Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00267802 Renewal 06/10/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.84The two most recent fire safety inspections for this program took place on 04/10/2024 and 05/30/2025, more than one year apart.The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.The community center that Agape uses is a multipurpose building, also used by the church for other activities. Agape Human Services did receive the most current fire safety inspections for 5/30/2025. 06/30/2025 Implemented
2380.111(a)Individual #2's most recent physical examination was conducted 02/22/2024. The Individual Record contained a physical examination form dated 02/20/2025; however, this form was missing the following required information: medical diagnoses, whether or not the individual was free from communicable disease, allergies, prescription medications, health maintenance recommendations, information pertinent to diagnosis and treatment in case of emergency, and dietary recommendations (if any). As this physical examination form lacked such a large amount of required information, it cannot be counted as a physical examination under this Chapter. As such, Individual #2 did not have a physical examination completed annually as required.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.The Plan of Correction is to reach out to the CLA to have the physician complete the information on the Staff Physical. 07/14/2025 Implemented
2380.181(a)Individual #1's two most recent Individual Assessments were dated 09/24/2023 and 11/12/2024---more than one year apart. This individual did not have an Individual Assessment conducted annually as required. Individual #2's two most recent Individual Assessments were dated 01/12/2024 and 02/03/2025---more than one year apart. This individual did not have an Individual Assessment conducted annually as required.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.The Provider Plan of Corrections is to complete the next individual Assessment within 365 days for individual #1 (before 11/12/2024) and individual #2 (before 2/3/2025) by the CPS Program Specialist. 06/30/2025 Implemented
2380.181(f)Per correspondence in the Individual Record, Individual #1's Individual Plan meeting was held on 12/16/2024. The letter containing Individual #1's 11/12/2024 Individual Assessment was dated 11/18/2024, fewer than 30 calendar days prior to the individual's Individual Plan meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.The Provider Plan of Corrections to to complete the next individual Assessment within 365 days for individual #1 (before 11/12/2024) to satisfy both the 365 guidances and the last annual ISP Meeting held on 12/16/2024. The Program Specialist will reach to the SC for all individuals to determine the schedule date according to their individual support plan (ISP) 06/30/2025 Implemented
2380.183(c)There was no documentation of the participants in Individual #1's 12/16/2024 Individual Plan meeting found within the Individual Record. There was no documentation of the participants in Individual #2's 03/06/2025 Individual Plan meeting found within the Individual Record.The list of persons who participated in the individual plan meeting shall be kept.Agape will request a copy of the individual sign in sheet from the Support Coordinator at the end of each ISP Review Meeting. 06/30/2025 Implemented
Article X.1007The Provider is required to maintain criminal history checks and hiring policies for the hiring, retention, and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). A Federal Bureau of Investigation (FBI) background check was not completed for Staff #1 or Staff #2, and there was no indication that either of these staff was a resident of Pennsylvania for two consecutive years prior to hire.When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application.Agape did receive email confirmation determining that the individual, in question, resided in Pennsylvania for two consecutive years. 06/30/2025 Implemented
SIN-00246741 Renewal 06/18/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(14)Individual #1 and Individual #2's annual assessments did not include the individual's ability to swim.The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.The annual assessments for both individual #1 and individual #2 include their ability to swim per my knowledge. It is documented that staff have not witnessed these individual swimming and have reached the parents/guardians for individual #1 for additional information for the annual assessment. For individual #2, there has not been an occasion to witness swimming. The annual assessment includes verbiage that staff should always be present, since there is not sufficient evidence to ensure the health and safety of the individuals. 07/18/2024 Implemented
2380.129(a)Staff #1 is not trained annually in medication administration training. Staff #1 was trained on 6/3/23 and had not completed training for 2024 as of the date of the inspection.A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures and treatments as specified in § 2380.122 (relating to medication administration).Staff #1 received the annual training with the Med Trainer and completed on 7/5/2024. 07/05/2024 Implemented
SIN-00227149 Renewal 06/27/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)Tuberculin skin testing with negative results every 2 years. Individual #1 had a Tuberculin skin testing with negative result on 3/9/18, and their next one occurred on 6/10/22, This exceeds the requirement.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.The individual cited received his TB on 6/10/2022. 06/28/2023 Implemented
2380.111(c)(6)Individual #2's physical examination dated 2/21/23 did not include if the person was free from communicable diseases as this section of the form was left blank. (Repeat Violation 6/23/22)The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals.The plan of correction is to notify the CLA that information is needed stating the individual is free from communicable diseasee. 08/30/2023 Implemented
