| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.44(b)(10) | The program specialist did not sign or date the monthly ISP review completed for the period of 8/2/16 to 9/1/16 for Individual #1. | The program specialist shall be responsible for the following: Reviewing, signing and dating the monthly documentation of an individual'ss participation and progress toward outcomes. | To ensure completion of monthly reports. RMPC has made it mandatory that all monthly reports be submitted to the CEO during our weekly administrative staff meetings which are held every monday at 11:00am. A monthly cannot be filed into the black binder without being reviewed by the CEO for completion. [Within 1 week of receipt of the plan of correction, the CEO shall educated the program specialist of the responsibilities of the position as per 6400.44(b)(1)-(19) and the aforementioned procedures to ensure the program specialist reviews, signs and dates the monthly documentation of all the individuals' participation and progress toward outcomes. Documentation of the training shall be kept. Documentation of the aforementioned reviews by the CEO shall be kept. (AS 9/12/17)] |
08/17/2017
| Implemented |
| 6400.112(e) | There was one fire drill held during sleeping hours on 6/30/17 between 8/29/16 and 6/30/17. | A fire drill shall be held during sleeping hours at least every 6 months. | RMPC has created a Fire Drill Calendar Through Google. This calendar sends an email or notification to all Staff indicating when a fire drill needs to take place and also outlines the designated fire location and appropriate exits to take.[NOT ACCEPTABLE (AS 9/12/17)] By doing this we can ensure that all rmpc homes are conducting fire drills in unison. Also the we can ensure that a variety of exits are being used throughout the year. Program specialist will ensure fire drills are completed and will monitor fire binders on a monthly basis. CEO will quarterly monitor all fire binders to ensure compliance. [Immediately, the CEO or designee shall develop and implement a procedures to ensure all fire drills are unannounced and conducted and documented as required as per 6400.112(a)-(I). Prior to conducting fire drills, the CEO or designee shall educate all staff person on the aforementioned procedures to ensure fire drills are conducted as required as per 6400.112(a)-(I). Documentation of trainings shall be kept. Documentation of aforementioned monitoring shall be kept. (AS 9/12/17)] |
08/17/2017
| Implemented |
| 6400.143(a) | On 1/25/16 Individual #1 refused to have a prostate examination, the next prostate examination was completed 1/31/17. There is no documentation of continued attempts to train the individual about the need for health care. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Refusal of treatment.a) If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual¿s record. (b) If an individual has a serious medical or dental condition, reasonable efforts shall be made to obtain consent from the individual or substitute consent in accordance with applicable law. See section 417(c) of the Mental Health and Intellectual Disability Act of 1966 (50 P.S. § 4417(c)).Purpose of this form: This form will be used in conjunction with RMPC¿s Refusal of Services form. Once a participant refuses any routine medical/ dental examinations or treatments, the staff person who is on shift with that participant MUST immediately fill out the Refusal of Services form and both the participant and staff person must sign the form acknowledging the participant's refusal. Once that form has been filled out it is then the responsibility of the Sr. DCS and Program Specialist assigned to the participant to reschedule another appointment and also fill out a the Participant Coaching Form.
The Coaching Form is meant to train/coach the participant on why is it important to comply with all scheduled medical,dental and mental health appointments. From a quality management standpoint this allows RMPC to ensure we are staying on top of our participants overall health.
Every time a participant refuses an appointment the same process will take place. However after three refusals for the same appointment RMPC will ask that the participants ISP reflect that there is a history of consecutive refusals in the `Health Evaluation¿ section of the ISP for the classified appointment. |
08/17/2017
| Implemented |