| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00289783
|
Unannounced Monitoring
|
04/27/2026
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Reports and photographic evidence reveal that Individual #1 had been neglected on at least two occasions prior to their elopement and subsequent collision with a moving vehicle resulting in grievous bodily injuries on 4/23/26.
Staff #3 reported that Individual #1 had been eloping on other staff and had apologized to them for the elopements in conversation. Staff #3 estimated that Individual #1 had eloped as many as seven times in the last year, always going to the church where they knew the inside and went in to get crayons and papers. Staff #3 noted that elopements would occur with CPS staff during transitions resulting in new procedures for drop-off and pick up to occur in the driveway of the home.
One such instance occurred the day prior, 4/22/26, when Individual #1 arrived home at 2:43pm. CPS staff remained in the general area of the backyard with Individual #1 but not within arm's length, until 2:46pm when CPS staff can be seen casually walking toward the front of the home. Individual #1 had not been within view of cameras for two minutes during which time Individual #1 eloped to the church across the street prompting the church to call the police. At 3:04pm cameras show a police officer knocking on the front door of the home. The door is not answered. At 3:08pm Provider Staff #4 arrives at the home and is approached by a police officer who by Staff #4's own report entered into Therap, notes that "When I arrived the police came over and talked to me and asked if I could come and get [them], I replied no I can't and they eventually brought [them] over." Staff #4 failed to provide the necessary supervision and support required by Individual #1in that moment.
An additional incident occurred on 3/31/26 and was entered into the Enterprise Incident Management (EIM) system as an unauthorized restraint due to staff attempting to physically redirect Individual #1 away from the church.
Staff #2 reported another incident to the Investigator, stating that Individual #1 eloped from the home while they were in the restroom. Staff #2 stated that they were able to catch up with the Individual at the church and redirect them home. Staff #2 could not provide a date for the incident although employment time period limits the date of the event to 12/25 to 4/23/26.
Per the Individual Support Plan (ISP) with an annual review date of 3/14/26 "[Individual #1] lacks traffic safety skills. [They] requires arm's reach supervision in the community to ensure [their] safety. [They] does not always look for oncoming traffic or recognize traffic dangers, i.e., car backing up in a parking lot. Staff should remain close to [Individual #1] and prompt [them] to look for potential dangers. [They] needs partial physical assistance to navigate traffic settings. Staff should be aware of [Individual #1's] location at all times in all traffic settings to ensure arm's length proximity." Additionally, "[Individual #1] cannot be left alone or unsupervised at any time. In the past, [Individual #1] has left the home and wandered into a neighbor's home." Despite the increased level of supervision witness accounts of the incident on 4/23/26 by Staff #2 and Staff #3 indicate that neither staff member was aware that Individual #1 had left the home until Staff #3 heard screams and went outside to investigate on their way off shift and leaving for the day, 23 seconds after Individual #1 left the home. Staff #2 reports that they were notified by Staff #3 as they motioned for them to come outside, nearly two and a half minutes after Individual #1 left the home. Staff #2 had not left the home prior. Staff #3 stated that a few minutes before the incident they had been upstairs with Individual #1 when Individual #1 went back downstairs where Staff #3 had reported last seeing Staff #2 asleep on the couch, directly adjacent to the front door and in front of the picture window facing the street. The door Individual #1 used to exit the home and run into the street. Staff #3 reported hearing Individual #1 in the closet and called out to them. They reported receiving a response then returned to cleaning tasks in the Individual's upstairs bedroom stating they had transferred responsibility of Individual #1 to Staff #2 having completed their shift at 11:00am. There was no direct line of sight from the bedroom to front door or closet without exiting the bedroom. On the day in question Staff #2 and Staff #3 failed to provide the outlined level of supervision noted to be required to ensure the safety of Individual #1. Staff #2 neglected to provide necessary supervision by sleeping on while care should have been provided. Staff #3 neglected Individual #1 by knowingly leaving supervision to Staff #2, the Staff person they reported to be sleeping. As a result of the neglect of duties of both Staff #2 and Staff #3 Individual #1 ran out of the home and was struck by a car.
