| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | Emmaus Home, Inc. Incident Management Policy states that a reportable incident is an event with potential to adversely impact an individual's health, safety, or rights. It refers to an unusual event, situation, or allegation involving Individuals served or not, that is reportable to the assigned agency Point Person(s) or Incident Manager(s). Additionally, the steps that staff members must take to report incidents are as follows: 1. Reporters are required to immediately call the assigned Point Person after witnessing or becoming aware of an incident or suspected incident. 2. Reporters are required to complete an agency Incident Report Form. Upon the Point Person being notified of the incident, several steps must take place which include notifying the Incident Managers and applicable IM Committee members of the incident, contacting the Individual, their designated person/team and assigning a certified investigator if applicable.
On 5/25/2026 Staff #1 observed Individual #1 utilizing their tablet and having a conversation with someone on the other end who was telling them to self-harm and engage in inappropriate sexual acts. Staff #1 also noted that Individual #1 was sharing their location and staff's personal information with strangers. Staff #1 notified their supervisor, Staff #2 immediately of the concern. Staff #2 contacted Individual #1 via telephone and discussed the dangers associated with engaging in this behavior online. Staff #2 failed to report this concerning allegation to the Incident Managers and applicable IM committee members at the time. The incident was not reported to the Incident Management Team until 5/28/2026.
Staff #1 also delayed in completing an Agency Incident Form upon contacting the Point Person, per agency policy. The Agency Incident Form was not completed until 5/28/2026. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | On 7/27/2026, Staff #1 and Staff #2 received retraining by the Compliance Manager, on the organization's Incident Management Policy to reinforce their understanding of the policy requirements and their responsibilities for recognizing, reporting, and responding to incidents. (Attachment 1 & 2) |
08/31/2026
| Implemented |
| 6400.64(a) | At the time of the physical site inspection on 6/3/2026, two dirty plates with food on them were found in the bottom pull out drawer of Individual #1's bedroom nightstand. One plate had an eaten piece of chicken with the left-over bone on it and the other had what appeared to be icing from a piece of cake. | Clean and sanitary conditions shall be maintained in the home. | On 7/27/2026, the Compliance Manager, , updated and implemented the location's Staff Cleaning List to include a daily task requiring evening staff to inspect the individual's bedroom for any food, dishes, or trash and remove any items found. This task was incorporated into the daily cleaning routine to promote ongoing monitoring and help ensure continued compliance with the applicable regulation. Additionally, on 7/27/2026, the Compliance Manager provided the location's staff with a Staff Cleaning List Completion Guide to ensure staff understand the requirements and the expectations for proper completion. (Attachment 3 & 4) |
07/27/2026
| Implemented |
| 6400.67(b) | At the time of the physical site inspection on 6/3/2026, there was a baseball sized ball of lint pulled from the lint trap of the dryer. The dryer did not have any items in it. | Floors, walls, ceilings and other surfaces shall be free of hazards. | On 7/27/2026, the Compliance Manager, , updated and implemented the location's Staff Cleaning List to include a daily task requiring day and evening staff to inspect and clean the dryer lint trap. Incorporating this task into the daily cleaning checklist will promote ongoing monitoring, reduce potential fire hazards, and help ensure continued compliance with the applicable regulation. Additionally, on 7/27/2026, the Compliance Manager provided the location's staff with a Staff Cleaning List Completion Guide to ensure staff understand the requirements and the expectations for proper completion. (Attachment 3 & 4) |
07/27/2026
| Implemented |
| 6400.114(b) | At the time of the physical site inspection on 6/3/2026 it was observed that there were cigarette butts and ashes disposed of in the kitchen trash can. Emmaus Home, Inc.'s Smoking Policy states that Emmaus Home will provide safe and appropriate containers for individuals to extinguish their cigarettes at each location. A kitchen trash can is not a safe and appropriate cigarette receptacle. | Written smoking safety procedures shall be followed. | A new cigarette receptacle was installed by the Compliance Manager,y, on 7/28/2026 to promote the safe disposal of smoking materials. Additionally, location staff reviewed the agency's Smoking Policy and Safe Disposal of Smoking Materials on 7/27/2026 and 7/28/2026. (Attachments 5 & 6) |
08/01/2026
| Implemented |
| 6400.181(e)(4) | Individual #1's current assessment dated 2/24/2026 references 6 different times of them having a doorway passthrough type of chime installed in the kitchen to notify staff of anyone who passes through the kitchen. The purpose of the chime was to ensure that when entering the kitchen, they (Individual #1) would not take things that do not belong to them. There is currently no chime in the kitchen, as it was reported that the chime was used when roommates lived in the home. Individual #1's roommate moved out of the home on 10/27/2025 and the assessment has not been updated according to their current need for supervision. | The assessment must include the following information: The individual's need for supervision.
