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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | There is not a screen in Individual #1's bedroom window. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Point of Caring, Inc. was in violation of 55 PA code 6400.72(a), by failing to ensure that all windows that can open were fitted with screens. 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 this violation, a screen was placed in the individual¿s window immediately. To ensure regulatory compliance and avoid violations of 55 PA code 6400.72(a), 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. will conduct an 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 continued 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. |
02/16/2023
| Implemented |
| 6400.74 | The outside steps in the front of the home did not have a nonskid surface. | Interior stairs and outside steps shall have a nonskid surface.
| Point of Caring, Inc. was in violation of 55 PA code 6400.74, by failing to ensure that all interior and exterior steps have a nonskid surface. 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 reduce the risk of falling when ascending or descending stairs for the individuals we serve.
In order to ensure the safety of the individual and avoid an accidental fall, and anti-skid surface was installed on the outside steps immediately. To ensure regulatory compliance and avoid violations of 55 PA code 6400.74, 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. will conduct an 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 continued 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. |
02/16/2023
| Implemented |
| 6400.142(a) | Individual #1's most recent dental examination was completed on 4/13/2021. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Point of Caring, Inc. was in violation of 55 PA code 6400.142(a), by failing to ensure that a dental examination was completed annually. This violation occurred due to a of lack of knowledge regarding completing regular and consistent follow up communications with the dental facility regarding the scheduling of the dental appointment. Adhering to dental requirements regulations is critical in providing necessary dental care to ensure adequate dental health for the individual.
In order to correct this violation and ensure the individual is receiving necessary dental care, an appointment with Accessible Dental has been scheduled for March 9, 2023 at 12:30 pm. To ensure regulatory compliance and avoid future violations of 55 PA code 6400.142(a), Point of Caring, Inc. will provide additional training to the house administrator and the office personnel in charge of medical oversight on dental regulations within the Regulatory Compliance Guide 55 PA Code 6400.142(a) regulations regarding regulatory compliance maintaining annual dental examination requirements for all individuals receiving services from Point of Caring, Inc. This training will be completed as of February 10, 2022. In addition to this training, Point of Caring, Inc. will conduct an administrative meeting with the house administrator, to discuss this regulatory violation and the importance of ensuring all individuals need to have an annual dental examination completed and documented. This meeting is scheduled for Thursday 16, 2023 at 3:00 pm. All trainings will be maintained in the personnel files, as proof of compliance with the plan of correction. |
02/16/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.166(a)(8) | During the inspection on 2/15/2022, Individual #1's February 2022 medication administration record did not include route of administration for the following medications: Star Dawg Northern Lights Haze and Garlic Cookies. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | Point of Caring, Inc. was in violation of 55 Pa Code Chapter 6400.166(a)(8), by failing to document the route of administration for medical marijuana listed in the MAR, 6400.166(a)(10), failing to record the administration time for a stool softener when rewriting the prescription in the MAR, 6400.166(a)(11), failing to record a diagnosis/purpose for multiple prescriptions listed in the MAR, and 6400.166(a)(13), failing to initial for the administration of a medication in the MAR. Proper medication record use and compliance is critical, as it creates a record of proper medication administration, allows physicians and emergency rooms to know when a medication was last administered, and creates a system to account for medications, especially controlled substances. This violation occurred, due to lack of training for house administrators and medication administration trained staff, and the failure to implement a 2-point checking system.
In order to ensure regulatory compliance and avoid future violations of 55 Pa Code Chapter 6400.166(a)(8), 6400.166(a)(10), 6400.166(a)(11), and 6400.166(a)(13), Point of Caring, Inc. will provide training to all medication administration trained staff on Point of Caring, Inc. Medication Policy and Procedure, which outlines the 55 Pa Code 6400 regulations regarding regulatory compliance in medication records. This policy addresses all of the above mentioned violations. This training will be completed as of March 15, 2022. In addition to this training, Point of Caring, Inc. is conducting a remote training with the house administrators, to discuss these regulation violations and the importance of maintaining complete and accurate medical records, and their responsibility to review the medical administration records, at the beginning of every shift, to ensure accurate and complete medication records and will serve as a 2-point checking system. This meeting will be conducted Wednesday February 23, 2022, and a hard copy of Point of Caring, Inc.¿s Medication Policy and Procedure and notes from the meeting will be sent to the house administrators to be posted in the office of every house, where medications and medication records are stored and medications are administered. All trainings will be maintained in the personnel files, as proof of compliance with the plan of correction. |
03/15/2022
| Implemented |
| 6400.166(a)(10) | During the inspection on 2/15/2022, Individual #1's February 2022 medication administration record did not include administration times for Stool Softener 8.6-50mg tablet. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | Point of Caring, Inc. was in violation of 55 Pa Code Chapter 6400.166(a)(8), by failing to document the route of administration for medical marijuana listed in the MAR, 6400.166(a)(10), failing to record the administration time for a stool softener when rewriting the prescription in the MAR, 6400.166(a)(11), failing to record a diagnosis/purpose for multiple prescriptions listed in the MAR, and 6400.166(a)(13), failing to initial for the administration of a medication in the MAR. Proper medication record use and compliance is critical, as it creates a record of proper medication administration, allows physicians and emergency rooms to know when a medication was last administered, and creates a system to account for medications, especially controlled substances. This violation occurred, due to lack of training for house administrators and medication administration trained staff, and the failure to implement a 2-point checking system.
