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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | At 11:37AM on 1/26/2023, an aerosol can of Spray Disinfectant with directions to contact Poison Control if ingested was in the unlocked and accessible in the cabinet above the toilet in the bathroom on the first floor of the home. Individual #1's Individual Service Plan, dated 12/19/2022 states Individual #1 "IS NOT AWARE OF THE DANGERS OF POISONOUS SUBSTANCES. THESE SUBSTANCES SHOULD BE LOCKED SO THAT [Individual #1] DOES NOT HAVE ACCESS TO THEM." | Poisonous materials shall be kept locked or made inaccessible to individuals. | Point of Caring, Inc. was in violation of 55 PA code 6400.62(a), by failing to ensure that poisonous materials were locked or made inaccessible to the individuals. This violation occurred due to a of lack of attention to ensuring all poisons in the home being locked or inaccessible to the individuals in the home. Adhering to this physical site regulation is critical in providing necessary safety for the individuals by ensuring that an individual will not be harmed by exposure to harmful substances.
To ensure the safety of the individuals residing at the site, the disinfectant spray was returned to the locked cabinet immediately. To ensure regulatory compliance and avoid violations of 55 PA code 6400.62(a), Point of Caring, Inc. will provide additional training to the house administrator and direct care staff that work at this site. This training will be completed at a house meeting scheduled for Friday February 17, 2022 at 9:00 am. All trainings will be maintained in the personnel files, as proof of compliance with the plan of correction. |
02/17/2023
| Implemented |
| 6400.72(b) | There is a one inch hole in the screen in Individual #1's bedroom window. There are two holes, two inches by one inch and one inch by a half inch, in the screen in Individual #2's bedroom window. | Screens, windows and doors shall be in good repair. | Point of Caring, Inc. was in violation of 55 PA code 6400.72(b), by failing to ensure that all windows that can open were fitted with screens that are in good repair. This violation occurred due to a lack of training for house administrators and maintenance staff, and the failure to implement a 2-point checking system. Adhering to site regulations is critical in providing a safe and clean environment for the individuals we serve.
In order to correct the violation, the screens were replaced immediately. To ensure regulatory compliance and avoid violations of 55 PA code 6400.72(b), Point of Caring, Inc. will provide additional training to the house administrator and maintenance staff on physical site regulations within the Regulatory Compliance Guide 55 PA Code 6400.61 through 6400.84, which outlines the 55 Pa Code 6400 regulations regarding regulatory compliance maintaining the mandatory physical site requirements in the individual¿s home. This training will be completed as of February 10, 2022. In addition to this training, Point of Caring, Inc. has conducted informational meeting with the house administrator, to discuss this regulatory violation and the importance of ensuring all mandatory physical site requirements at the home, and their responsibility to conduct physical site inspections monthly, to ensure regulatory compliance. This meeting will be conducted February 16, 2023. All trainings will be maintained in the personnel files, as proof of compliance with the plan of correction. |
02/17/2023
| Implemented |
| 6400.214(b) | At 12:00PM on 1/26/23, Individual #3's most recent Individual Service Plan was not at the home. [Repeat Violation, 2/16/2023] | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Point of Caring, Inc. was in violation of 55 PA code 6400.214(b), by failing to ensure that the most recent ISP for an individual was stored at the home. This violation occurred due to an oversight by the house administrator and the direct care staff that work at this site. Adhering to this regulation is critical in providing necessary information on the individuals by ensuring that the most recent and up to date ISP was available at the home. It is important that all staff have access to the imperative information regarding the individuals in their care.
To ensure regulatory compliance and avoid violations of 55 PA code 6400.214(b), Point of Caring, Inc. replaced the out of date ISP with a current one immediately. To avoid future violations of 55 PA Code 6400.214(b) Point of Caring, Inc. will provide training to the house administrator and all direct care staff that work at this site. This training will be completed at a house meeting scheduled for Friday February 17, 2022 at 9:00 am. All trainings will be maintained in the personnel files, as proof of compliance with the plan of correction. |
02/17/2023
| Implemented |
| 6400.216(a) | At 11:20AM on 1/26/2023, Individual #1, Individual #2 and Individual #3's records including but not limited to their demographic sheets with Social Security Numbers, Individual Service Plans and Individual Assessments were unlocked in a room in the front of the home. | An individual's records shall be kept locked when unattended.
| Point of Caring, Inc. was in violation of 55 PA code 6400.77(b), by failing to ensure the first aid kit in the home had a manual. This violation occurred due to an of the house administrators and the failure to implement a 2-point checking system. Adhering to this regulation is important in ensuring that all direct care staff have information on how to properly utilize the materials maintained in the first aid kit, and the ability to provide necessary first aid to the individual in a correct and timely manner.
In order to protect the individuals¿ privacy the documentation was locked immediately. To ensure regulatory compliance and avoid future violations of 55 PA code 6400.77(b), Point of Caring, Inc. will provide additional training to the house administrator on the Regulatory Compliance Guide 55 PA Code 6400.77(b), which outlines the 55 Pa Code 6400 regulations regarding regulatory compliance. This training will be completed as of February 10, 2023. In addition to this training, Point of Caring, Inc. will conduct an informational meeting with the house administrator, to discuss this regulatory violation and the importance of adhering to the 55 PA Code 6400 regulations. This meeting will be conducted February 16, 2023 at 3:00 pm. All trainings will be maintained in the personnel files, as proof of compliance with the plan of correction. |
02/17/2023
| Implemented |
| 6400.166(a)(13) | Individual #1's January 2023 Medication Administration Record does not include the names of the employees administering the medications. [Repeat Violation, 2/16/2022] | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Point of Caring, Inc. was in violation of 55 PA code 6400.166(a)(13), by failing to ensure that the names and initials of the med trained personnel were located in the Medication Administration Record/Medical Binder. This violation occurred due to an oversight by the house administrator and the medication trained employees that work at this site. Adhering to this regulation is critical in providing necessary safety for the individuals by ensuring that all medications are administered by a medical trained employee.
In order to ensure that all personnel administering medications received medication administration training, the current signature sheet was placed in the individual¿s MAR. To ensure regulatory compliance and avoid violations of 55 PA code 6400.166(a)(13), Point of Caring, Inc. will provide remediation training, by Point of Caring¿s med trainer, for the house administrator and all med trained staff that work at this site. This training will be completed at a house meeting scheduled for Friday February 16, 2022 at 9:00 am. All trainings will be maintained in the personnel files, as proof of compliance with the plan of correction. |
02/17/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The bottom of the inside of the oven was covered with ash and grime causing a potential fire hazard. | Clean and sanitary conditions shall be maintained in the home. | Direct care staff were instructed to clean the oven on 2/12/2015. A picture of the cleaned oven was provided to the licensing agent on 2/12/2015. The House Administrator will be required to complete bi-weekly checks of the oven to ensure its cleanliness. A form has been created to document these checks. The House Administrator will be trained on the new form and on the importance of clean and sanitary conditions of the oven, which will be completed by 2/27/2015. |
02/27/2015
| Implemented |
| 6400.77(b) | The first aid kit did not contain scissors. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The House Administrator was instructed to replace the missing scissors on 2/13/2015. Monthly checks will be conducted by the House Administrator to ensure that scissors are located in the first aid kit. A form has been created in order to document the monthly checks. House Administrators will be trained on licensing requirements regarding contents of first aid kit. Training to be completed on 2/27/2015. |
02/27/2015
| Implemented |
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