| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Staff #3 was hired on 1/1/2018. A copy of her criminal history check was not in her file. Staff #4 was hired on 1/1/2018. He didn't have a criminal history check until 2/8/2018. | 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.
| Criminal history checks have been completed on Staff #3 and Staff #4. Prior to an official offer of employment Agape Human Services will procure documentation indicating a Pennsylvania criminal history record check was submitted to the State Police within 5 working days after the person's date of hire. |
05/14/2018
| Implemented |
| 6400.31(b) | Individual #1 was admitted on 1/14/2018. As of the date of this inspection, his Individual Rights have not been signed. | Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. | Individual #1 and his partent reviewd and signed his Individual Rights on 4/3/18. At the time of admission all individuals admitted to Agape Human Services will sign and date a statement acknowledging receipt of information on their individual rights. The individual will also acknowledge receipt of information on their individual rights annually. |
04/03/2018
| Implemented |
| 6400.110(e) | There are 4 stories in this residence. There interconnected alarms were not working properly. Only the basement & 1st floor were connected to each other. The 2nd floor and attic operated separately. | 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. | The smoke alarms were repaired and are working properly. On an monthly basis the smoke alarms will be tested by the House Manager and/or Program Specialist. Alarms not in working order will be replaced immediately. |
04/04/2018
| Implemented |
| 6400.113(a) | Individual #1 was admitted on 1/14/2018. There is no documentation of him receiving initial fire safety training. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. | Individual #1 received the initial fire safety training on 1/20/18. A receipt of receiving the initial fire safety training has been added to his personal folder. Upon admission to Agape Human Services and annually thereafter, all individuals will receive 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 and smoking safety procedures if individuals smoke at the home. A receipt of receiving fire safety training has been added to their personal folder. |
04/04/2018
| Implemented |
| 6400.141(a) | Individual #1 was admitted on 1/14/2018. He didn't have a physical exam until 1/16/2018. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Prior to admitting any individual to Agape Human Services, Agape Human Services will require the individual has completed a physical examination within 12 months prior to admission
((The Program Specialist will be retrained on the requirements of this regulation. The Program Specialist will be responsible for ensuring completed physicals are procured prior to admission -CH 5/24/2018)) |
05/14/2018
| Implemented |
| 6400.141(c)(1) | This section was not addressed on Individual #1's physical exam dated 1/16/2018. | The physical examination shall include: A review of previous medical history. | Individual 1 was given a physical exam on 4/17/18. The physical examination did include a review of his medical history. Agape Human Services did obtain a new physical examination form which includes a review of previous medical history. This form will be used for all future physical examinations. |
04/17/2018
| Implemented |
| 6400.141(c)(2) | This section was not addressed on Individual #1's physical exam dated 1/16/2018. | The physical examination shall include: A general physical examination. | Individual 1 was given a physical exam on 4/17/18. The physical examination did include a rgeneral physical examination. Agape Human Services did obtain a new physical examination form which includes a rgeneral physical examination. This form will be used for all future physical examinations. |
04/17/2018
| Implemented |
| 6400.141(c)(3) | This section was not addressed on Individual #1's physical exam dated 1/16/2018. | 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 was given a physical exam on 4/17/18. The physical examination did include a immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. Agape Human Services did obtain a new physical examination form which includes a immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. This form will be used for all future physical examinations. |
04/17/2018
| Implemented |
| 6400.141(c)(4) | This section was not addressed on Individual #1's physical exam dated 1/16/2018. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual 1 was given a physical exam on 4/17/18. The physical examination did include vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Agape Human Services did obtain a new physical examination form which includes a vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. This form will be used for all future physical examinations. |
04/17/2018
| Implemented |
| 6400.141(c)(6) | This section was not addressed on Individual #1's physical exam dated 1/16/2018. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Individual 1 was given a physical exam on 4/17/18. The physical examination did include Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Agape Human Services did obtain a new physical examination form which includes Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. This form will be used for all future physical examinations. |
04/17/2018
| Implemented |
| 6400.141(c)(10) | This section was not addressed on Individual #1's physical exam dated 1/16/2018. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Individual 1 was given a physical exam on 4/17/18. The physical examination did include specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. Agape Human Services did obtain a new physical examination form which includes Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. This form will be used for all future physical examinations. |
04/17/2018
| Implemented |
| 6400.141(c)(11) | This section was not addressed on Individual #1's physical exam dated 1/16/2018. | 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. | Individual 1 was given a physical exam on 4/17/18. The physical examination did include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Agape Human Services did obtain a new physical examination form which includes an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This form will be used for all future physical examinations. |
