| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.21(a) | Direct Service Worker #1, date of hire 6/10/13, had a Pennsylvania criminal history record check submitted on 7/26/13. | An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire.
| RMPC has created an Employee Regulatory check list which indicates all regulatory documents must be obtained before an official employment offer can be made. That form is placed in the employee file and is monitored every 3-months to compliance purposes.[Immediately and prior to working with individuals, the CEO, VP or HR staff shall ensure criminal background checks are requested and completed as required. Within 30 days of receipt of the plan of correction all staff persons responsible for requesting and review criminal background checks should review regulation 6400.21(a)-e(e) and the Older Adults protective services act with regards to obtaining criminal background checks for staff who live or have live outside PA in the 2 years prior to hire. Documentation of initial and three month employee file checks shall be kept. (AS 10/5/16)] |
08/22/2016
| Implemented |
| 6400.44(c) | Program Specialist #2, date of hire 10/19/15, does not have the work experience required for the program specialist position. | A program specialist shall have one of the following groups of qualifications: (1) A master's degree or above from an accredited college or university and 1 year work experience working directly with persons with mental retardation. (2) A bachelor's degree from an accredited college or university and 2 years work experience working directly with persons with mental retardation. (3) An associate's degree or 60 credit hours from an accredited college or university and 4 years work experience working directly with persons with mental retardation. | As of 8/4/2016 RMPC has changed the job title, functions and responsibilities of PS #2 to an Operations Assistant, while training and gaining experience to become a Program Specialist. RMPC will review more closely the qualification of Program Specialist and all other positions during hiring process. [The other program specialist shall complete all duties of the program specialist as per 6400.44(b)(1)-(19). Prior to hire the CEO and/or HR department staff will review qualification of the candidate to ensure the qualification are met for the program specialist position. Staff person #2 will not complete program specialist duties until work experience qualification are met and documented.(AS 10/5/16)] |
08/04/2016
| Implemented |
| 6400.163(c) | Individual #1 had a psychotropic medication review completed 8/24/15 and then again on 12/8/15. Individual #1's psychotropic medication reviews completed 8/24/15, 12/8/15, 2/8/16, 4/25/16 and 7/21/16, did not include the reason for prescribing the medications, the need to continue the medications and the necessary dosages. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | RMPC has created a medication review form for the Program Specialist to have the Psychiatrist complete every 3-months. The medication review process is:
1. Once it is determined that an individual needs psychiatric care, the Program Specialist must schedule an appointment and it is that date that must be used to determine the date for the every 3 months medication review process whether the individual is to be seen by the psychiatrist every 3 months or not, the medication review process must take place.
2. The medication review form must be taken to the appointment and given to the psychiatrist to complete.
3. The staff person who will be assisting the individual at the appointment (Program Specialist or Team Lead) must review the medication review form for completeness and accuracy before leaving the appointment.
4. Program Specialist must sign and date the form and file it in the individuals program binder.[Within 30 days of receipt of the plan of correction, the CEO or designated management staff person shall train the program specialist and team lead of the aforementioned procedures to include required information and timeliness of medication reviews. For the next 6 months CEO or designated management staff person, shall review all medication reviews to ensure policies and procedures are being implemented and that all psychiatric medication reviews contain all required information and are completed timely. Documentation of trainings and reviews shall be kept. (AS 10/5/16)] |
08/22/2016
| Implemented |
| 6400.181(f) | The program specialist did not provide Individual #1's assessment dated 7/1/16 to all plan team members including the day program. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| Program Specialist will provide an assessment to SC, all team members and Day Program 30 day prior to ISP meeting which will include developments, annual updates and revisions to the ISP.[Within 30 days of receipt of the plan of correction, the CEO shall develop and implement policies and procedures to ensure the program specialist provides the assessment to the SC and plan team members at least 30 calendar days prior to an ISP meeting to include a review of all individual ISPs and invitation letters and other records to ensure entire team is provide the assessment and keeping correspondence documentation showing all team members were sent the assessment as required. At least quarterly, the CEO will review the correspondence documentation to ensure all plan team members were provided the assessment as required. Within 60 days of receipt of the plan of correction, the CEO shall train the program specialist on the aforementioned policies and procedures. (AS 10/5/16)] |
08/22/2016
| Implemented |
| 6400.186(b) | Individual #1's ISP reviews dated 11/1/15, 2/1/16, 5/1/16, and 8/1/16 were not dated by the individual and program specialist upon review. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | RMPC has updated its ISP Review form by adding a signature and date line for the Program Specialist to sign and date as well as the individual to sign and date.[Within 30 days of receipt of program specialist, the CEO shall train the Program specialist of the new procedures for signing dating the aforementioned form. At least quarterly for 1 year, CEO or designee will review all ISP reviews for all individual to ensure the program specialist and Individual sign and date upon review. (AS 10/6/16)] |
08/22/2016
| Implemented |