Per the ISP Individual #1 requires "door chimes to notify staff if [Individual #1] is attempting to elope." Both Staff #2 and Staff #3 reported that the door chime on the front door had not been working for an extended period of time prior to and the day of the 4/23/26 elopement. Staff #3 reported that the broken chime was placed on the desk of Staff #1 at some time in the previous weeks although an exact date was not provided. Staff #1 reports that they never saw the alarm on their desk. At time of inspection on 5/1/26 the front door alarm in question was not working properly and loosely held to the door with scotch tape.
The provider neglected Individual #1 by failing to provide necessary supervision and take established measures to assist in ensuring the safety of Individual #1 on 4/23/26 and in the weeks prior. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Individual #1 no longer resides in the home and was discharged from Agape Human Services to reside with their parents/guardians. Staff #2 and Staff #3 are no longer employed by Agape Human Services.
Agape Human Services reviewed the circumstances surrounding the incident and reinforced staff responsibilities regarding supervision, implementation of individual support plans, health and safety protections, incident reporting, and accountability for maintaining required supports and safety measures. The agency also implemented monitored ADT alarm systems in residential homes to enhance notification of door openings and support individuals identified as being at risk for elopement. |
06/26/2026
| Implemented |
| 6400.21(c) | Staff #2 was reported to be a contracted worker supplied by an outside staffing agency. Staff #2 reported that they began working shifts for the provider agency around "Christmas 2025." The PA criminal history record submitted was completed on 10/1/24. Outside of the one year prior to the person's hire date time frame as required. | The Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person¿s date of hire.
| Staff #2, a contracted employee supplied through an outside staffing agency, is no longer assigned to Agape Human Services and is no longer providing services to individuals supported by the agency.
Agape Human Services reviewed the personnel documentation requirements for employees and contracted staff and reinforced the requirement that Pennsylvania Criminal History Record Checks and FBI Criminal History Record Checks, when applicable, must be completed within the required timeframe prior to assignment. The agency reviewed its contractor onboarding process and verification procedures to ensure required background checks are obtained, reviewed, and documented prior to a contracted employee providing services. |
06/19/2026
| Implemented |
| 6400.18(a)(5) | Staff #1 created a neglect-failure to provide needed supervision report #9838052 in Enterprise Incident Management (EIM) on 5/1/26 at 5:06:11pm with a discovery date of 5/1/26 at 12:00pm.
The EIM report noted that "On 5/1/26, victim, [Individual #1]'s photograph staff sleeping on shift, (4/21/2026 @ 2:39pm)."
Evidence supports that the discovery date entered is not accurate and the incident not reported within the required 24 hours.
Staff #1 was shown a picture of Staff #2 sleeping while Staff #1 was at the hospital on the day of injury to Individual #1 on 4/23/26.
On 4/30/26 at 8:40pm Staff #1 emailed an outside party providing contracted staffing to the Provider noting that "This picture was taken by the client on Tuesday 4/21/26 @ 2:39pm two days before the car accident. The parents sent this to me showing [Staff #2] asleep on the couch."
The email created by Staff #1 illustrates that they received proof of Staff #2 sleeping on 4/21/26 at 2:39pm on or before 4/30/26. Staff #1 also received report of the 4/21/26 incident of neglect on 4/23/26 not 5/1/26 at 12:00pm as reported.
The incident was not entered within the required 24 hours of discovery by a staff person. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Neglect.
| The staff member recognized the reporting concern and entered the incident into Enterprise Incident Management (EIM). Agape Human Services reviewed Incident Management reporting requirements and reinforced the requirement that all reportable incidents, alleged incidents, and suspected incidents be reported through EIM within 24 hours of discovery and that discovery dates accurately reflect the earliest known awareness of the event. |
06/19/2026
| Implemented |
| 6400.32(c) | Individual #1 has the right to be free from neglect.
Reports and photographic evidence reveal that Individual #1 had been neglected on at least two occasions prior to their elopement and subsequent collision with a moving vehicle resulting in grievous bodily injuries on 4/23/26.
Staff #3 reported that Individual #1 had been eloping on other staff and had apologized to them for the elopements in conversation. Staff #3 estimated that Individual #1 had eloped as many as seven times in the last year, always going to the church where they knew the inside and went in to get crayons and papers. Staff #3 noted that elopements would occur with CPS staff during transitions resulting in new procedures for drop-off and pick up to occur in the driveway of the home.