| On 7/23/2026, the Program Specialist, , updated Individual #1's Assessment to accurately reflect their living arrangement, effective 10/27/2025, as well as their current supervision needs. The updated Assessment was completed and filed in the individual's record. (Attachment 7) |
08/03/2026
| Implemented |
| 6400.181(e)(13)(iv) | Individual progress over last 365 days and current level in -- personal adjustment -- Individual #1's current assessment dated 2/24/2026 references many times that Individual #1 currently has housemates and the dynamic between them and their housemate. Individual #1's housemate moved out of the home on 10/27/2025 and they now live alone. There is no documentation or mention of how Individual #1 has adjusted since living alone from October 2026 until February 2026 when the assessment was updated. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | On 7/23/2026, the Program Specialist, , updated Individual #1's Assessment to accurately reflect their living arrangement, effective 10/27/2025, and their adjustment to the move since transitioning to the new residence. The updated Assessment was completed and filed in the individual's record. (Attachment 7) |
08/03/2026
| Implemented |
| 6400.216(a) | At the time of the physical site inspection on 6/3/2026, there were purged files from Individual #1's record that were in a folder sitting on the top left shelf of an unlocked closet in the unlocked office. | An individual's records shall be kept locked when unattended.
| On 7/27/2026, the Compliance Manager, updated and implemented the location's Staff Cleaning List to include a daily task requiring day and evening staff to ensure all individual documentation, including inactive records, are secured in the locked filing cabinet when not in use. Incorporating this task into the daily cleaning checklist will promote ongoing monitoring, safeguard confidential information, and help ensure continued compliance with the applicable regulation. Additionally, on 7/27/2026, the Compliance Manager provided the location's staff with a Staff Cleaning List Completion Guide to ensure staff understand the requirements and the expectations for proper completion. (Attachment 3 & 4) |
07/27/2026
| Implemented |
| 6400.18(h)(4) | EIM Incident #9855862 involving an allegation of neglect of Individual #1 was assigned to the Certified Investigator (CI) on 5/29/2026. The initial interview was conducted in person with Individual #1 on 5/30/2026. As of 6/16/2026, the individual's signature had not been obtained on the interview documentation despite the interview being conducted in person.
Additionally, written witness statements were not obtained immediately following several remote interviews. For example, Staff #5 was interviewed by telephone on 6/1/2026 at 10:43 a.m.; however, the emailed witness statement was not received until 6/11/2026. Staff #1 was interviewed by telephone on 6/3/2026 at 1:47 p.m., but the emailed witness statement was not received until 6/13/2026. Staff #2 was interviewed in person on 5/30/2026 at 2:30 p.m.; however, a written witness statement was not obtained during the interview, and an emailed statement was not received until 6/11/2026. Staff #8 was interviewed in person on 5/30/2026 at 7:03 p.m.; however, the witness's signature was never obtained on the interview documentation.
According to the current ODP Certified Investigator's Manual, when a remote interview is conducted, the CI should remain with the witness while the witness prepares and sends the emailed statement and confirm receipt before concluding the interview. If this is not feasible, the CI should instruct the witness to complete and send the emailed statement immediately following the interview. The CI is also required to document the reason the interview could not be conducted in person.
The investigation was not conducted in accordance with the processes and quality standards outlined in the current ODP Certified Investigator's Manual. | A Department-certified incident investigator shall conduct the investigation of the following incidents: Neglect. | Individual #1's witness statement was signed on 5/30/2026. Additionally, on 7/27/2026, 7/28/2026, and 7/29/2026, the organization's Incident Managers reviewed the identified deficiencies, acknowledged the need for enhanced oversight of the Certified Investigator process, and committed to implementing ongoing monitoring to ensure compliance with all applicable investigative requirements and help prevent future occurrences. (Attachment 8 & 9) |
08/03/2026
| Implemented |
| 6400.182(c) | Individual #1's current Individual Service Plan (ISP) contains inconsistent information regarding required room checks. In the Supervision Care Needs section, the ISP states that hourly room checks are to be conducted to ensure the individual's personal hygiene, the cleanliness of the home, and overall safety. However, the Psychosocial Information section indicates that room checks are to be completed three times daily to verify completion of hygiene tasks and maintenance of a sanitary living environment.
The discrepancy between these two sections creates confusion regarding the frequency of required staff checks. Additionally, a review of completed checklists from 5/25/2026 through 6/2/2026 showed that staff documented room checks only one to two times per day, and on one day no room checks were not documented at all. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | On 7/27/2026, the Compliance Manager, , requested that the individual's Supports Coordinator update the Supervision Care Needs and Psychosocial Information sections of the Individual Service Plan (ISP) to ensure the room check requirements are consistent throughout the document and accurately reflect the individual's current supervision needs, thereby promoting ongoing compliance with the applicable regulation. (Attachment 10) |
08/31/2026
| Implemented |
| 6400.186 | Individual #1's current assessment dated 2/24/2026 states that they have a hygiene checklist that that they go through with their staff during every shift. Upon the physical site walkthrough on 6/3/2026, the daily bedroom hygiene checklist and daily bathroom hygiene checklists were reviewed for dates 5/25/2026 -- 6/2/2026. Both checklists were not completed by each shift during those dates. On 6/1/2026, neither checklist was completed at all. | The home shall implement the individual plan, including revisions. | On 7/27/2026, 7/28/2026, and 7/29/2026 the location's staff received retraining on the individual's Daily Bedroom Hygiene Checklist and Daily Bathroom Hygiene Checklist. The Compliance Manager, , developed and provided a Hygiene Checklist Completion Guide to reinforce the documentation requirements, ensure a clear understanding of the required checks and tasks, and serve as an ongoing reference for staff. (Attachment 11) |
07/28/2026
| Implemented |