Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00281912 Renewal 01/28/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.32(r)The individuals in the home did have locks on their doors, however the key to both individual's bedroom door locks were located in the handle of the door. This prevents the purpose of having lock available for the privacy and protection of the individual belongings as anyone has access to open the bedroom door as the key is left in the door.An individual has the right to lock the individual's bedroom door.The Program Manager immediately removed both individuals' keys from their bedroom door locks. Keychains were purchased, and the keys were returned directly to each individual. The individuals' rights, specifically their right to privacy and to lock their own bedroom door were reviewed with them, and this review was documented. A home wide audit of all bedroom doors was completed. No keys were found in any locks, and any issues identified during the inspection were corrected at the time. Staff Training: All Agape House staff were retrained on Individual Rights, including proper key control procedures and the requirement that no bedroom keys remain in door locks. Staff training sign-in sheets were completed and filed in the staff training file as verification of completion. 01/29/2026 Implemented
SIN-00235584 Renewal 01/17/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.211(b)(1)Individual #1 emergency information did not include the name, address, telephone number and relationship of the person to be contacted in the event of an emergency.Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. The emergency contact was omitted on the information brief (face sheet) of the individual. The program director made the necessary correction on the face sheet immediately to include the emergency contact information for the individual. This includes the name, address, telephone number, and relationship of the person to be contacted in the case of an emergency. 01/17/2024 Implemented
6400.211(b)(3)Individual #1 emergency information did not include the person who is able to give consent for emergency medical treatment.Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable. The emergency contact for the person who is able to give consent for medical treatment was omitted on the information brief (face sheet) of the individual. The program director made the necessary correction on the face sheet immediately to reflect the person who is able to give consent for emergency medical treatment. This includes the name, address, telephone number, and relationship of the person to be contacted in the case of an emergency medical treatment. 01/17/2024 Implemented
SIN-00207184 Renewal 01/24/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill conducted on 5/22/22 at 5:08 did not include the designation of AM/PM for the time of day that the fire drill occurred.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. UCCH provider reviewed the fire drill forms, the designation of AM/PM was not documented. The residential supervisor shall make sure all fire drills forms are completed thoroughly. The designation od AM/PM shall be documented on all fire drill forms completed per regulation 6400.112(c). 02/10/2023 Implemented
6400.151(a)A staff person who comes into direct contact with the individuals shall have a physical examination within 12 months prior to employment. Staff #1's date of hire is 8/1/21 and their physical examination occurred on 8/4/21. This exceeds the requirement. 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. This error was noted beforehand in the year 2021, HR specialist was hired to keep track of all employees' onboarding process which includes their physical examinations and corrections were made moving forward. This shall be completed prior employment with UCCH in order to remain complaint. 02/10/2023 Implemented
6400.151(c)(2)Staff #1's date of hire is 8/1/21 and their initial chest x-ray with results noted occurred on 8/4/21. This exceeds the requirement. 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. This error was noted beforehand in the year 2021, which UCCH proceeded in hiring a HR specialist to keep track of all employees' onboarding process and corrections were made moving forward with employees completing their TB testing prior to being hired by UCCH in order to remain complaint. 02/10/2023 Implemented
6400.165(g)Individual #3 is prescribed medication to treat symptoms of a psychiatric illness. Individual #3 had psychiatric medication reviews 11/1/22 and 12/13/22 and the form used for both appointments did not include documentation of the reason for prescribing the medication.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.Psychiatric medication management form has been reviewed and revised by the CEO. The program specialist shall make sure that the residential supervisor completes their section prior to the appointment date, and have the psychiatrist completes all sections on the forms which must include the reason for prescribing the medication, continuity of medication and necessary dosage. The program specialist shall check all forms and make sure all sections are completed before filing in the individual medical binders. If the doctor misses any blank, the program specialist shall fax form back to the doctor's office and follow up to make sure it has been completed and fax or emailed back to UCCH. 02/10/2023 Implemented