2380.111(c)(7)Individual #1's physical examination dated 9/19/22 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work this section of the form was left blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.The individual is scheduled for his next physical in September 2023 in which Agape will insure the individual's health maintenance needs, medication regiment and the need for the blood are populated on the phsysical. 09/21/2023 Implemented
2380.111(c)(9)Individual #1's physical examination dated 9/19/22 did not include allergies or contraindicated medication this section of the form was left blank.The physical examination shall include: Allergies or contraindicated medication.The individual is scheduled for his next physical in September 2023 in which Agape will ensure Individual's allergies and contraindicated medication are populated on the physical. 09/21/2023 Implemented
2380.111(c)(10)Individual #1's physical examination dated 9/19/22 did not include medical information pertinent to diagnosis and treatment in case of an emergency this section of the form was left blank. (Repeat Violation 6/23/22)The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The individual is scheduled for his next physical in September 2023 in which Agape will ensure Individual's information is filled in properly. 09/21/2023 Implemented
2380.111(c)(11)Individual #1's physical examination dated 9/19/22 did not include special instructions for an individual's diet this section of the form was left blank.The physical examination shall include: Special instructions for an individual's diet.The individual is scheduled for his next physical in September 2023 in which Agape will ensure Individual's allergies and contraindicated medication are populated on the physical. 09/21/2023 Implemented
2380.113(a)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 persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Staff #2 had a physical examination on 6/2/23 and there is no record of one prior, and their date of hire is 4/4/19.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 persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.The staff did have their latest physical on 6/2/2023. Their next schedule physical is for 6/1/2025 06/02/2023 Implemented
2380.113(c)(2)Tuberculin skin testing with negative results every 2 years. Staff #1, had Tuberculin skin testing with negative results on 6/2/23 and their previous once occurred on 5/10/21 Staff#2 had Tuberculin skin testing with negative results on 6/2/23 and there is no record of one being complete prior.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the 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, certified nurse practitioner or certified physician's assistant.The staff did have their TB read on 6/2/2023 06/02/2023 Implemented
2380.113(c)(3)Staff #3 physical examination dated 1/31/22 did not include a signed statement that the person is free of serious communicable diseases.The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in §  27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.The plan of correction for staff #3 to receive a new physical and TB. 08/15/2023 Implemented
2380.36(b)Program specialists and direct service workers shall be trained annually by a fire safety expert fire safety. Staff #1 had fire safety training on 2/1/22 and there is no record or documentation that they received training since. This exceeds the requirement.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The plan of correction is that Program Specialist complete the general fire safety. 08/05/2023 Implemented
SIN-00205388 Renewal 06/23/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Poisonous materials were found unlocked and accessible in the main program area. Three bottles of alcohol-based liquid hand sanitizer, labeled with the instructions to contact poison control if ingested, were found on a table near the rear door of the program. *Staff removed the bottles at the time of the inspection.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.The poisonous material was the Hand Sanitizer used by the individuals in the facility. The immediate plan of correction was to locked up the hand sanitizer and only use when needed. Once used for the individual in CPS, the hand sanitizer are immediately locked when not in use. 06/23/2022 Implemented
2380.59(b)The hot water temperature was measured at 129.3 degrees Fahrenheit in the ladies bathroom at the time of the inspection. *Staff turned the water temperature down at the time of the inspection.Hot water temperatures in areas accessible to individuals may not exceed 120°F.Upon the inspection, staff turn the temperature down on the unit in the closet area to ensure that the temperature did not exceed the 120 degrees F. 06/23/2022 Implemented
2380.70(b)There was no pillow or blanket in the first aid area.The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit.Agape Human Services purchased a pillow and blanket in the first aid area 06/24/2022 Implemented
2380.89(c)The fire drill record for the drill that occurred on 8/12/2021 did not document the time of the 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 was operative.Agape Human Services conducted another fire drill for July and August and ensured the required information (date, time, and the amount of time it took for evacuation. 08/18/2022 Implemented
2380.111(c)(6)The physical examination record dated 2/14/2022 did not document whether the Individual was free from serious communicable disease.The physical examination shall include: Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals.Agape Human Services CPS receives the physical examination from the Residential Provider. The plan of correction is to ensure to the best of ability that all items are completed in the Physical Examination form without neglecting services to the individuals. CPS will work with the Residential Provider and/or family to ensure that the information completed and may have return documentation from the sending source (family or Residential CLA) to complete missing information. 08/17/2022 Implemented
