| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | An attestation of residency for Staff person #7 was provided 9/11/2024, dated 9/10/2024 for Pennsylvania residency. Therefore, at time of hire an FBI background check should have been completed for the staff person at the time of hire which was 5/17/2024. An attestation of residency for Staff person #8 was provided 9/11/2024, dated 9/10/2024 for Pennsylvania residency. Therefore, at time of hire an FBI background check should have been completed for the staff person at the time of hire. An attestation of residency for Staff person #9 was provided 9/11/2024, dated 9/10/2024 for Pennsylvania residency. Therefore, at time of hire an FBI background check should have been completed for the staff person at the time of hire which was 1/22/2024. | If a prospective employe who will have direct contact with individuals resides outside this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person's date of hire.
| AOA HR designated person sent staff # 7 the attestation form to be signed and placed into his file. |
09/10/2024
| Implemented |
| 6400.77(b) | The first aid kit is kissing a thermometer, tweezers, and scissors. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | AOA has placed all missing Items such as thermometer, tweezers, and scissors in the first aid kit as required by My ODP regulations. |
09/18/2024
| Implemented |
| 6400.105 | The dryer needs to be cleaned as the lint trap was full upon inspection. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| AOA CEO Cleaned the lint trap from the dryer during inspection and will train staff during house meeting about fire safety training. |
09/10/2024
| Implemented |
| 6400.112(d) | Drills conducted consistently exceeded the 2.5-minute requirement. On 1/22/2024 -- it lasted four minutes and was not reattempted that month. 2/23/2024 - nine minutes; 3/24/2024; three minutes. 4/23/2024 - seven minutes; 5/22 -- four minutes; 6/24 -- 3 minutes; 8/24/2024 -- three minutes. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | AOA retrained staff on the importance of conduction the fire drill in a timely manner as required by My ODP for the health and safety of the individuals. |
09/23/2024
| Implemented |
| 6400.151(a) | Initial physical not found for staff person #6. Staff member's hire date was 6/28/2023 with a start date of 7/11/2023. There is a physical on file for 9/5/2024. A physical was provided for the staff member dated 6/12/2024. It cannot be determined if the staff person had a physical prior to the hire date of 9/30/2022 and start date of 6/19/2023 for staff person #10. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Staff #3 Physical was submitted to the inspector on 9/10/24. |
09/10/2024
| Implemented |