04/17/2018
| Implemented |
| 6400.141(c)(12) | This section was not addressed on Individual #1's physical exam dated 1/16/2018. | The physical examination shall include: Physical limitations of the individual. | Individual 1 was given a physical exam on 4/17/18. The physical examination did include physical limitations of the individual. Agape Human Services did obtain a new physical examination form which includes physical limitations of the individual. This form will be used for all future physical examinations. |
04/17/2018
| Implemented |
| 6400.141(c)(14) | This section was not addressed on Individual #1's physical exam dated 1/16/2018. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual 1 was given a physical exam on 4/17/18. The physical examination did include medical information pertinent to diagnosis and treatment in case of an emergency. Agape Human Services did obtain a new physical examination form which includes Medical information pertinent to diagnosis and treatment in case of an emergency. This form will be used for all future physical examinations. |
04/17/2018
| Implemented |
| 6400.141(c)(15) | This section was not addressed on Individual #1's physical exam dated 1/16/2018. | The physical examination shall include:Special instructions for the individual's diet. | Individual 1 was given a physical exam on 4/17/18. The physical examination did include special instructions for the individual's diet. Agape Human Services did obtain a new physical examination form which includes special instructions for the individual's diet. This form will be used for all future physical examinations. |
04/17/2018
| Implemented |
| 6400.151(a) | Staff #1 was hired on 7/1/2017. He did not have a physical exam until 1/23/2018. Staff #2 was hired on 7/1/2017. Her physical exam was not in her record. Staff #3 was hired on 1/1/2018. Her most current physical exam is dated 12/6/2016. Staff #4 was hired on 1/1/2018. His physical exam was not in his record. | 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. | Prior to an official offer of employment Agape Human Services will procure documentation indicating a physical examinaiton within 6 months prior to employment offer.
((Staff #2, Staff #3, and Staff #4 will have a physical examinations completed. Program Specialist will be retrained in the requirements of this regulations. -CH 5/24/2018)) |
05/14/2018
| Implemented |
| 6400.151(c)(2) | Staff #1 was hired on 7/1/2017. He did not have a TB test until 1/23/2018. Staff #3 was hired on 1/1/2018. Her most current TB test was dated 10/31/2016. Staff #4 was hired on 1/1/2018. He didn't have a TB test until 3/8/2018. | 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. | Prior to an official offer of employment Agape Human Services will procure documentation indicating a tuberculin test by Mantoux method with a negative result was completed during aphysical examinaiton within 12 months prior to employment offer.
((The Program Specialist will be retrained in the requirements of this regulations -CH 5/24/2018)) |
05/14/2018
| Implemented |
| 6400.168(a) | Staff #2 has been passing medications since Individual #1's admission on 1/14/2018. Documentation of her initial med training is not in her record. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | 1. Staff #2's initial med training has been added to her training record.
2. Prior to passing medications, House Manager and Director will ensure staffs' initial med training certification is included on training record. |
05/14/2018
| Implemented |
| 6400.168(d) | Staff #2 has been passing medications since Individual #1's admission on 1/14/2018. Documentation of her annual practicum is not in her record. | A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | 1. Staff #2's initial med training has been added to her training record.
2. Prior to passing medications, House Manager and Director will ensure staffs' initial med training certification is included on training record.
((Staff #2 had medication administration training on 1/25/18 -CH 5/30/2018)) |
05/14/2018
| Implemented |
| 6400.181(e)(10) | This area wasn't evaluated on Individual #1's assessment dated 2/14/2018. | The assessment must include the following information: A lifetime medical history. | Lifetime medical history will be attached to Indiviual #1's assessment. |
05/16/2018
| Implemented |
| 6400.181(e)(12) | There were no recommendations in Individual #1's assessment dated 2/14/2018. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The following recommendedations for training has been added to Individual #1's assessment:
I will clean the kitchen table after each meal with 5 verbal/gestural cues.
I will be provided the opportunities to take part in activities outside of my home on a monthly basis.
I will brush my teeth for 10 seconds with hand over hand cues. |
05/16/2018
| Implemented |
| 6400.181(e)(13)(viii) | This area wasn't evaluated on Individual #1's assessment dated 2/14/2018. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | The following statement has been added to Individual #1's assessment, "Individual needs full assistance with managing his personal property. No changes have been noted in the past 365 days." |
05/29/2018
| Implemented |
| 6400.181(e)(14) | This area wasn't evaluated on Individual #1's assessment dated 2/14/2018. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The following has been included in the assessment: Individual #1's day program states he enjoys swimming. He will tread in shallow water. He must wear a vest when in deep water. He will not enter waters he does not feel safe in. Whenever Individual #1 is in a large open body of water he would need eyesight supervision at all times to maintain his safety while swimming. Future assessments will contain a section specific to water safety and ability to swim. |
05/14/2018
| Implemented |
| 6400.213(1)(i) | Identifying marks are not listed in Individual #1's record. | Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.
| A body outline containing any identifying marks and placement of identifying marks will be placed in Individual #1's record. Upon admission to Agape Human Services the House Manager and/or Program Specialist will conduct an initial full body check which will document all identifying marks. |
04/04/2018
| Implemented |