One such instance occurred the day prior, 4/22/26, when Individual #1 arrived home at 2:43pm. CPS staff remained in the general area of the backyard with Individual #1 but not within arm's length, until 2:46pm when CPS staff can be seen casually walking toward the front of the home. Individual #1 had not been within view of cameras for two minutes during which time Individual #1 eloped to the church across the street prompting the church to call the police. At 3:04pm cameras show a police officer knocking on the front door of the home. The door is not answered. At 3:08pm Provider Staff #4 arrives at the home and is approached by a police officer who by Staff #4's own report entered into Therap, notes that "When I arrived the police came over and talked to me and asked if I could come and get [them], I replied no I can't and they eventually brought [them] over." Staff #4 failed to provide the necessary supervision and support required by Individual #1in that moment.
An additional incident occurred on 3/31/26 and was entered into the Enterprise Incident Management (EIM) system as an unauthorized restraint due to staff attempting to physically redirect Individual #1 away from the church.
Staff #2 reported another incident to the Investigator, stating that Individual #1 eloped from the home while they were in the restroom. Staff #2 stated that they were able to catch up with the Individual at the church and redirect them home. Staff #2 could not provide a date for the incident although employment time period limits the date of the event to 12/25 to 4/23/26.
Per the Individual Support Plan (ISP) with an annual review date of 3/14/26 "[Individual #1] lacks traffic safety skills. [They] requires arm's reach supervision in the community to ensure [their] safety. [They] does not always look for oncoming traffic or recognize traffic dangers, i.e., car backing up in a parking lot. Staff should remain close to [Individual #1] and prompt [them] to look for potential dangers. [They] needs partial physical assistance to navigate traffic settings. Staff should be aware of [Individual #1's] location at all times in all traffic settings to ensure arm's length proximity." Additionally, "[Individual #1] cannot be left alone or unsupervised at any time. In the past, [Individual #1] has left the home and wandered into a neighbor's home." Despite the increased level of supervision witness accounts of the incident on 4/23/26 by Staff #2 and Staff #3 indicate that neither staff member was aware that Individual #1 had left the home until Staff #3 heard screams and went outside to investigate on their way off shift and leaving for the day, 23 seconds after Individual #1 left the home. Staff #2 reports that they were notified by Staff #3 as they motioned for them to come outside, nearly two and a half minutes after Individual #1 left the home. Staff #2 had not left the home prior. Staff #3 stated that a few minutes before the incident they had been upstairs with Individual #1 when Individual #1 went back downstairs where Staff #3 had reported last seeing Staff #2 asleep on the couch, directly adjacent to the front door and in front of the picture window facing the street. The door Individual #1 used to exit the home and run into the street. Staff #3 reported hearing Individual #1 in the closet and called out to them. They reported receiving a response then returned to cleaning tasks in the Individual's upstairs bedroom stating they had transferred responsibility of Individual #1 to Staff #2 having completed their shift at 11:00am. There was no direct line of sight from the bedroom to front door or closet without exiting the bedroom. On the day in question Staff #2 and Staff #3 failed to provide the outlined level of supervision noted to be required to ensure the safety of Individual #1. Staff #2 neglected to provide necessary supervision by sleeping on while care should have been provided. Staff #3 neglected Individual #1 by knowingly leaving supervision to Staff #2, the Staff person they reported to be sleeping. As a result of the neglect of duties of both Staff #2 and Staff #3 Individual #1 ran out of the home and was struck by a car.
Per the ISP Individual #1 requires "door chimes to notify staff if [Individual #1] is attempting to elope." Both Staff #2 and Staff #3 reported that the door chime on the front door had not been working for an extended period of time prior to and the day of the 4/23/26 elopement. Staff #3 reported that the broken chime was placed on the desk of Staff #1 at some time in the previous weeks although an exact date was not provided. Staff #1 reports that they never saw the alarm on their desk. At time of inspection on 5/1/26 the front door alarm in question was not working properly and loosely held to the door with scotch tape.