6400.182(c)Individual #3's Individual Support Plan (ISP) states he is unable to manage his own finances, therefore, his sister is representative. Individual #1 has a debit card from his rep payee in which $20 is deposited weekly for his spending money. Individual #1 can manage up to $25 on his own without staff guidance. Individual #1 holds on to his card and gives staff his receipts. Individual #1's assessment dated 12/6/22 states that his finances are managed by his sister as she is representative payee. Individual #3 receives $10 weekly. He can independently hold his money, but he needs verbal instructions to understand the value of money and to spend wisely. The individual plan shall be revised when an individual's needs change based upon a current assessment.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The program specialist has reviewed the individual's assessment. An update has been completed and would be sent to the support coordinator to reflect changes to the individual ISP. 02/10/2023 Implemented
SIN-00197758 Renewal 02/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Individual #5's Individual Service Plan indicates that poisons are locked in the individuals' home due to an incident where the individual reported drinking bleach. Individual #5's bathroom contained two types of Colgate Toothpaste and Anticavity Mouthwash. Both items stated to contact poison control if ingested.Poisonous materials shall be kept locked or made inaccessible to individuals. Toothpaste and mouthwash were found in the individual's bathroom which indicates "call poison control when ingested". The items were locked up immediately. All poisonous substances shall remain locked and inaccessible to the individual in that home. These substances will only be used under staff supervision. Staff shall always read the substance label when items such as toothpaste, shampoo, body wash, dish soap, hand soap etc. are brought into the house and if it reads, "call poison control when ingested, shall be kept locked at all times. 02/07/2022 Implemented
SIN-00183660 Renewal 02/22/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff #1's date of hire was 8/16/2020. Staff 1 did not have a Pennsylvania State Police Criminal background check completed within 5 working days of hire. The Pennsylvania State Police Criminal background check was not completed until January 31, 2021. Staff #2 was hired 8/16/2020. Staff 1 did not have a Pennsylvania State Police Criminal background check completed within 5 working days of hire. The Pennsylvania State Police Criminal background check was not completed until January 31, 2021.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees 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.UCCH got her first individual on 8/17/2021, all focus was on this individual. UCCH completed FBI Fingerprint Check on staff. UCCH thought employees who does FBI Fingerprint clearance would not need to complete PA police criminal background check. UCCH re-read the 6400 regulations and the agency policies regarding Criminal background checks with the assistance of the CEO, and all employees PA police criminal background check were completed on 1/31/2021. 01/31/2021 Implemented
6400.21(b)Staff #1's date of hire was 8/16/2020. Staff 1 did not have an FBI background check completed within 5 days of hire. The FBI background check was not completed until October 15, 2020. Staff #2 's date of hire was 8/16/2020. Staff 2 did not have an FBI background check completed within 5 days of hire. The FBI background check was not completed until September 22, 2020.If a prospective employee 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.UCCH got her first individual on 8/17/2021, all focus was on this individual. UCCH put in an application for FBI background check and got a latter date, staff could not do a walk-in due to high rise in COVID-19 cases. UCCH re-read the 6400 regulations and the agency policies regarding Criminal background checks with the assistance of the CEO. Staff will not be allowed to work directly with the individuals until PA state background check is completed as well as FBI background checks within 5 working days. 01/31/2021 Implemented
6400.34(a)Individual 1 signed her rights statement on 8/8/20. Individual Rights have not been updated to reflect the current Chapter 6400 regulations. The missing rights include: 32k, 32p, 32q, 32s and 32t.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.UCCH has updated the individual rights to meet the 6400 regulations. The missing rights 32k, 32p,32q,32s and 32t has been included in order to be complaint and also have the home inform and explain the full individual rights to the individual. The program specialist will be responsible to make sure that the individual rights meets all requirements in the 6400 regulations. The update individual rights has been read to the individual and signed for as well. 04/19/2021 Implemented
SIN-00164552 Initial review 10/29/2019 Compliant - Finalized