| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff person # 2's date of Hire is 3/28/19, and their criminal background check was completed on 5/31/19.
Staff person # 3's date of hire is 8/10/18, and their criminal background check was completed on 11/14/18. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| Staff persons #2 and #3 have current criminal background checks. Moving forward, Administrator will ensure that all prospective employees of Agape Family Home including part-time and temporary staff persons who will have direct contact with individuals receive a criminal history record check submitted to the State Police. (POC Attachment 3) |
07/11/2019
| Implemented |
| 6400.46(f) | Staff person # 1's training records did not have fire safety training. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Staff #1 has received fire safety training on 07/15/2019. Moving forward, Administrator will ensure all staff shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. (POC Attachment 3) |
07/15/2019
| Implemented |
| 6400.141(c)(3) | Individual # 1's physical exam dated 1/29/19 had the last completed diphtheria and tetanus as 12/1/97. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Individual #1 last completed diphtheria and tetanus was 12/07/2010. Records were attached to the current physical upon review. (POC Attachment 3) |
07/11/2019
| Implemented |
| 6400.141(c)(13) | Individual # 1's physical exam dated 1/29/19 did not indicate if the individual had any allergies. | The physical examination shall include: Allergies or contraindicated medications. | Individual #1's Physical has been updated to include information about his allergies. Moving forward, Agape Family Home's nurse will review all individual physicals to ensure that physical examinations include: Allergies or contraindicated medications. (POC Attachment 2) |
07/12/2019
| Implemented |
| 6400.144 | Generic Tylenol Acetaminophen was listed in the Medical Administration Record (MAR) to be taken as needed (PRN) for individual #1, but no medication was found on site. | 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.
| Generic Tylenol Acetaminophen was listed in the Medical Administration Record (MAR) requested for, delivered by the pharmacy and placed in the individual's medication box. Moving forward, Agape Family Home Nurse and program coordinator will check all medications delivered at the beginning of every month, to ensure that all prescribed medications for all individual are provided and administered as prescribed. (POC Attachment 1) |
07/12/2019
| Implemented |