| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | The furnace inspections and cleanings were completed 3-9-17, and then again on 4-9-18. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| his regulation is important is ensure there are no Carbon Monoxide Leaks and and also air circulating throughout the home is safe for our particpants. RMPC Compliance Officer Alice Taylor was responsible for scheduling furnace inspections for all RMPC sites. Alice failed to review the the dates for the previous year furnace inspections in a timely manner. Once she finally reviewed the dates we were already out of compliance and past the 10 day grace period allotted. In previous years RMPC has relied on our compliance officers to monitor furnace inspections however, to ensure we have a solid system in place Sr. Program Specialist Loren Weadon has developed a spreadsheet that will track all dates for Furnace Inspections. Beginning on 8/1/18 and reoccuring on a monthly Basis an email will automatically be sent to RMPC Program Specialists Imari Lee and Monae Clark who will review the spreadsheet and ensure the furnaces at their sites are in compliance. The PS is responsible for manually entering in the due date for the upcoming years furnace inspection. Once the PS enters the exact due date of the furnace inspection the spreadsheet will continue to track the date and once we are within 30 days of the inspection due date the cell that contains the date will highlight yellow. This notifies the PS to schedule the inspection if there is not already a scheduled date. If the cell highlights red this indicates we have missed the due date and are pass the 10 day grace period. Furthermore if a PS fails to enter a new due date for the upcoming year the spreadsheet will highlight grey indicating to the PS the due date is missing. The spreadsheet which was programmed by Loren Weadon is very simple and each PS was trained on how to use the spreadsheet on 8/3/18 at our weekly team meeting. To ensure the PS¿s are reviewing this spreadsheet as directed Sr.PS Loren Weadon is also responsible to review this document on a monthly basis. |
08/01/2018
| Implemented |
| 6400.141(c)(9) | The physical examination completed on 9-8-17 for Individual #1, date of birth 1-18-65, did not include a prostate examination. | The physical examination shall include: A prostate examination for men 40 years of age or older. | The physical Sr. Program Specialist Loren Weadon accepted for the admissions physical did not include a prostate exam for men over the age of 40. Loren was aware of the regulation and attempted to get the physical redone on RMPC documents which do have a section for prostate examination. However, the physician refused to complete RMPC's form and instead stapled a summary printout of the physical. Loren presented these documents to the state licensing officials who informed him it would not be accepted. Loren has updated the Residential Admissions Policy to address admitting physicals. PS's must follow these guidelines as outlined in Admissions Policy to ensure compliance. Prior to admission Sr. PS will review admitting documentation. In addition, PS's will further review documents as a back to the Sr.PS. The PS's were trained on the updated residential admissions policy on 7/31/18.[Individual #1 has a physical examination scheduled for 9/5/18. Upon completion of all individuals' physical examinations including Individual #1s, a designated staff person trained in the requirements of physical examinations as per 6400.141(c)(1)-(15), shall audit all individuals' current physical examination to ensure all required information is included and there are not any areas of required information left blank. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 8/23/18)] |
07/31/2018
| Implemented |
| 6400.141(c)(11) | The physical examination completed on 9-8-17 for Individual #1did not include an assessment of the individual's health maintenance needs. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The physical Sr. Program Specialist Loren Weadon accepted for the admissions physical did not include an assessment of the individuals health maintenance needs. Loren was aware of the regulation and attempted to get the physical redone on RMPC documents which do have a section for prostate examination. However, the physician refused to complete RMPC's form and instead stapled a summary printout of the physical. Loren presented these documents to the state licensing officials who informed him it would not be accepted. Loren has updated the Residential Admissions Policy to address admitting physicals. PS's must follow these guidelines as outlined in Admissions Policy to ensure compliance. Prior to admission Sr. PS will review admitting documentation. In addition, PS's will further review documents as a back to the Sr.PS. The PS's were trained on the updated residential admissions policy on 7/31/18. It important to have this information included on the physical to ensure all recommendation and health maintenance needs are being addressed by the RMPC.[Individual #1 has a physical examination scheduled for 9/5/18. Upon completion of all individuals' physical examinations including Individual #1s, a designated staff person trained in the requirements of physical examinations as per 6400.141(c)(1)-(15), shall audit all individuals' current physical examination to ensure all required information is included and there are not any areas of required information left blank. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 8/23/18)] |
07/31/2018
| Implemented |
| 6400.141(c)(14) | The physical examination complete on 9-7-17 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The physical Sr. Program Specialist Loren Weadon accepted for the admissions physical did not include medical information pertinent to diagnosis and treatment in the case of an emergency. Loren was aware of the regulation and attempted to get the physical redone on RMPC documents which do have a section for emergency treatment. However, the physician refused to complete RMPC's form and instead stapled a summary printout of the physical. Loren presented these documents to the state licensing officials who informed him it would not be accepted. Loren has updated the Residential Admissions Policy to address admitting physicals. PS's must follow these guidelines as outlined in Admissions Policy to ensure compliance. Prior to admission Sr. PS will review admitting documentation. In addition, PS's will further review documents as a back to the Sr.PS. The PS's were trained on the updated residential admissions policy on 7/31/18. It important to have this information included on the physical to ensure all emergency plans include information pertinent to the participants diagnosis. [Individual #1 has a physical examination scheduled for 9/5/18. Upon completion of all individuals' physical examinations including Individual #1s, a designated staff person trained in the requirements of physical examinations as per 6400.141(c)(1)-(15), shall audit all individuals' current physical examination to ensure all required information is included and there are not any areas of required information left blank. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 8/23/18)] |
07/31/2018
| Implemented |
| 6400.163(c) | Individual #1's psychiatric medication reviews on 11-29-17, 3-28-18 and 7-12-18, did not include the necessary dosage as to the amount to be administered per day for Klonopin, 1 mg, Effexor XR, 150 mg and Seroquel, 125 mg. | 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. | The Psych Med Review Forms previously used were not being filled out in there entirety by physicians. We have had ongoing issues with physicians who refuse to fill out our forms. We were informed during our state licensing it would best to fill in as much of the information for the physician and if the physician continues to refuse to fill out our forms we may need to look for a new provider. Using this technical advice given and to make things simple for the physicians The Sr. Program Specialist Loren Weadon has decided to prepopulate our Psych Med Review Forms for each participant. The form will already include the medication, dosage/time and reasoning for the medication. As medications change or are discontinued, the PS must make those adjustments to the form prior to next med review. Being that there is typically three months between med reviews the PS will have enough time to update the forms. By pre populating the form we can mitigate the likelihood of a physician refusing to fill/complete our documentation. All Sr.DCS and PS's were trained on this new form as of 8/3/18 at our weekly team meeting.[Upon completion, a designated staff person shall review all individuals' psychiatric medication review to ensure completion as required and physicians' orders are followed and individuals are administered medications as prescribed. Documentation of audits shall be kept. (DPOC by AES,HSLS on 8/23/18)] |
08/01/2018
| Implemented |