The provider neglected Individual #1 by failing to provide necessary supervision and take established measures to assist in ensuring the safety of Individual #1 on 4/23/26 and in the weeks prior. Individual #1 has the right to be free from neglect. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | Individual #1 no longer receives services from Agape Human Services and was discharged to reside with their parents/guardians. Agape Human Services reviewed the circumstances surrounding the incident and reinforced staff responsibilities regarding supervision, implementation of individual support plans, protection of individual rights, and incident reporting requirements.55 PA Code Chapter 6400.46(a) |
06/22/2026
| Implemented |
| 6400.46(a) | Staff #2 reported beginning work with the agency around Christmas of 2025. File review noted that fire safety training was completed with the staffing agency on 9/21/25 but was not specific to the provider home. There was no documentation to support that Staff #2 received the required fire safety training on the designated meeting place outside the building or within the fire safe area in the event of an actual fire, or smoking safety procedures if individuals or staff persons smoke at the home as required. | 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. | Staff #2, a contracted employee supplied through US Medical, is no longer working with Agape Human Services and has been terminated from US Medical. There are currently no US Medical staff assigned to Agape Human Services.
Agape Human Services reviewed its onboarding and training procedures for employees and contracted staff and reinforced the requirement that all staff receive and document site-specific fire safety training prior to working independently in a residential home. This training includes evacuation procedures, responsibilities during fire drills, designated meeting locations, fire safe areas, smoking safety procedures when applicable, use of fire extinguishers, smoke detectors and fire alarms, and notification procedures for the local fire department. |
06/19/2026
| Implemented |
| 6400.51(b)(4) | There was no documentation to support that Staff #2 received training on recognizing and reporting incidents as required. | The orientation must encompass the following areas: recognizing and reporting incidents. | Staff #2, who is a US Medical Contracted Employee is no longer working on the Agape Human Services account and was also terminated by US Medical. |
06/19/2026
| Implemented |
| 6400.52(c)(6) | Documentation indicates that Staff #3 last received training on the implementation of the Individual Support Plan (ISP) for Individual #1 on 2/11/25. The annual plan review date was completed on 3/14/26 with critical revisions completed prior on 12/19/25. Annual training should have occurred after the 3/14/26 annual review. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Staff #3 is no longer employed by Agape Human Services. Individual #1 was discharged from Agape Human Services on 6/19/2026 and now resides with his parents/guardian for support.
Agape Human Services reviewed its training procedures regarding implementation of individual support plans. Management reinforced the requirement that employees who work directly with individuals receive training on the implementation of the individual's current plan following annual plan reviews and significant revisions, as applicable. The agency reviewed staff training records and procedures to ensure training related to individual support plans is completed and documented in accordance with regulatory requirements. |
06/26/2026
| Implemented |
| 6400.186 | Per the Individual Support Plan (ISP) with an annual review date of 3/14/26 "[Individual #1] needs constant supervision to prevent elopement and injury. Staff must remain within the home with [them] 24 hours per day" and "[Individual #1] lacks traffic safety skills. [They] requires arm's reach supervision in the community to ensure [their] safety. [They] does not always look for oncoming traffic or recognize traffic dangers" and "door chimes to notify staff if [Individual #1] is attempting to elope."
The home failed to provide the required level of supervision on 4/23/26.
The home failed to ensure that door alarms were in working order.
The ISP for Individual #1 was not implemented as written. | The home shall implement the individual plan, including revisions. | At the time of the investigation on 5/1/2026, the door chimes were functioning. The front door chime was determined to not have been functioning properly at the time of the incident on 4/23/2026 due a missing piece not reported by staff however, the back door chime was functioning. As an interim measure, the door chime was secured to ensure continued operation pending installation of an enhanced alarm system.
Individual #1 no longer resides in the home. The individual was discharged from the hospital to the guardians' home on 5/13/2026 and was subsequently discharged from Agape Human Services at the request of the guardians.
