Failure to Provide Services Due to Insurance Status
Penalty
Summary
The facility failed to provide necessary services to residents without discrimination based on their payment source, affecting two residents. Resident R45, who was admitted with conditions including high blood pressure and a dental abscess, did not receive timely dental services due to her insurance status being pending. Despite having a physician's order for a dental consult and being on antibiotic therapy, the resident was not seen by a dentist because she was awaiting medical assistance approval. The facility's clerk and business office manager confirmed that the resident was not scheduled for a dental appointment due to her insurance status. Similarly, Resident R87, admitted with high blood pressure, heart failure, and diabetes, was not provided with ordered therapy services. The resident had physician's orders for physical, occupational, and speech therapy evaluations and treatments, but these services were not initiated because her insurance paperwork was still being processed. Interviews with the rehabilitation manager and business office manager revealed that the resident was only screened for therapy services and not started on them due to the lack of an established payer source. The nursing home administrator confirmed the facility's failure to provide the required services for both residents, acknowledging that Resident R45 did not receive dental services and Resident R87 did not receive therapy services as ordered. The facility's actions were in violation of regulations requiring equal treatment of residents regardless of their payment source, as outlined in 28 Pa Code: 201.18(e)(1) Management.
Plan Of Correction
Dental appointment was made immediately for R45. R87 was immediately evaluated by therapy. Therapy was started for R87. Education will be conducted on equal access to quality care to Medical Records, Social Services, and Therapy Manager by DON or designee on or before 2/11/2025. Audits will be conducted by DON or designee on prompt services such as dental care and therapy weekly x 4 weeks and monthly x 1 month. Audit results will be reviewed through the monthly QAPI process/meeting.