| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.125(a) | Individual #1 began receiving services through PA Child with Family members #1-3, on 7/14/2022. The agency, PA Child Corporation, identified via their 3/23/2023 self-assessment document of the home, that they did not have record of Family members #1-#3's physical examination records and requirements [PA Code 55 Chapter 6500.125(a)-(c)(4)]. The agency did not include an applicable plan of correction on their 3/23/2023 self-assessment document. At the time of the 4/5/2023 inspection, Family members #2-#3 have not received a physical examination. Family member #1's physical examination was signed and dated by a physician for being completed on 3/1/2023, after the individual moved into the home but the date of the actual physical examination is unclear. | Family members and persons living in the home shall have a physical examination within 12 months prior to the individual living in the home. | A root cause analysis was completed and determined: The Prior to move in Checklist did not include a section for family members, only for the provider, and for the individual, so family members 2 and 3 were not included in preparation for the move in. Family member #2 and #3 are scheduled for a physical on 5/15/23.
Family member #1 had a physical completed on 5/18/22. The original form was lost. Family member #1 returned to the office on 3/1/23 and requested the doctor complete another form based on the exam from 5/18/22. The doctor did so, signed and dated as of 3/1/23. A note was included that the exam took place 5/18/22 and was signed by the doctor. The original form was not located. |
05/15/2023
| Implemented |
| 6500.124 | (Repeat from Inspection completed on 4/5/22) On 9/27/22 it was recommended that Individual #1's therapy increase to twice a week. At no point, did Individual #1 attend therapy once a week. Individual #1 was attending weekly counseling. Individual #1 did not attend counseling at all the following weeks: 10/11/22, 11/8/22, 11/15/22, 12/5/22, or 1/3/23. On 8/17/22, it was recommended that Individual #1 have a swallow study/upper GI completed. No documentation was provided verifying that the swallow study/upper GI was completed. On 9/26/22, it was recommended that Individual #1 have a repeat ultrasound to look at their cyst. No documentation was provided that the repeat ultrasound occurred. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. | A root cause analysis was completed. Individual #1 has many appointments. Individual #1's POA frequently forgets to get paperwork completed. The POA does not communicate with PA Child frequently so details about treatment recommendations were lost or incomplete. The twice weekly therapy was discussed with Individual #1. Individual #1 did decline this increase in September. The service denial document was completed for that service on 4/21/23.
Individual #1 has declined to complete the Upper GI/Swallow study and a service denial form was completed for that service on 4/21/23. MPOA will discuss with the physician, who ordered the test to see if it is still relevant, and if so PS and LSP will work with Individual #1 to overcome the objections to this service and document doing so.
The repeat ultrasound was not completed. It was recommended to be transvaginal, and Individual #1 was not in agreement with this. A service declination form was completed on 4/21/23. The POA will discuss other options with the doctor to see if an external abdominal ultrasound will suffice. LSP will talk with Individual #1 about their discomfort with this procedure. |
04/21/2023
| Implemented |
| 6500.125(c)(2) | Individual #1 began receiving services through PA Child with Family members #1-3, on 7/14/2022. The agency, PA Child Corporation, identified via their 3/23/2023 self-assessment document of the home, that they did not have record of Family members #2 and #3 receiving Tuberculin skin testing by Mantoux method with negative results. The agency did not include an applicable plan of correction on their 3/23/2023 self-assessment. At the time of the 4/5/2023 inspection, Family members #2-#3 have not received a Tuberculin skin test with negative results. | The physical examination shall include: (2) Tuberculin skin testing by Mantoux method with negative results every 2 years for family members 1 year of age or older; or, if a tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or licensed practical nurse instead of a licensed physician. | A root cause analysis was completed and determined: "The Prior to move in Checklist" did not include a section for family members, only for the provider, and for the individual, so family members 2 and 3 were not included in preparation for the move in. Family member #2 and #3 are scheduled for a TB test on 5/15/23. |
05/15/2023
| Implemented |
| 6500.45(a) | Individual #1 began receiving services through PA Child with Family member #1, on 7/14/2022. Family member #1 received training in basic first aid, online, by American Academy of CPR and First Aid Inc. on 8/2/2022 but did not receive training in Heimlich techniques. According to Family member #1's first aid certificate, the training was for completion of the basic first aid course. According to the American Academy of CPR and First Aid Inc., the basic first aid course does not include training on Heimlich techniques. | The primary caregiver shall be trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid and Heimlich techniques prior to an individual living in the home and annually thereafter. | A root cause analysis determined the Program Director did not review the training prior to the LSP taking the course and was unaware that the Heimlich maneuver was not included. Family member #1 took another training that included the Heimlich maneuver on 4/27/23. |
04/27/2023
| Implemented |
| 6500.135(g) | The quarterly psych med reviews completed on 7/19/22, 8/30/22, and 11/1/22 for Individual #1 did not include the reason for prescribing the medication. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the r reason for prescribing the medication, the need to continue the medication and the necessary dosage. | A root cause analysis was completed, and it was determined that: Individual #1 has many appointments, their POA frequently forgets to get paperwork completed. PA Child's forms were not utilized for these visits, going forward PS will remind, when reviewing upcoming monthly appointments, LSP and MPOA to make sure the paperwork gets completed at the appointments. |
04/12/2023
| Implemented |