In order to ensure regulatory compliance and avoid future violations of 55 Pa Code Chapter 6400.166(a)(8), 6400.166(a)(10), 6400.166(a)(11), and 6400.166(a)(13), Point of Caring, Inc. will provide training to all medication administration trained staff on Point of Caring, Inc. Medication Policy and Procedure, which outlines the 55 Pa Code 6400 regulations regarding regulatory compliance in medication records. This policy addresses all of the above mentioned violations. This training will be completed as of March 15, 2022. In addition to this training, Point of Caring, Inc. is conducting a remote training with the house administrators, to discuss these regulation violations and the importance of maintaining complete and accurate medical records, and their responsibility to review the medical administration records, at the beginning of every shift, to ensure accurate and complete medication records and will serve as a 2-point checking system. This meeting will be conducted Wednesday February 23, 2022, and a hard copy of Point of Caring, Inc.¿s Medication Policy and Procedure and notes from the meeting will be sent to the house administrators to be posted in the office of every house, where medications and medication records are stored and medications are administered. All trainings will be maintained in the personnel files, as proof of compliance with the plan of correction. |
03/15/2022
| Implemented |
| 6400.166(a)(11) | During the inspection on 2/15/2022, Individual #1's February 2022 medication administration record did not include diagnosis or purpose for the following medications: Chlorpromazine 200mg tablet, Clomipramine 50mg capsule, Haloperidol 5mg tablet, Star Dawg Northern Lights Haze, and Garlic Cookies. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Point of Caring, Inc. was in violation of 55 Pa Code Chapter 6400.166(a)(8), by failing to document the route of administration for medical marijuana listed in the MAR, 6400.166(a)(10), failing to record the administration time for a stool softener when rewriting the prescription in the MAR, 6400.166(a)(11), failing to record a diagnosis/purpose for multiple prescriptions listed in the MAR, and 6400.166(a)(13), failing to initial for the administration of a medication in the MAR. Proper medication record use and compliance is critical, as it creates a record of proper medication administration, allows physicians and emergency rooms to know when a medication was last administered, and creates a system to account for medications, especially controlled substances. This violation occurred, due to lack of training for house administrators and medication administration trained staff, and the failure to implement a 2-point checking system.
In order to ensure regulatory compliance and avoid future violations of 55 Pa Code Chapter 6400.166(a)(8), 6400.166(a)(10), 6400.166(a)(11), and 6400.166(a)(13), Point of Caring, Inc. will provide training to all medication administration trained staff on Point of Caring, Inc. Medication Policy and Procedure, which outlines the 55 Pa Code 6400 regulations regarding regulatory compliance in medication records. This policy addresses all of the above mentioned violations. This training will be completed as of March 15, 2022. In addition to this training, Point of Caring, Inc. is conducting a remote training with the house administrators, to discuss these regulation violations and the importance of maintaining complete and accurate medical records, and their responsibility to review the medical administration records, at the beginning of every shift, to ensure accurate and complete medication records and will serve as a 2-point checking system. This meeting will be conducted Wednesday February 23, 2022, and a hard copy of Point of Caring, Inc.¿s Medication Policy and Procedure and notes from the meeting will be sent to the house administrators to be posted in the office of every house, where medications and medication records are stored and medications are administered. All trainings will be maintained in the personnel files, as proof of compliance with the plan of correction. |
03/15/2022
| Implemented |
| 6400.166(a)(13) | During the inspection on 2/15/2022, Individual #1's February 2022 medication administration record did not include Name and initials of the person administering the medication for Desmopressin 0.2mg tablet on 2/2/22 at 8:00pm. | 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 Chapter 6400.166(a)(8), by failing to document the route of administration for medical marijuana listed in the MAR, 6400.166(a)(10), failing to record the administration time for a stool softener when rewriting the prescription in the MAR, 6400.166(a)(11), failing to record a diagnosis/purpose for multiple prescriptions listed in the MAR, and 6400.166(a)(13), failing to initial for the administration of a medication in the MAR. Proper medication record use and compliance is critical, as it creates a record of proper medication administration, allows physicians and emergency rooms to know when a medication was last administered, and creates a system to account for medications, especially controlled substances. This violation occurred, due to lack of training for house administrators and medication administration trained staff, and the failure to implement a 2-point checking system.
In order to ensure regulatory compliance and avoid future violations of 55 Pa Code Chapter 6400.166(a)(8), 6400.166(a)(10), 6400.166(a)(11), and 6400.166(a)(13), Point of Caring, Inc. will provide training to all medication administration trained staff on Point of Caring, Inc. Medication Policy and Procedure, which outlines the 55 Pa Code 6400 regulations regarding regulatory compliance in medication records. This policy addresses all of the above mentioned violations. This training will be completed as of March 15, 2022. In addition to this training, Point of Caring, Inc. is conducting a remote training with the house administrators, to discuss these regulation violations and the importance of maintaining complete and accurate medical records, and their responsibility to review the medical administration records, at the beginning of every shift, to ensure accurate and complete medication records and will serve as a 2-point checking system. This meeting will be conducted Wednesday February 23, 2022, and a hard copy of Point of Caring, Inc.¿s Medication Policy and Procedure and notes from the meeting will be sent to the house administrators to be posted in the office of every house, where medications and medication records are stored and medications are administered. All trainings will be maintained in the personnel files, as proof of compliance with the plan of correction. |
03/15/2022
| Implemented |
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