To enhance safety and support implementation of individual support plans requiring elopement prevention measures, Agape Human Services installed an ADT monitored alarm system at the Northview residential home. Installation of the ADT monitored alarm system at the John Street residential home was scheduled for 6/29/2026. Management also reviewed staff responsibilities regarding implementation of ISP supervision requirements, monitoring of safety devices, and reporting of malfunctioning equipment. |
06/29/2026
| Implemented |
|
|
|
SIN-00284075
|
Renewal
|
03/10/2026
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | Individual #1 is prescribed Benzonate 100 mg capsule, take 1 capsule by mouth three times as needed for cough. At the time of the inspection, the medication was not in the home. | 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.
| The Provider's Plan of correction is having the PCP discontinue the medication and issue instructions for a different PRN. |
03/12/2026
| Implemented |
| 6400.151(a) | Staff #1's date of hire is 8/11/25 and their physical examination was completed on 8/18/25. | 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. | The Provider's Plan of Correction is to ensure that all employees, during the pre-hiring process, per Job Offer, complete the required items, Criminal Background and Annual Physical and Mantoux prior to employment for all future hires for the company per 6400.151 regulatory requirements. |
03/10/2026
| Implemented |
| 6400.151(c)(2) | Staff #1's date of hire is 8/11/25 and their Tuberculin skin testing by Mantoux method with negative results was completed on 8/18/25. | 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. | The Provider's Plan of Correction is to ensure that all employees, during the pre-hiring process, per Job Offer, complete the required items, Annual Physical and Mantoux prior to employment for all future hires for the company. |
03/10/2026
| Implemented |
| 6400.181(a) | Individual #1's annual assessment was completed on 6/9/24 and their next one was completed on 11/7/25. | 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. | The provider created MS Access Report that shows all history of all 6400 Annual Assessment along with the date that the next one is due. The plan of correction is to send out the Annual Assessment within 6 to 9 months of the previous assessment. and to check with each individual Support Coordinator of the expected annual review to ensure that the individual plan team members receive the annual assessment at least 30 calendar days prior to an individual plan meeting based ARU date. |
03/10/2026
| Implemented |
|
|
|
SIN-00246730
|
Renewal
|
06/10/2024
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(2) | Staff #1 documentation notes a Mantoux test completed on 5/15/21 then not again until 6/2/23 which extends beyond the two-year timeframe and additional grace period. | The physical examination shall include: A general physical examination. | Staff #2 latest physical was on 10/7/2022 in which she was in compliance. I think that the latest records were not in the employee books during the licensing audit. The most current physical has been added to staff #2 employee book. Agape is in the process of uploading all staff files to the company share point drive in the events that the physical documentation is misplaced. Staff #2 latest physical existed on the SharePoint drive but not in her physical employee book. |
07/22/2024
| Implemented |
| 6400.141(c)(4) | Individual #1 had documentation of a vision screening completed on 1/31/23. Notes on the appointment form indicate that Individual #1 should return in one year. There was no documentation to support that Individual #1 returned in one year as recommended. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The Plan of Correction is to reach out and work with the individual's guardian to scheduled the vision appointment for 2024. The guardians has communicated with Agape that wan to be responsible for scheduling all appointments. An email has been sent out to the guardians to complete the vision appointment as soon as possible. The scheduled date is to be determined upon availability. I will enter a late provider correction date to account for the vision provider's availabilty. |
08/30/2024
| Implemented |
| 6400.142(a) | Documentation of dental visits indicate that Individual #1 was seen on 10/5/22 with a notation to return in 6 months. Individual #1 returned on 5/26/23 with a notation for a 6 month recall. There was no documentation to indicate that Individual #1 returned for a 6-month recall or annual examination as required. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | The individual was diagnosed with COVID at the time of his 6-month appointment. An incident was entered into EIM in November 2023 for having COVID. The 6-month appointment had to be rescheduled. The earlier date that he can be rescheduled is for August 2024. |
07/22/2024
| Implemented |
| 6400.165(f) | At time of inspection the June 2024 Medication Administration Record for Individual #1 included an entry for Alprazolam 1mg to be taken as needed for anxiety, the medication was not in the home and had not been administered since July 2023. At the time of inspection there was no protocol in place to address the social, emotional and environmental needs of the individual that directs the staff on indicators for, or the process of, administering the PRN medication as required. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | On 6/9/2024, we reached KD¿s parents, who take KD to all medication appointments that the Alprazolam was expired and if new medication would be available. KD was assigned to a new psychiatrist and had a scheduled visit on 6/22/2024 in which they would receive further guidance on this medication. The new psychiatrist chose to keep KD on the medication, and we have received the new medication. KD¿s guardian has chosen to handle all medication appointments for KD. The new medication is now on site for us.
