| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff person # 4's date of hire is 3/8/19, and their criminal history check was completed on 5/31/19.
Staff person #6's date of hire is 9/24/18, and their criminal history check was completed on12/17/18.
Staff person # 7's date of hire is 9/24/18, and their criminal history check was completed on 12/17/18. | 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 #4 has a current criminal background check. 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 within 5 working days after the person's date of hire. (Attachment 5) |
07/11/2019
| Implemented |
| 6400.46(f) | Staff #2 training record, it could not be determined during inspection, and no documentation found of fire safety training being conducted | 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 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 4) |
07/15/2019
| Implemented |
| 6400.67(a) | The Countertop in the kitchen was not in good repair and appeared to be bubbled up throughout | Floors, walls, ceilings and other surfaces shall be in good repair. | Work order has been submitted to remodel the kitchen in the home. Remodeling is set to start on 10/25/2019. Upon completion, Floors, walls, ceilings and other surfaces will be in good repair. Moving forward, Property manager and house manager will conduct quarterly inventory checks on all Floors, walls, ceilings and other surfaces to ensure that they are in good repair. If any surfaces require repair or replacement, the house manager will complete a work order and submit to the administrator. Repairs will be made within 7 calendar days. (Work Order, POC Attachment 12) |
11/08/2019
| Implemented |
| 6400.72(b) | The Screens in Individual #1 room and throughout home were not in good repair | Screens, windows and doors shall be in good repair. | Screens and windows in the home have been replaced and are in good repair. Moving forward, Property manager and house manager will conduct quarterly inventory checks on all Screens, windows and doors to ensure that they are in good repair. If Screens, windows and doors need repaired or replaced, the house manager will complete a work order and submit to the administrator. Repairs will be made within 7 calendar days. |
07/19/2019
| Implemented |
| 6400.110(e) | The interconnected fire alarm system was not working at the time of physical site inspection. The house contained 3 levels, basement, main level and attic. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Interconnected fire alarm at the site has been serviced and in in good working order. Monthly, after every fire drill, house manager and property manager will test the system to ensure that all smoke detectors on each floor interconnected and audible throughout the home. In the event that the interconnected system is not in good working order, the property manager will complete a work order and have the system maintenance within 24hours. |
07/12/2019
| Implemented |
| 6400.141(c)(4) | The physical exam dated 3/15/19 for individual #2 did not include a hearing screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | : Individual #2 Physical has been updated to include Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Moving forward, Agape Family Home's nurse will review all individual physicals to ensure that physical examinations include Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. (POC Attachment 11) |
07/15/2019
| Implemented |
| 6400.46(a) | Program Specialist, records does not include documentation of Orientation before working with Individuals. | 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. | Program Specialist received orientation 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 prior to working with individuals. Training materials were in program specialist file upon review. However, sign In sheets on the above training topics was not in the file. Sign in sheets have been placed in the program specialist file. Moving forward, administrator will ensure that all staff receive orientation and training materials/sign in sheets placed in personnel files and available for review. (POC Attachment 10) |
07/12/2019
| Implemented |