| 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 |