agencies:
Obtain required criminal background checks, and
Make informed hiring decisions that prioritize individual health, safety, and rights.
Importance:
Protects vulnerable individuals from potential harm
Demonstrates due diligence in hiring practices
Provides documentation showing the agency reviewed and assessed risk, not just obtained the report
2. Review of the Violation
What happened:
The criminal history check was completed and disseminated.
The report indicated the staff member had a criminal history.
The employee was hired, but the agency did not document review of the report or justification for the hiring decision.
This resulted in incomplete compliance documentation.
3. Why the Violation Happened
Hiring procedures did not include a required step to document review and decision-making when criminal history exists
Staff responsible for onboarding were not trained on documentation expectations, beyond obtaining the background check
No standardized form existed to capture hiring rationale
4. Immediate Corrective Action (What Was Done Right Away)
The Direct Service Worker #2 submitted a written document at time of hire concerning the criminal history report.
The criminal history report and document submitted by Direct Service Worker #2 was reviewed by management.
A written criminal history review and hiring determination was completed and placed in the employee's personnel file.
The determination documented that the criminal history did not disqualify the employee from direct contact under applicable regulations. |
12/18/2025
| Implemented |
| 6400.113(a) | Individual #1 was admitted on 2/15/2025 as an emergency respite placement and was instructed in general fire safety 3/07/2025. | 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. | 1. Understanding the Regulation 6400.113(a) and Why It Is Important
Purpose: This regulation ensures individuals understand fire safety and emergency evacuation procedures immediately upon admission, regardless of the type of placement.
Importance:
Protects individuals from injury or death during fire emergencies
Ensures individuals know how to respond during drills and real emergencies
Supports life-safety compliance and emergency preparedness
2. Review of the Violation
What happened:
Individual #1 did not receive fire safety instruction at the time of admission on 02/15/2025.
Fire safety instruction was provided on 03/07/2025, which exceeded the required timeframe.
This resulted in noncompliance with 6400.113(a).
3. Why the Violation Happened
Emergency respite admission procedures did not require immediate fire safety instruction documentation
Staff relied on standard orientation timelines rather than same-day instruction
No checklist was in place to verify completion at admission
4. Immediate Corrective Action (What Was Done Right Away)
Individual #1 was instructed in general fire safety, evacuation procedures, responsibilities during fire drills, and designated meeting locations in their primary mode of communication.
Documentation of instruction was completed and placed in the individual's record.
Staff were reminded of immediate instruction requirements upon admission. |
12/18/2025
| Implemented |
| 6400.141(c)(5) | Individual #1 was admitted on 2/15/2025 as an emergency respite placement. Upon admission Individual #1's most recent Tetanus and Diphtheria immunization was administered on 7/29/2013. | The physical examination shall include: Immunizations and screening tests for individuals 17 years of age or younger, as recommended by the Standards of Child Health Care of the American Academy of Pediatrics, Post Office Box 1034, Evanston, Illinois 60204. | 1. Understanding the Regulation 6400.141(c)(5) and Why It Is Important
Purpose: This regulation ensures that minors receive age-appropriate immunizations in accordance with nationally recognized pediatric standards.
Importance:
Protects individuals from preventable diseases
Ensures early identification of medical risks
Promotes overall health and safety for individuals under 18
2. Review of the Violation
What happened:
At the time of admission, Individual #1's immunization record showed the last Td vaccination was administered in 2013.
This did not reflect compliance with current AAP immunization recommendations for individuals under 18.
Individual #1 birthday is 9/21/1978 which makes her 47.
3. Why the Violation Happened
Emergency respite admission occurred without immediate verification of immunization compliance
4. Immediate Corrective Action (What Was Done Right Away)
Individual #1 has an appointment to get the Tenatus and Diphtheria immunizations on 1/6/2026
Documentation of immunization status will be placed in the individual's medical record |
12/18/2025
| Implemented |
| 6400.34(a) | Individual #1 was admitted on 2/15/2025 as an emergency respite placement and was informed of individual rights 3/07/2025. Individual #2 was informed of individual rights 7/1/2024 and then again 7/16/2025. | 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 understand their rights, protections, and how to report violations immediately upon admission and on a yearly basis.
