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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.84 | The facility did not have an annual onsite fire safety inspection by a fire safety expert in 2022 or 2023. | The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept. | Point of Caring, Inc. was in violation of 55 PA code 2380.84, by failing to have a fire safety inspection conducted at their Adult Training Facility for the years 2022 and 2023. This violation occurred due to a lack of training for the adult training facility director and the CEO, and a failure to implement a 2-point checking system. Proper fire safety inspections are critical as it ensures Point of Caring, Inc. adult training facility is following department regulated fire safety protocol and regulations, as well as ensuring all equipment is in proper working condition, and ensuring the safety of the individuals attending the adult training facility.
To ensure regulatory compliance, a fire safety expert was contacted, and a department approved fire safety inspection was conducted on July 7, 2023. Point of Caring, Inc. passed the inspection and the report will be provided as supporting documentation in addition to the qualifications of the fire safety expert. |
07/07/2023
| Implemented |
| 2380.36(b) | Direct Service Professional #1, date of hire 12/13/17, most recent completed fire safety training was completed on 03/15/22. This exceeds the annual requirement. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Point of Caring, Inc. was in violation of 55 PA Code 2380.36(b), by failing to ensure an employee of Point of Caring, Inc. completed his fire safety training annually. This violation occurred due to a lack of training for the Point of Caring, Inc. personnel in charge of staff trainings, and the failure to implement a 2-point checking system. Annual fire safety trainings are critical as it ensures staff are trained on a proper and immediate response in the event of a fire.
To ensure regulatory compliance, the staff member received fire safety training on July 7, 2023. |
07/07/2023
| Implemented |
| 2380.155(b) | The behavior support component of the Restrictive Procedure Plan and Individual Support Plan for Individual #1, date of admission 12/10/13, was reviewed on 09/07/22 and then again on 03/10/23. This exceeds 6-months between reviews. The behavior support component of the Restrictive Procedure Plan and Individual Support Plan for Individual #2, date of admission 12/05/12, was reviewed on 09/07/22 and then again on 03/10/23. This exceeds 6-months between reviews. The behavior support component of the Restrictive Procedure Plan and Individual Support Plan for Individual #3, date of admission 04/11/16, was reviewed on 09/07/22 and then again on 03/10/23. This exceeds 6-months between reviews. The behavior support component of the Restrictive Procedure Plan and Individual Support Plan for Individual #4, date of admission 11/26/12, was reviewed on 09/07/22 and then again on 03/10/23. This exceeds 6-months between reviews. | The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews. | Point of Caring, Inc. was in violation of 55 PA code 2380.155(b), by exceeding 6 months between reviews and revisions of the individuals¿ restrictive procedure plan. This violation occurred due to a lack of training for the behavior specialist, and the failure to implement a 2-point checking system. Compliance with 55 PA Code 2380.155(b) is important as the plan and this information regarding the individual must be correct and current to avoid any unnecessary and unapproved restrictions, and so the individual¿s team has access to current and correct information regarding the individual. |
07/28/2023
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.111(c)(5) | Individual #1 had a Tuberculin skin test by Mantoux method placed by a licensed practical nurse on 06/22/20 and then read by a medical assistant on 06/25/20. 2380.111(d) states: Immunizations, vision and hearing screening and tuberculin skin testing may be completed, signed and dated by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted. | Point of Caring, Inc. was in violation of 55 PA Code Chapter 2380.111(d), by failing to ensure the tuberculin skin test was completed and certified by a licensed practical nurse or registered nurse. This violation occurred due to lack of training for the house administrators and direct care staff, and the failure to implement a 2-point checking system. In order to avoid future violations of 55 PA Code Chapter 2380.111(d), Point of Caring, Inc. will provide training to all staff, which will include the regulation as well as the proper credentials of the medical personnel, who are completing and certifying the tuberculin skin test. This training has been completed by all house administrators, as of 3/26/2021, and direct care staff, as of 4/15/2021. This training will be provided upon the hiring of all new staff as well. In addition, Point of Caring, Inc. will attach a letter to all annual physical forms, as a reminder for all house administrators and direct care staff, to request the appropriate medical personnel, and to assist in their personal review of the Individual's annual physical form, upon completion. In addition to the letter, The requirements of 55 PA Code Chapter 2380.111(d) will be printed on the annual physical form by the section of the annual physical form that requires completion of the tuberculin skin test results and highlighted, as a reminder for the medical personnel completing the annual physical form, as a reminder, in the absence of Point of Caring staff. Upon completion of the annual physical exam, the annual physical form will be returned to the office and will be reviewed by the Chief Executive Officer, who is responsible for all medical information for all individuals residing at Point of Caring. The Chief Executive Officer will review the physical form to serve as a 2-point checking system. All trainings will be maintained in the personnel files, as proof of compliance with the plan of correction. |
08/05/2021
| Implemented |
| 2380.113(c)(2) | The Chief Executive Officer, hired on 10/08/07, had a tuberculin skin test by Mantoux method placed on 09/03/19 by a medical assistant and read by a medical assistant on 09/05/19.
