Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00244268 Renewal 04/25/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)77(b). First aid kit. The first aid kit did not contain an antiseptic. 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. Violation 77 (b) was completed and documented accordingly. See POC attachment # 1 04/25/2024 Implemented
6400.81(k)(6)81(k)(6). Individual bedrooms. The bedroom of Individual, number 1, did not have a mirror.In bedrooms, each individual shall have the following: A mirror. Violation 81 (k) (6) was completed for individual number 1 bedroom and documented accordingly. See POC attachment # 2 04/25/2024 Implemented
6400.144144. Health services. The medication Triamcinolone 0.1% cream was not administered to individual 2, on 04/25/24 at 8:00 AM.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Violation 144 was delivered to site by pharmacy and documented accordingly. As part of program efforts to ensure delivery effectiveness, there was a team meeting between Grane RX and Agape Family Home to discuss service best practices and provider expectation. It was established during said meeting that RX Pharmacy services will be nothing short of par excellence moving forward. See POC attachment # 3. 04/26/2024 Implemented
6400.32(h)32(h). Rights of the individual. There are 3 security cameras in the common areas of the home.An individual has the right to privacy of person and possessions.Violation 32 (h) regarding cameras violation was corrected and documented accordingly. Going forward, Agency provisions for individual rights will be followed as well as ensure appropriate cameras consents are put into place before any camera installations at the individuals home. Please note that all sites reflect this changes. See POC attachment # 1&2. 09/05/2024 Implemented
6400.163(g)163(g). Storage and disposal of medications. The outer container for medication Albuterol Sulfate HFA 108 MCG/act for individual, number 2, had part of a medication label with RX #41568996 for individual, number 1, stuck to it.Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions.Violation 163 (g) was corrected. As part of program efforts to ensure delivery effectiveness, there was a team meeting between Grane RX pharmacy and Agape Family Home to discuss service best practices and provider expectation. It was established during said meeting that Grane Pharmacy will now have all labels sealed with protective plastic as well as reassure provider that their services will be nothing short of par excellence moving forward. See POC attachment #5 reflecting new labeling practice. 04/25/2024 Implemented
6400.166(a)(2)166(a)(2). Medication record. The MAR for individual, individual number 2, did not have the name of the medication prescriber on it.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.Violation 166 (a) (2) was corrected and MAR redelivered to site by pharmacy and documented accordingly. As part of program efforts to ensure delivery effectiveness, there was a team meeting between the pharmacy and Agape Family Home to discuss service best practices and provider expectation. It was established during said meeting that Grane Pharmacy MAR will include physician/subscriber names moving forward. See POC attachment # 6. 04/29/2024 Implemented
SIN-00224009 Renewal 04/28/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff One hire date of 10/17/22 and criminal history check completed late on 10/27/22.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. Violation 21 (a) was identified on Staff One file following the inspector review the day of audit. See Attachment #1. 04/28/2023 Implemented
6400.112(a)There were fire drills missing for the month of February 2022 and March 2023. An unannounced fire drill shall be held at least once a month. Violation 112 (a) was completed and documented accordingly including a tracking sheet for all future fire drills. See attachments #4,5,6 & 7. 04/29/2023 Implemented
6400.169(a)(1)Staff Two Last medication practicum was completed on 5/6/21.To be considered capable of self-administration of medications an individual shall: Be able to recognize and distinguish the individual's medication. Violation 169 (a) (1) was completed and documented accordingly. See attachments #8,9,10 & 11. 04/29/2023 Implemented
6400.34(a)The rights signed by Individual One on 1/30/23 did not cover all the current individual rights. Discussion of privacy in bedroom and technology were not discussed on the signature page.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.Agape Family Home LLC updated the Individual Rights statement to reflect the current up to date rights. All The new updates form has now been adopted for all individuals. The new rights have been explained to the individuals who have signed them accordingly. The new Rights include right to bedroom privacy and technology usage. Please see attachment 29 08/09/2023 Implemented
6400.165(g)Documentation for the reason for prescribing psychotropic medication individual one was not provided every 90 days prior to the medication reviews of 12/2/22 and 3/7/23 for the 2022 calendar year. Medications were refilled and prescribed but documentation was not provided.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Violation 165 (g) status is still pending upon physician response. 04/29/2023 Implemented
6400.181(f)Documentation that Individual One's Assessment dated 4/12/22 and 3/15/2022 was sent out to the team 30 days prior to the ISP meeting was not timely. The letter provided was dated 3/16/23 which was not at least 30 days from 4/11/2023's individual team meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Violation 181 (f) was completed and sent out to the team accordingly. See attachment #12. 04/29/2023 Implemented