2380.111(c)(10)The physical examination record dated 2/14/2022 for Individual #1 did not document "information pertinent to diagnosis and treatment in case of emergency."The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Agape Human Services CPS receives the physical examination from the Residential Provider. The plan of correction is to ensure to the best of ability that all items are completed in the Physical Examination form without neglecting services to the individuals. CPS will work with the Residential Provider and/or family to ensure that the information completed and may have return documentation from the sending source (family or Residential CLA) to complete missing information. 08/18/2022 Implemented
2380.21(s)The Individual Rights that were reviewed with and signed by Individual #2 on 1/01/2022 did not include: "The facility shall assist affected individuals to negotiate choices in accordance with the facility's procedures for individuals to resolve differences and make choices."The facility shall assist the affected individuals to negotiate choices in accordance with the facility's procedures for the individuals to resolve differences and make choices.The individual signed off on the 6400 Individual Rights form rather than the 2380 which includes the additional information. The individuals resigned the 2380 forms which includes "The facility shall assists affected individuals to negotiate choicces in accordance with the faicility's procedures of individuals to receive differences and make choices" 07/31/2022 Implemented
2380.21(t)The Individual Rights that were reviewed with and signed by Individual #2 on 1/01/22 did not include the following: "An individual's rights may only be modified in accordance with § 2380.185 (RELATING TO CONTENT OF THE INDIVIDUAL PLAN) to the extent necessary to mitigate a significant health and safety risk to the individual or others. "An individual's rights may only be modified in accordance with § 2380.185 (RELATING TO CONTENT OF THE INDIVIDUAL PLAN) to the extent necessary to mitigate a significant health and safety risk to the individual or others.The individual signed off on the 6400 Individual Rights form rather than the 2380 which includes the additional information. The individuals resigned the 2380 forms which includes "An individual's rights may only be modified in accordance with § 2380.185 (RELATING TO CONTENT OF THE INDIVIDUAL PLAN) to the extent necessary to mitigate a significant health and safety risk to the individual or others." 07/31/2022 Implemented
SIN-00169150 Renewal 01/15/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.84The annual fire safety inspection is scheduled for tomorrow, 1/16/2020. A copy of 2019's fire safety inspection wasn't available at the time of this inspection.The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.A fire safety inspection safety check has been done. The results have been has been dated by the inspector and the documentation has been filed. 01/16/2019 Implemented
2380.89(d)The fire drill held on 12/19/2019 did not document the amount of time it took to evacuate the program.Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.Staff will be retrained in completing all components of the Fire Drilled on 2/18/2020 to ensure all documentation for future fire drill are completed and proving that the required time are met. CEO and Director reviewed 2380.89d with staff on 2/18/2019. 02/18/2020 Implemented
2380.111(a)Individual #3 (DOB: 9/12/1997) was admitted on 6/10/2019. He didn't have a physical exam within 1 year prior to admission. His physical exams are dated 5/2/2018 and 9/20/2019.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.Prior to admission into CPS, Director, CEO, and Program Specialist will ensure that all physical examination and TB are completed. Agency will created an admission checklist to ensure that all pre-requisite to admission are completed. CEO will train staff on this on 2/18/2020. 02/18/2020 Implemented
2380.111(c)(3)Individual #3 (DOB: 9/12/1997) was admitted on 6/10/2019. He didn't receive his DT vaccine until 9/25/2019.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Prior to admission into CPS, Director, CEO, and Program Specialist will ensure that all physical examination and TB are completed. Agency will created an admission checklist to ensure that all pre-requisite to admission are completed. Retrained staff on 2380.111(c)(3) 02/18/2020 Implemented
2380.111(c)(5)Individual #3 (DOB: 9/12/1997) was admitted on 6/10/2019. He didn't have a TB test until 9/25/2019.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.Prior to admission into CPS, Director, CEO, and Program Specialist will ensure that all physical examination and TB are completed. Agency will created an admission checklist to ensure that all pre-requisite to admission are completed. Retrained staff on 2380.111(c)(5). CPS Director and Program Specialist will verifying physical admission and will notified parent or provider otherwise, 02/18/2020 Implemented
2380.111(c)(7)Health maintenance needs was blank on Individual #1's (DOB: 3/8/1995) physical exam dated 2/13/2019The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.Staff will ensure the required fields on the physical examination is completed by the Physician before leaving the examination. The agency will request that the physician complete all field which may included NA. Agency will ensure that staff transporting consumer for the physician are re-trained to ensure that all physical documentation are completed in full. Review 2380.111(c)(7) with staff on 2/18/2020. 02/18/2020 Implemented
2380.111(c)(10)This section was blank on Individual #1's (DOB: 3/8/1995) physical exam dated 2/13/2019 and Individual #2's (DOB: 6/26/1996) physical exam dated 4/22/2019.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Staff will ensure the required fields on the physical examination is completed by the Physician before leaving the examination. The agency will request that the physician complete all field which may included NA. Agency will ensure that staff transporting consumer for the physician are re-trained to ensure that all physical documentation are completed in full. Retrained staff on 2380.111(c)(10) 02/18/2020 Implemented