During the licensing audit, we explained the process to the auditor, but the procedures were not documented. The process is that staff on shift must get approval from the House Supervisor, Program Specialist, Agency Administrator, and CEO before administering this medication.
The following documentation will be attached to the MAR for the individual:
PRN Medication: Alprazolam 1mg
Process for Administration:
Staff must get approval from the Program Specialist (Enock Berluche), Agency Administrator (Donna Johnson), and CEO (Terence Johnson) before administering this medication. The Program Specialist, Agency Administrator, and CEO must determine administration, since is a control substance, if a chemical restrictive procedure is required. |
07/01/2024
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medication to treat symptoms of a psychiatric illness. Three-month medication reviews were conducted on 3/20/24, 10/2/23, 11/2/23, and 8/7/23. Documentation of the appointments did not include the dosage of the medications prescribed as required. | 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. | Agape Human Services has modified the psych forms to include the dosage of the medications prior to the psych visit for Individual #2. The individual had a scheduled psych appointment with his psychiatrist and the Program Specialist pre-filled the medication and dosage on the form.
The plan of correction is documented and notified, the individual's guardian, House Supervisor, Plan Lead, Agency Administrator, and Program Specialist of the next psych appointment, which is scheduled for October 2024. This will reoccur every 90 days for the scheduling of the appointment and an email reminder 30 days prior to the appointment. |
07/18/2024
| Implemented |
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|
|
SIN-00227147
|
Renewal
|
06/05/2023
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.151(a) | Staff #6 had a late physical. Staff #6 has a physical completed on 2/29/20 and did not have another completed until 5/31/22. | 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 received Physical on 5/13/2023 and is scheduled to complete the next physical and TB by 5/12/2025 |
05/13/2023
| Implemented |
| 6400.32(n) | Individual #3's right to unrestricted and private access to telecommunications has been violated. There are two phones in the home, and both are located in the locked staff office preventing Individual #3 from having unrestricted access. | An individual has the right to unrestricted and private access to telecommunications. | The phone was returned to the kitchen area of the home. |
06/06/2023
| Implemented |
| 6400.52(c)(2) | Staff #4 and Staff #5 completed a training on abuse; however the training did not include all the requirements of the regulation. The training did not address the Older Adult Services Protective act, Child protective Services Act and the Adult Protective Services Act. The training was an over of what abuse is. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | All staff will complete the MYodp Abuse and Neglect Training for the 2023 fiscal year |
12/31/2023
| Implemented |
|
|
|
SIN-00205385
|
Renewal
|
06/14/2022
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | A spare bedroom located on the first floor had no light fixture in it. The light in the lamp located in the spare bedroom on the second floor did not work at the time of the inspection. Rooms shall be lit. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Place a lamp in the spare bedroom located on the first floor. Installed light in the lamp located in the spare bedroom on the second floor. |
07/26/2022
| Implemented |
| 6400.67(b) | Pieces of a shattered and broken lightbulb were on the basement floor. Floors shall be free of hazards. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Removed pieces of shattered and broken lightbulb on the basement floor. |
06/15/2022
| Implemented |
|
|
|
SIN-00189379
|
Renewal
|
06/28/2021
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The face of the drawer in the kitchen is missing. | Floors, walls, ceilings and other surfaces shall be in good repair. | Fixed the face of the drawer in the kitchen. The Consumer has a tendency of tearing things in the house and sometimes breaking doors and destroying tables. |
07/31/2021
| Implemented |
| 6400.77(b) | The first aid kit did not contain any bandaids. | 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. | Populate the first aid kit with bandaids. |
06/30/2021
| Implemented |
| 6400.82(f) | There were no paper towels or cloth towels available for Individuals to dry their hands in the second-floor bathroom. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Agape Human Service has placed paper towels in the upstairs bathroom. Hand towels were on the rack for the consumers. |
06/29/2021
| Implemented |
| 6400.112(e) | There was not a sleeping fire drill completed in May 2021. The last sleeping fire drill was completed in November 2020. | A fire drill shall be held during sleeping hours at least every 6 months. | Agape Human Service completed an overnight fire drill by 7/31/2021. The next schedule fire drill will be in October 2021 and will be conducted every April and October in the year for all residential homes to ensure compliance. |
07/31/2021
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medication to treat the symptoms of a psychiatric illness and there was no documentation to show that psychiatric medication reviews occurred at least every 3 months. | 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. | Agape Human Services modified the psychiatric illness form to include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. |
07/18/2021
| Implemented |
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SIN-00177037
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Renewal
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09/29/2020
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(d) | The record for Staff #1 did not contain the final report for the PA State Police Background check (only the initial request was retained in the employee file). | A copy of the final reports received from the State Police and the FBI, if applicable, shall be kept.