SIN-00159073 Renewal 07/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff person # 4's date of hire is 3/8/19, and their criminal history check was completed on 5/31/19. Staff person #6's date of hire is 9/24/18, and their criminal history check was completed on12/17/18. Staff person # 7's date of hire is 9/24/18, and their criminal history check was completed on 12/17/18.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. Staff persons #4 has a current criminal background check. Moving forward, Administrator will ensure that all prospective employees of Agape Family Home including part-time and temporary staff persons who will have direct contact with individuals receive a criminal history record check submitted to the State Police within 5 working days after the person's date of hire. (Attachment 5) 07/11/2019 Implemented
6400.46(f)Staff #2 training record, it could not be determined during inspection, and no documentation found of fire safety training being conductedProgram specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. Staff #2 has received fire safety training on 07/15/2019. Moving forward, Administrator will ensure all staff shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. (POC Attachment 4) 07/15/2019 Implemented
6400.67(a)The Countertop in the kitchen was not in good repair and appeared to be bubbled up throughoutFloors, walls, ceilings and other surfaces shall be in good repair. Work order has been submitted to remodel the kitchen in the home. Remodeling is set to start on 10/25/2019. Upon completion, Floors, walls, ceilings and other surfaces will be in good repair. Moving forward, Property manager and house manager will conduct quarterly inventory checks on all Floors, walls, ceilings and other surfaces to ensure that they are in good repair. If any surfaces require repair or replacement, the house manager will complete a work order and submit to the administrator. Repairs will be made within 7 calendar days. (Work Order, POC Attachment 12) 11/08/2019 Implemented
6400.72(b)The Screens in Individual #1 room and throughout home were not in good repair Screens, windows and doors shall be in good repair. Screens and windows in the home have been replaced and are in good repair. Moving forward, Property manager and house manager will conduct quarterly inventory checks on all Screens, windows and doors to ensure that they are in good repair. If Screens, windows and doors need repaired or replaced, the house manager will complete a work order and submit to the administrator. Repairs will be made within 7 calendar days. 07/19/2019 Implemented
6400.110(e)The interconnected fire alarm system was not working at the time of physical site inspection. The house contained 3 levels, basement, main level and attic.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. Interconnected fire alarm at the site has been serviced and in in good working order. Monthly, after every fire drill, house manager and property manager will test the system to ensure that all smoke detectors on each floor interconnected and audible throughout the home. In the event that the interconnected system is not in good working order, the property manager will complete a work order and have the system maintenance within 24hours. 07/12/2019 Implemented
6400.141(c)(4)The physical exam dated 3/15/19 for individual #2 did not include a hearing screening.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. : Individual #2 Physical has been updated to include Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Moving forward, Agape Family Home's nurse will review all individual physicals to ensure that physical examinations include Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. (POC Attachment 11) 07/15/2019 Implemented
6400.46(a)Program Specialist, records does not include documentation of Orientation before working with Individuals.Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.Program Specialist received orientation 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered prior to working with individuals. Training materials were in program specialist file upon review. However, sign In sheets on the above training topics was not in the file. Sign in sheets have been placed in the program specialist file. Moving forward, administrator will ensure that all staff receive orientation and training materials/sign in sheets placed in personnel files and available for review. (POC Attachment 10) 07/12/2019 Implemented
SIN-00130311 Renewal 04/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Staff #1's record did not include a current physical examination. 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 #1 was removed from the schedule and did not work with our Individuals until Agape Family Home received a completed physical exam which was done on 3/24/2018. Agape Family Home will ensure going forward that all employees complete a physical exam prior to hire. The HR officer will ensure compliance with this. 03/26/2018 Implemented
6400.151(c)(2)Staff #1's record did not include a current Tuberculin test. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Staff #1 was removed from the schedule and did not work with our Individuals until Agape Family Home received a completed Tuberculin skin test which was done on 3/12/2018 The test was negative. Agape Family Home will ensure going forward that all employees complete a TB screening prior to hire. The HR officer will ensure compliance with this. 03/26/2018 Implemented
6400.163(c)There was no documentation to show that Individual #1's psychiatric medication were reviewed 8/22/17 and 1/28/18. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.On 8/24/17 the consumer had her psychiatric medication reviewed by the doctor, and also on 1/9/18 she had another medication review. Documentations of the reviews were misplaced by a previous program specialist Agape's new program specialist will document on all medication review going forward and the CEO will provide monitoring to ensure compliance. 05/09/2018 Implemented
