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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(2) | Individual #1's mattress and box spring are directly on the floor. | In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. | Point of Caring, Inc. was in violation of 55 PA code 6400.81(k)(2), by failing to ensure that one of the individuals had a bed frame. This violation occurred due to a lack of training for the house administrator. When discussing the lack of a bed frame with the individual, the individual stated that he did not like his bedframe and asked for it to be removed, because he was hitting his toe on the leg of the bedframe. The house administrator failed to inform the program specialist regarding the individual¿s wishes, thus resulting in failure to document this request in the individual¿s SEEP, Assessment, and in his ISP. It is important to meet the individual¿s needs and wishes, while maintaining record of these wishes in order to ensure that the individual is afforded all necessities and to document that all necessities are offered and available if the individual should change his/her mind.
In order to correct this violation and ensure the individual has access to a bed frame, a bed frame was ordered and was placed in his bedroom, on Monday, February 13, 2023 as soon as it arrived in the mail. 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 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 on or before February 10, 2022. In addition to this training, Point of Caring, Inc. has conducted a informational meeting with the house administrators, 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 at 3:00 pm. At this meeting all house administrators will be reminded of the importance of communicating all wants and needs that pertain to the physical site regulations and the individual¿s desire not to adhere to these regulations, in order to work with the individual and attempt to accommodate the individual and the 55 P Code 6400 regulations. All trainings will be maintained in the personnel files, as proof of compliance with the plan of correction. Upon discovery that the individual did not like his bed frame, Point of Caring ordered a bed frame that does not have legs to hurt his toe as it has padding for extra safety from injury. The individual agreed to try the new frame. The individual¿s SEEP, assessment and ISP has been updated to reflect the concerns of the individual. If the individual decides he does not want the new bed frame, it will be stored in the home and placed in his room immediately upon his request. |
02/17/2023
| Implemented |
| 6400.216(a) | At 2:40PM 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 cabinet in the living room of the home. | An individual's records shall be kept locked when unattended.
| Point of Caring, Inc. was in violation of 55 PA code 6400.216(a), by failing to ensure that individuals¿ records are locked when unattended. This violation occurred due to a lack of training for house administrators and staff, and the failure to implement a 2-point checking system. Adhering to individual records location regulations are critical in protecting individuals¿ privacy.
In order to protect the individuals¿ privacy, the documentation books were locked immediately. To ensure regulatory compliance and avoid violations of 55 PA code 6400.216(a), Point of Caring, Inc. will provide additional training to the house administrator direct care staff on individual privacy regulations within the Regulatory Compliance Guide 55 PA Code 6400.216(a), which outlines the 55 Pa Code 6400 regulations regarding regulatory compliance and Point of Caring, Inc.¿s Individual Record Policy and Procedure, ensuring individual privacy. This training will be completed as of February 10, 2022. In addition to this training, Point of Caring, Inc. has conducted an informational meeting with the house administrator, to discuss this regulatory violation and the importance of ensuring all individual privacy, and their responsibility to ensure all individual records are locked at all times when they are not in use to ensure regulatory compliance. This meeting will be conducted February 16, 2023 at 3:00 pm. A house meeting held on Tuesday, February 7, 2023 at 9:00 am for all direct care staff at that site discussed the violation at the home and all staff were trained on the 55 PA code 6400.216(a) and the importance of maintaining the individuals¿ privacy. 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 |
| 6400.214(b) | During the inspection on 2/16/2022, Individual #1, Individual #2, and Individual #3s' most recent dental examination, dental hygiene plan, and incident reports relating to the individual were not present in the home. | 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(a), by failing to keep individuals¿ current record information at their home. This violation occurred due to a lack of training for house administrators and staff, and the failure to implement a 2-point checking system. Proper record keeping within the home is critical as it allows for immediate access of crucial information in the event that an individual is missing, or experiences a medical or behavioral emergency requiring immediate treatment.
To ensure regulatory compliance and avoid violations of 55 PA code 6400.214(a), Point of Caring, Inc. will provide additional training to all staff on Point of Caring, Inc.¿s Individual Records Policy and Procedure, which outlines the 55 Pa Code 6400 regulations regarding regulatory compliance maintaining the required record information. in the individual¿s home. This training will be completed as of March 15, 2022. In addition to this training, Point of Caring, Inc. has conducted a remote training with the house administrators, to discuss this regulatory violation and the importance of maintaining all required record information at the home, and their responsibility to review the record information, to ensure regulatory compliance. This meeting was conducted February 23, 2022, and a hard copy of Point of Caring, Inc.¿s Individual Record Policy and Procedure and notes from the meeting will be sent to the house administrators to be posted in every house. 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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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(d) | The fire drill held on 11/13/18 had an evacuation time of 2 minutes and 45 seconds. The home does not have an extended evacuation time in writing by a fire safety expert. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | February 7, 2019 the fire drill documentation form was updated and a step by step self training document was developed explaining how to document, what is required in each section and what is a successful drill versus a failed drill. All Point of Caring homes were notified of the updated form and were given the documentation training to be provided at each home. All employees must read, initial and date the self review training.
To prevent future incidences, Point of Caring, Inc. has added a procedure in the monthly fire drill documentation that requires all House Supervisors on the second to the last day of each month they review the fire drill documentation form. They are to review each line to ensure accuracy, completed in its entirety, and if all regulations were met to determine if it was a successful drill or failed drill. Every three months the Program Specialist will review the fire drill binders from each home to check for thoroughness and to ensure each regulation is being met. |
02/07/2019
| Implemented |
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