| Agape Human Service had put a previous plan of correction in place pull Background Check on all new hire after previous citation. Staff #1 background check preceded the plan of correction. Prior to the previous plan of corrections, it was up to individual to request or bring their background check. Going forward after the 9/29/2020 inspection, Agape Human Service will pull background upon immediately receipt of the Job Offer Letter acceptance rather than having the new employee pull their own background. For Staff #1, Agape Human Service will first determine if a final report available. If not, Agape will another background on Staff #1 and attached to the original for future reference |
11/30/2020
| Implemented |
| 6400.46(i) | Staff #1's training in First Aid, Heimlich Maneuver and CPR is late. The most recent training that Staff #1 received in the areas was on 3/15/2017. | Staff #1 was retrained in First Aid, Heimlich Maneuver, and CPR. Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | The plan of correction to review First Aid, Heimlich Maneuver, and CPR for each employee and then set an annual training schedule for all employees by an individual certified as trainer by a hospital or recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. |
11/30/2020
| Implemented |
| 6400.62(a) | Poisonous materials, including Rain-X and house paint (labeled "contact poison control if ingested") and a 5 gallon container with gasoline inside, were found unlocked and accessible in the garage area of the home. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The plan of correction is to ensure that all poisonous material are locked up in a storage space or removed from property. All house paints have been discarded from the property. |
10/30/2020
| Implemented |
| 6400.66 | In the walk-in closet to the left of the top of the stairs there was a light switch that appeared to have no connection to a light source. Through this area and behind a door there was an unfinished storage area that also had no illumination. This area led out over the first floor of the home and was absent of flooring. Floor joists were exposed.
Proper lighting in all areas ensures rapid evacuation and minimizes the risk of falls or other injury. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| a. Immediate Action:
The light in the walk-in-closet to the left of the top of the stairs has been fitted with a light source
b. Plan Going Forward:
Agape Human Service, according to 6400.66, will ensure that all rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The House Supervisor, in each Residential, will do a walk through and check all lightings on a weekly basis. The Agency Administrator, Residential Program Director/Program Specialist, and or CEO will do a monthly walkthrough in each Residential home. Agape Human Service will create a lighting checklist. |
11/30/2020
| Implemented |
| 6400.67(a) | Significant water damage was found on the back wall below the window in the dining area. Paint on the wall was bubbled covering a roughly 2 ft by 2 ft area. The windowsill had a small amount of standing water and build up.
Safe surfaces help maintain sanitary conditions in the home, minimize risk and provide dignified living conditions. | Floors, walls, ceilings and other surfaces shall be in good repair. | n of Correction
a. Immediate Action:
Removed the Air Condition unit which was the cause of the water leak into the walk. Agape Human Service hired a person to scrape off the paint and repaint wall
b. Plan Going Forward:
Agape Human Service, according to 6400.67, will ensure all floors, walls, ceilings and other surfaces shall be in good repair and that floors, walls, ceilings and other surfaces shall be free of hazards. Program Specialist, House Supervisor, Agency Administration, and CEO will inspect home monthly to ensure that everything is good repairs. Agape will create a monthly check list for our internal inspection |
11/30/2020
| Implemented |
| 6400.68(b) | The hot water temperature was measured at 140.2 degrees Fahrenheit in the second floor hall bathroom.
