| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | There was a gallon of milk located in the refrigerator of the home that was dated 3/12/22. The milk was clearly curdled. | Clean and sanitary conditions shall be maintained in the home. | Immediately discard gallon of mik in the refrigerator of the home that was dated 3/12/22. Staff has been addressed and retrained on the necessity to checking food in both refrigerators and freezer. |
06/14/2022
| Implemented |
| 6400.67(a) | There was a hole in the ceiling in the garage that appeared to have water damage. There was insulation exposed from the hole that was covered in a black substance. It is unclear what the substance was.
The screen door on the sliding doors exiting the lower level of the home fell off the track when the Licensing Rep attempted to open the door.
There were two broken chairs next to the sliding door in the backyard.
There was a broken umbrella laying in the shrubs behind the home.
There was a rusted-out fire pit in the backyard of the home. The fire pit, if used would present as a fire hazard as there was no bottom to it.
The railing going the stairs upon entering the front door of the home was loose.
The close door in Individual #3's bedroom was off the tracks.
The dryer vent on the outside of the home was full of lint presenting a fire hazard. | Floors, walls, ceilings and other surfaces shall be in good repair. | Replace screen door on the sliding doors exiting the lower level of the home
Remove the two broken chairs next to the sliding door in the backyard.
Remove broken umbrella laying in the shrubs behind the home.
There was a rusted-out fire pit in the backyard of the home. The fire pit, if used would present as a fire hazard as there was no bottom to it.
Fixed railing going the stairs upon entering the front door of the home was loose.
Fixed close door in Individual #3's bedroom was off the tracks.
Cleaned dryer vent on the outside of the home was full of lint presenting a fire hazard.
Repaired ceiling. |
07/31/2021
| Implemented |
| 6400.114(b) | There was a glass jar outside of the home next to the sliding doors in the back of the home that was full of cigarette butts. The home's smoking policy indicates that smoking should take place 50 feet from the home. | Written smoking safety procedures shall be followed. | The individual in the home smokes and use glass jar outside of the home. Removed the glass jar outside of the home and re-educated individuals regarding the smoking policy. An outdoor ash trail has been outside for the individual to use. |
06/15/2022
| Implemented |
| 6400.141(c)(4) | Individual #2's annual vision exam was completed 41 days late. Individual #2 had a vision exam completed on 12/23/20. Individual #2 was scheduled for an annual vision exam on 12/8/21 that was rescheduled to 1/10/22. The 1/10/22 exam was not attended and individual #2 did not have an annual vision exam until 2/2/22. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | Individual #2 was scheduled for his annual eye examination on 12/23/2021 but was reschedule twice by Lehigh Valley Eye associates (from 12/23/21 to 1/10/2022 and then from 1/10/2022 to 2/2/2022) on December 13,2021. Agape Human Service also emailed the Support Coordinator on December 13,2022 regarding the second re-schedule appointment. Agape spoke with Lehigh Valley Eyes associates and fax documentation verifying rescheduledappointment. |
07/26/2022
| Implemented |
| 6400.141(c)(9) | Individual #2 did not have an annual prostate examination completed the most recent prostate examination was completed on 2/4/21. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Scheduled a prostate examination for individual for August 4, 2022 and then will have PCP complete prostate during next physical examination in February 2023. |
08/04/2022
| Implemented |
| 6400.181(e)(14) | Individual #2's annual assessment dated 12/28/21 does not address the individual's ability to swim. The assessment states that the individual has not expressed any interest in going to the pool. Staff believes that the individual needs to be supervised at all times when near large bodies of water. | 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 Program Specialist, going forward will update the assessment with no-change in individual #1 ability to swim for the next annual assessment sent to the Support Coordinator. Individual #2 next schedule annual ISP Review will around the February 2023 timeframe. |
07/26/2022
| Implemented |
| 6400.15(b) | There was not a self-assessment of homes completed on the Department's licensing inspection instrument. The self-assessment was completed on a self-assessment score sheet. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | The plan of correction is to use the Department¿s licensing inspection instruction rather than the self-assessment score for all residential service locations. The next self-inspection must be scheduled 3-6 month before the expiration of the certificate which should be between November 2022 and Februrary 2023. Agape will use the correct licensing inspection instrument for the home. |