Importance:
Protects individuals from abuse, neglect, or exploitation
Ensures individuals know how to advocate for themselves
Supports transparency, dignity, and informed consent
2. Review of the Violation
What happened:
Individual #1 did not receive a rights explanation at the time of admission, despite being an emergency respite placement.
Individual #2's annual rights review exceeded the required 12-month timeframe.
Both situations resulted in noncompliance with the regulation.
3. Why the Violation Happened
Emergency respite admission procedures did not include a rights explanation checklist
Annual rights reviews were not tracked or monitored for timely completion
Staff were not consistently aware of the annual requirement for rights reviews
4. Immediate Corrective Action (What Was Done Right Away)
Individual #1 and Individual #2 were immediately informed and re-educated on their individual rights and the process to report a rights violation.
Documentation of rights education was completed and placed in each individual's record.
Designated persons were notified as applicable. |
12/18/2025
| Implemented |
| 6400.46(b) | Direct Service Worker #1, date of hire 2/4/2025, was trained in fire safety on 1/22/2025 via an online training. This training did not include an in-person, site-specific component. Program Specialist #2, date of hire 11/11/2025, was trained in fire safety on 11/5/2025 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) 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:
Direct Service Worker #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 |
| 6400.51(b)(1) | Direct Service Worker #1, date of hire 2/04/2025, completed orientation training on 2/03/2025 and 2/04/2025, on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. 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 #1 (date of hire: 02/04/2025) completed orientation training related to:
Person-centered practices
Community integration
Individual choice
Supporting individuals to develop and maintain relationships
On 02/03/2025 and 02/04/2025, 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 #1 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 #1, date of hire 2/04/2025, completed orientation training on 2/03/2025 on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse. 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. |
12/18/2025
| Implemented |
| 6400.51(b)(3) | Direct Service Worker #1, date of hire 2/04/2025, completed orientation training on 2/4/2025 on individual rights. 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 #1 (date of hire: 02/04/2025) completed orientation training on individual rights on 02/04/2025. 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 #1 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 #1, date of hire 2/04/2025, completed orientation training on 2/4/2025 on recognizing and reporting incidents. 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 #1 (date of hire: 02/04/2025) completed orientation training on recognizing and reporting incidents on 02/04/2025. 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 #1 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 #1, date of hire 2/04/2025, had orientation training 2/3/2025 and 2/4/2025, which did not include training in job-related knowledge and skills. Program Specialist #2, date of hire 11/11/2025, had orientation training completed 11/05/2025, which did not include training in 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 #1 (date of hire: 02/04/2025) completed orientation training on 02/03/2025 and 2/4/2025. 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 #1 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 |
| 6400.166(b) | Individual #1's prescribed medication, Vitamin Gummies, was not initialed as administered on 12/3/2025 at 8:00AM. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | 1. Understanding the Regulation 6400.166(b) and Why It Is Important
Purpose: This regulation ensures accurate, real-time documentation of medication administration, including who administered the medication and when.
Importance:
Prevents medication errors such as missed or duplicate doses
Ensures continuity of care across staff shifts
Provides legal and clinical documentation to protect individuals and staff
2. Review of the Violation
What happened:
Vitamin Gummies were prescribed for Individual #1 and reportedly administered at 8:00 AM on 12/03/2025.
The staff member administering the medication did not initial the MAR at the time of administration.
This resulted in incomplete medication documentation.
3. Why the Violation Happened
Staff oversight during medication administration
Failure to document administration immediately after giving the medication
Lack of secondary review to ensure MAR completeness
4. Immediate Corrective Action (What Was Done Right Away)
The MAR was reviewed with the staff involved to verify medication administration.
Staff received immediate retraining on proper medication documentation requirements.
Supervisory staff reviewed all MARs for the shift to ensure no additional omissions occurred. |
12/18/2025
| Implemented |
| 6400.213(1)(i) | On 12/03/2025 Individual #1'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 |