The provider turned the water temperature down at the time of the inspection and was instructed to run the hotter water out of the water tank and measure the water temperature prior to any individual's using the hot water without supervision. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | a. Immediate Action:
Agape Human Services made the repair while the inspection was going on. This information was communicated to the auditor at the end of day on 9/29/2020
b. Plan Going Forward:
Agape, according to 6400.68 will ensure that hot water temperatures in bathtubs and showers may not exceed 120°F. Agape Human Services will test the bathtub and hot water during each fire drill at all Residential Group homes and will keep a temperature log. The House Supervisor will ensure that temperature checks are completed and signed. Residential Director, Program Specialist, Agency Administrator, and CEO will review these logs monthly for certification. |
09/29/2020
| Implemented |
| 6400.73(a) | There were three steps from the attached garage into the house and no handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | Plan of Correction: Installed handrails |
10/31/2020
| Implemented |
| 6400.82(f) | There was no hand soap in the second floor bathroom. | a. Immediate Action:
Agape did place hand soap in the second floor bathroom and ensured that all bathroom had non-poisonous soap.
b. Plan Going Forward:
Agape Human Service, according to 6400.82f, will ensure that each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. Agape will including checking that each bathroom and toilet area will have poison safe soap, toilet paper, individual clean paper or cloth towels and trash receptacle as a part of the daily clean routine. These items will be added to the daily check list and signed off by the House Supervisor and/or plan lead. | Placed hand soap in each bathroom in the home. |
09/30/2020
| Implemented |
| 6400.181(a) | Individual #1's date of admission was 2/21/2020 and the initial assessment was not completed until 5/05/2020. | 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. | Program Specialist was retrained on 55 PA Code Chapter 6400,181 (a). |
10/30/2020
| Implemented |
| 6400.181(e)(1) | The initial assessment for Individual #1, completed on 5/05/2020, did not contain the individual's functional strengths, needs and preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Program Specialist was retrained on 55 PA Code Chapter 6400,181 (e)(1). The assessment will be updated to include the individual's functional strengths, needs, and preference |
11/30/2020
| Implemented |
| 6400.181(e)(10) | The initial assessment for Individual #1, completed on 5/05/2020, did not contain the individual's lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Program Specialist was retrained on 55 PA Code Chapter 6400,181 (e)(10). The lifetime medical history is completed and will be updated in the client's book prior to his next scheduled ISP Meeting |
11/30/2020
| Implemented |
| 6400.51(b)(3) | The orientation training for Staff #2 did not encompass training in the area of individual rights. | The orientation must encompass the following areas: Individual rights. | The plan of correction going forward to create a checklist to ensure that individual rights are in the employee files. The individuals rights has been placed in Staff #2 employee file. Agape Human Service will designate an individual to review all employee files monthly |
10/30/2020
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medication to treat the symptoms of a psychiatric illness and there was no documentation to show that psychiatric medication reviews occurred at least every 3 months. | a. Immediate Action:
Due to the coronavirus pandemic delayed visits medical appointments. Individual #1 was rescheduled and saw a licensed physician on 10/29/2020. Individual #1 parents request that they take Individual #1 to doctor's appointments as they work with Agape.
b. Plan Going Forward:
Agape Human Service, according to 6400.165f, individuals who received medication prescribed to treat symptoms of a psychiatric illness be reviewed by a licensed physician at least every 3 months that includes documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage. Going forward, Agape will designate and individual (House Supervisor, Program Specialist, Agency Administrator, or other person), to schedule and maintain all appointments at the beginning of each year (existing individual) or the remainder of the current year (new individuals receiving medication) with the licensed physician and document these appointments in advance. Agape will document any changes to the scheduled appointments. | The coronavirus pandemic delayed visits medical appointments. Individual #1 was rescheduled and saw a licensed physician on 10/29/2020. |
10/29/2020
| Implemented |
| 6400.169(a) | Staff #1 completed and passed the initial Department-approved medications administration course on 2/16/2018, but has not completed the annual renewal requirements and currently administers medication. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | a. Immediate Action:
Staff #1 is the Agape Human Services Med AdministrationTrainer and has received his renewal and pass as of 10/31/2020
b. Plan Going Forward:
Agape Human Service, according to 6400.169(a), will ensure that all staff, including Agape Human Services, Med Administration Trainer, |
11/30/2020
| Implemented |
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SIN-00268140
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Renewal
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06/05/2025
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Compliant - Finalized
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