07/31/2022
| Implemented |
| 6400.51(b)(5) | Staff #7 did not receive orientation training in job-related knowledge and skills, specifically training in Behavior Support Plans. | The orientation must encompass the following areas: Job-related knowledge and skills. | Program specialists, direct service workers and drivers of and aides staff will receive annual training on the safe and appropriate use of behavior supports for the 2022 Calendar Training. |
12/31/2022
| Implemented |
| 6400.52(c)(5) | Staff #6 was not trained in the safe and appropriate use of behavior supports if the person works directly with an individual. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Program specialists, direct service workers and drivers of and aides staff will receive annual training on the safe and appropriate use of behavior supports for the 2022 Calendar Training |
12/31/2022
| Implemented |
| 6400.52(c)(6) | Staff #6 did not receive annual training in the implementation of the individual plan if the person works directly with an individual. | 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 #6 reviewed the individual plan but did not sign off on documentation. The individual support plan for all individuals will review provide sign off on documentation. |
08/05/2022
| Implemented |
| 6400.163(h) | Individual #3 was prescribed Risperidone 1mg tablet, take one tablet by mouth at bedtime for psychosis, "noncycle" please reorder 8/11/21. Risperidone 0.5mg tablet take one tablet by mouth every night at bedtime, "noncycle" please reorder 8/19/21, aripiprazole 2mg tablet, take one tablet by mouth at bedtime "noncycle" please reorder, expired 9/27/21 and Flonase 50mg, instill 2 sprays in each nostril everyday for allergies, expired 1/21/20. These medications were found in a supply closed in the basement. There was a package of Gentle Stool softener, Docusate sodium 100mg located in a supply closet. There was no label on the medication and the medication was expired in 5/2021. Staff indicated that the medications were expired or discontinued, and this was where they placed them. Medications are not being disposed of properly upon discontinuation or expiration. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Agape discarded all discontinued medication according to Federal and State status and regulations |
06/15/2022
| Implemented |
| 6400.166(a)(4) | Individual #2 is prescribed MVI (multivitamin). The medication administration record did not include the name of medicine. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | The PCP provided a prescription for individuals Centrum Silver multivitamin. August MAR is updated with the name of vitamin "Centrum Silver" |
07/31/2022
| Implemented |
| 6400.166(a)(6) | Individual #2 is prescribed MVI (multivitamin). The medication administration record did not include the dosage form. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | The PCP provided a prescription for individual for Centrum Silver multivitamin to be adminstered daily (BD) |
07/31/2022
| Implemented |
| 6400.166(a)(7) | Individual #2 is prescribed MVI (multivitamin). The medication administration record did not include the dose of medicine. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The PCP provided a prescription for individuals Centrum Silver multivitamin. Since this is a multivitamin there is are no dosage (mg) on the bottle. |
07/30/2022
| Implemented |
| 6400.166(a)(8) | Individual #2 is prescribed MVI (multivitamin). The medication administration record did not include the route of administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | The MAR has been updated to include route of administration for the multiple vitamin (Centrum Silver) |
08/01/2022
| Implemented |
| 6400.166(a)(15) | Individual #2 is prescribed Calcium 500mg, adult take one 1-2x's daily with water and a meal. The medication administration record (MAR) does not include the special precautions of taking the medication with water and a meal. Individual #2 is prescribed CoQ10 100mg, take one (1) soft gel daily with the meal of your choice. The MAR states to take 1 cap by mouth daily. It does not include the special precaution to take with a meal of your choice. Individual #2 is prescribed Magnesuim 400mg, for adults, take one soft gel daily, preferably with a meal. The MAR states: take 1 cap by mouth daily and does not include the special precaution of preferably taking with a meal. Individual #2 is prescribed MVI (multivitamin). The MAR did not include the special precautions of taking the medication with food. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. | The special precaution for taking medication with food has been updated in the MAR |
08/01/2022
| Implemented |