Plan of Correction (POC) – Castleton Home Care Deficiency Identified: During our initial state survey, it was found that one employee had an expired TB test in their personnel file, resulting in acitation.1. Methods & Procedures for Correction The affected nurse obtained a new TB test and received a negative result on 3/10/25, and the updated documentation has been added to their personnel file. Documentation of the negative result can be made available to the State upon request. Implemented an Employee Compliance Tracking System in AxisCare, which now tracks the expiration dates of all state-mandated certifications, including but not limited to: CPR Certification First Aid Certification CNA License (if applicable)TB Test Results Driver’s License & Auto Insurance (if required for job duties) Added a requirement to the New Hire Onboarding Checklist: The onboarding supervisor must enter certification expiration dates into AxisCare upon completing employee orientation. The Compliance Manager is now responsible for updating certification expiration dates for all renewed documents submitted throughout an employee’s tenure. 2. Dates for Correction Completion New TB test completed: 03/10/2025Employee records audit completed: 03/10/2025AxisCare tracking system updated with all employee expiration dates: 03/10/2025Automated certification/compliance reminders activated in AxisCare: 03/10/25 3. Monitoring & Maintaining Compliance Automated reminders now notify both management and employees of expiring certifications 30, 15, and 7 days before expiration to prevent lapses. Quarterly internal audits of employee files will be conducted to verify compliance. Employees with expired certifications will be temporarily removed from scheduling until compliance is restored. This corrective action has been incorporated into Castleton Home Care’s official Policies & Procedures Manual to ensure ongoing compliance. Final Statement: Castleton Home Care takes compliance seriously and has implemented corrective measures to ensure this issue does not recur. All actions have been completed or are in progress to maintain full compliance with Georgia PHCP regulations.