SIN-00110383 Renewal 03/23/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(c)The staff file for staff #1 who is the CEO does not contain at least 24 hours of current training. The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually.As of 07/01/2017 staff #1 is no longer with the agency. The new CEO will contract with a trainer and training agency to instruct all training classes for agency on 05/15/2017. The CEO will schedule every other month of training courses for new hires and existing employees in order to obtain 24 hours of training annually. The CEO will monitor employee training hours monthly. (K.W.) 04/20/2017 Implemented
6400.46(d)The staff file for staff #2 who is a program specialist does not contain at least 24 hours of current training. Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. Director will be responsible to monitor training hours at least one time quarter to make sure hours being completed. (K.W.)Staff #2 completed CPR and First Aid 12/20/2016, Abuse and Neglect 03/28/2017, Fire Safety 03/28/2017, HIPPA 03/28/2017 and Roles & Responsibility 04/01/2017. Staff #2 has completed Incident Management on 08/16/2017. The CEO has contracted with an agency to instruct all classes for agency on 05/15/2017. The CEO will schedule every other month training courses for new hires and existing employees in order to obtain 24 hours of training annually. CEO will monitor training monthly. 04/20/2017 Implemented
6400.46(f)The staff file for staff #1 does not contain current fire safety training. Also the staff file for staff #2 does not contain current fire safety training.Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. As of 07/01/2017 staff #1 is no longer with the agency. Staff #2 completed fire safety training on 03/28/2017. The CEO has contracted with a training agency on 04/01/2017 and independent contractor to instruct all classes for agency on 05/15/2017. The CEO will schedule every other month training courses for new hires and existing employees in order to obtain 24 hours of training annually. The CEO will monitor training hours monthly. 03/28/2017 Implemented
6400.68(a)The home did not have running water under pressure at the time of inspection.A home shall have hot and cold running water under pressure. The CEO contracted with maintenance to make sure the home has running hot and cold water under pressure on 04/05/2017. The home currently has hot and cold water under pressure. The CEO and maintenance will be responsible to check water pressure during monthly inspections for house repairs. The program manager will complete monthly inspection forms. 04/05/2017 Implemented
6400.73(a)The stairway outside leading from the basement has more than 2 steps and there is no handrail. Also the stairway inside the home leading to the attic has more than 2 steps and does not have a handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The CEO installed a handrail in the basement and attic on 04/05/2017. The CEO and maintenance worker will be responsible to check handrails during monthly inspections for house repairs. The program manager will complete monthly inspection forms. 04/05/2017 Implemented
6400.74The interior stairs leading to the attic do not have nonskid surfaces. Interior stairs and outside steps shall have a nonskid surface. The CEO installed a nonskid surface on the interior stairs and outside steps on 04/05/2017. The program manager and maintenance worker will be responsible to complete monthly inspections for house repairs. The program manager will complete monthly inspection forms. 04/05/2017 Implemented
6400.110(e)The smoke detectors are not interconnected and the home has 3 stories including the basement and attic. If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. The CEO is responsible for making sure the smoke detectors are interconnected and audible throughout the home. As of 06/29/2017 the automatic fire alarm system is audible throughout the home. The program manager monitors the detectors once per month during fire drills and documents on fire drill forms to ensure they are working properly. 04/05/2017 Implemented
6400.111(a)The fire extinguisher in the basement is not charged and is inoperable. Also the fire extinguisher in the attic is not charged and is inoperable. There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. The CEO charged the fire extinguisher in the basement on 04/07/2017. Program Specialist completing a monthly check on all fire extinguishers to make sure they are charged and operable. The program specialist will date and initial when the fire extinguishers were checked at all programs. 04/07/2017 Implemented
SIN-00087533 Initial review 12/22/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There is a crack in the upper right hand corner of the window in bedroom #1.Floors, walls, ceilings and other surfaces shall be in good repair. Crack in the upper right hand corner of the window in bedroom #1 is already fixed on 12/24/2015. Picture was emailed to Danielle Duckett and Desmond Pessima on 2/10/16 (modified by Desmond Pessima) On a monthly bases the Program Specialist will check floors, walls, ceilings, and other surfaces, to make sure they are in good condition or repair (Modified by Desmond Pessima). 12/24/2015 Implemented
6400.110(a)The attic did not have an operable smoke detector.A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. We have already installed an operable smoke detector on 12/24/2015. A picture of the smoke detector in the attic was emailed to the licensing Representative on 2/10/16 (DP 2/12/16). On a monthly bases the program specialist(DP 2/12/16) will check the smoke detector to make sure they are working, and will be documented on a monthly report, sign, date and initial. Staff were trained on Home Safety Inspection and Smoke Detector Checks on 2/8/16. See attached training sign in sheet (DP 2/12/16). 12/24/2015 Implemented
SIN-00186416 Renewal 04/08/2021 Compliant - Finalized