Direct Service Worker #2, hired on 06/03/14, had a tuberculin skin test by Mantoux method placed on 07/08/20 by a medical assistant and read by a medical assistant on 07/10/20.
Direct Service Worker #3, hired on 05/20/21, had a tuberculin skin test by Mantoux method placed by a medical assistant on 05/17/21 and read by a registered nurse on 05/19/21. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the 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, certified nurse practitioner or certified physician's assistant. | Point of Caring, Inc. was in violation of 55 PA Code Chapter 2380.113©(2), by failing to ensure the tuberculin skin test was completed and certified by a licensed practical nurse or registered nurse. This violation occurred due to lack of training for the house administrators and direct care staff, and the failure to implement a 2-point checking system. In order to avoid future violations of 55 PA Code Chapter 2380.113(c)(2), Point of Caring, Inc. will provide training to all staff, which will include the regulation as well as the proper credentials of the medical personnel, who are completing and certifying the tuberculin skin test. This training has been completed by all house administrators, as of 3/26/2021, and direct care staff, as of 4/15/2021. This training will be provided upon the hiring of all new staff as well. In addition, Point of Caring, Inc. will attach a letter to all annual physical forms, as a reminder for all house administrators and direct care staff, to request the appropriate medical personnel, and to assist in their personal review of their own bi-annual physical form, upon completion. In addition to the letter, The requirements of 55 PA Code Chapter 2380.113(c)(2) will be printed on the annual physical form by the section of the bi-annual physical form that requires completion of the tuberculin skin test results and highlighted, as a reminder for the medical personnel completing the annual physical form, as a reminder, in the absence of Point of Caring staff. Upon completion of the bi-annual physical exam, the physical form will be returned to the office and will be reviewed by the Human Resource personnel responsible for maintaining al Point of Caring staffs¿ medical records. The Human Resource personnel will review the physical form to serve as a 2-point checking system. All trainings will be maintained in the personnel files, as proof of compliance with the plan of correction. |
08/04/2021
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.59(b) | At 10:29 AM, the hot water temperature at the sink in the women's restroom measured 124.7 degrees Fahrenheit. At 10:30 AM, the hot water temperature at the sink in the men's restroom measured 125.2 degrees Fahrenheit. | Hot water temperatures in areas accessible to individuals may not exceed 120°F. | Point of Caring will begin checking water temperatures on a weekly basis leading up to the opening of the adult training facility site, to ensure the water temperature has been regulated and remains under 120 degrees. Upon the opening of the adult training facility, Point of Caring will conduct water temperature checks immediately following each fire drill, as per Point of Caring policy. If the water check measures over 120 degrees, the hot water tank will be adjusted and checked the following day and weekly for the next two weeks to ensure temperature regulation. I have attached both forms Point of Caring utilizes for each water temperature check. [Blank Documentation of fire drill form with water temperature space submitted to the Department. Documentation of weekly water temperature check for 6400.68 water temperature check submitted to the department with water temperature at the men's bathroom measuring 117° at 9:30AM on 10/20. Immediately and upon hire, the CEO or designee shall educate all staff persons responsible for measuring water temperature of the policies and procedures including measuring, documenting and addressing water temperatures exceeding 120°F to ensure water temperature in areas accessible to individuals does not exceed 120°F. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 10/20/20)] |
10/20/2020
| Implemented |
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