2380.181(a)Individual #1 was admitted on 6/10/2019. His assessment is dated "2019" so it couldn't be determined if it was completed within 60 days after his admission. Individual #2 was admitted on 6/10/2019. His assessment is dated "2019" so it couldn't be determined if it was completed within 60 days after his admission.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.Going forward, all assessment will be reviewed by Director of CPS and CEO for approval. Program Specialist (Individual #1) will sign and date the assessment and update consumer's (Individual's book. CEO and Director will remind Staff #1 of the 2380 guidelines concerning assessment. The Program Specialist will complete an initial assessment of all consumer's admitted within the program. The agency will establish an admission checklist. Retrained staff on 2380.181(a) 02/18/2020 Implemented
2380.181(d)Staff #1 did not sign and date the assessments for Individual #1 (2019), Individual #2 (6/2019) and Individual #3 (2019).The program specialist shall sign and date the assessment.Going forward, all assessment will be reviewed by Director of CPS and CEO for approval. Program Specialist will sign and date the assessment and update consumer's (Individual's book. CEO and Director will remind Staff #1 of the 2380 guidelines concerning assessments. CEO reviewed 2380.181(d) with Program Specialist and CPS Director on 2/18/2020. Retrained staff on 2380.181(d) 02/19/2020 Implemented
SIN-00148274 Initial review 01/11/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(b)The hot water temperature was measured at 134.2 degrees Fahrenheit in the bathroom sink.Hot water temperatures in areas accessible to individuals may not exceed 120°F.The water temp in the bathrooms will be adjusted to no higher than 120 degrees fahrenheit. Water temp will be checked monthly. 02/15/2019 Implemented
2380.61There was no landline telephone in the facility.The facility shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.A landline phone will be installed on the premises that will be accessible to individuals and staff. The landline will remain operable at all times 02/15/2019 Implemented
2380.62Emergency telephone numbers were not posted in the facility.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.We will post the numbers of the local police department, ambulance, and poison control center by each telephone in the facility with an outside line. The numbers will be checked and updated quarterly. 02/15/2019 Implemented
2380.65The exterior steps leading to the front and rear entrances did not have a non-skid surface. Interior stairs and outside steps shall have a nonskid surface.All interior and exterior step will have nonskid surfaces. The skids will be checked monthly for security. 02/15/2019 Implemented
2380.68There was no designated space for hanging coats and storing personal belongings.Space shall be provided for hanging hats and coats and storing personal belongings.We will install pegs in which to hang all hats and coats. We will also provide storage bins/cubbys in which to store person belongings. We will make monthly maintenance checks to ensure pegs and storage bins and/or cubbys are in good working order. 02/15/2019 Implemented
2380.70(a)There was no first aid area separated by partition or privacy screen from the program area.The facility shall have a first aid area that is separated by partition or privacy screen from program areas.We will purchase a screen that will create a private area and serve as a partition between the medical area and program area. The screen will be portable and will remain in the closet until it is the be used. 02/15/2019 Implemented
2380.70(b)There was no bed or cot, blanket, pillow or first aid kit.The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit.We will provide portable cot, a blanket and pillow in the facility, along with the first aide kit. The items will be stored in the office closet until needed. 02/15/2019 Implemented
2380.70(c)The facility did not have a first aid kit.Each floor of the facility shall have a first aid kit accessible to staff persons.The facility will purchase a first aide kit that is accessible to all staff person. The kit will be checked monthly to ensure all necessary items are restocked and in place. 02/15/2019 Implemented
2380.70(d)There were no first aid supplies required for a first aid kit.First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors.Our purchased first aide kit will include adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape and scissors. The first aide will be checked monthly to ensure all contents are present. 02/15/2019 Implemented
2380.70(e)There was no first aid manual.A first aid manual shall be kept with each first aid kit.We will ensure the first aide manual is located along with the first aide kit. We will check the kit monthly to ensure the manual is in the kit. 02/15/2019 Implemented
2380.72(b)The sidewalk leading to the front entrance of the building had a gap between two large concrete slabs, creating a potential tripping hazard.The outside of the building and the facility grounds shall be well maintained, in good repair and free from unsafe conditions.We will fill in the gap between the slabs in the front of the building. The work will be completed early spring when the weather is more conducive to the setting of the concrete. We will check for cracks and potential hazards monthly. 05/16/2019 Implemented
2380.88(f)The fire extinguishers in the facility were last inspected and approved in August 2017.Fire extinguishers shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher.We will install be at least a fire extinguisher with a minimum 2-A rating inside the facility. Fire extinguishers will be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. 01/15/2019 Implemented