| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(b) | Attestation of residency was not provided for Staff person #4. Therefore, at the time of hire an FBI background check should have been completed for the staff person at the time of hire as their start date was 6/6/2024. An attestation of residency was provided for Staff person #5 on 9/11/2024, dated 9/10/2024; although they were hired on 3/18/2024. | 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 |
| 6400.67(b) | An active leak was discovered in the home which resulted in water in the basement in the area in front of the washer and dryer. | Floors, walls, ceilings and other surfaces shall be free of hazards. | On 9/11/24 the leak in the home was repaired and all water was cleaned up in the area in front of the washer and dryer. |
10/02/2024
| Implemented |
| 6400.77(a) | The home was missing a first aid kit. | A home shall have a first aid kit. | AOA first aid kit was place in the kitchen cabinet during the inspection. The first aid kit is currently in the staff office. |
09/16/2024
| Implemented |
| 6400.141(a) | A physical completed twelve months prior to the admission date of 10/10/2023 could not be located for Individual #2. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #2 was taken to the doctor for his physical on 09/20/24. |
09/26/2024
| Implemented |
| 6400.151(a) | No physical is on file for this staff person #3. Their start date was 6/24/2023. | 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 |
| 6400.181(a) | The initial individual assessment was completed on 1/10/2024 which exceeds the 60-day threshold. Individual #2 moved into the home on 10/10/2023. | 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. | AOA CEO retrained the program specialist on the importance of completing the individual's assessment in a timely manner as required by ODP. |
09/18/2024
| Implemented |
| 6400.32(r) | The criteria related to locking mechanism is missing from Individual Rights form signed by Individual #2 on 10/10/2023 upon admission. | An individual has the right to lock the individual's bedroom door. | AOA individual Rights form was updated to reflect the criteria for locking mechanism. Individual #2 was retrained on the updated form on 09/23/24. |
11/01/2024
| Implemented |