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F0552
E

Failure to Inform Residents of Telehealth Physical Therapy and Limited Session Frequency

San Rafael, California Survey Completed on 04-10-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to fully inform residents about the nature and frequency of their physical therapy services prior to admission, specifically that therapy would be provided via telehealth and limited to one or two sessions per week. Multiple residents and their family members reported that they were not told about the telehealth format or the reduced frequency of therapy sessions before admission. Some residents expected in-person therapy and a higher frequency of sessions, as was communicated to them by hospital staff or based on their previous experiences in other facilities. The marketing director and staff involved in admissions did not consistently disclose these details, and there was no written consent for telehealth therapy; only verbal consent was obtained at the start of sessions. Observations and interviews revealed that the facility had been unable to hire a full-time physical therapist, resulting in reliance on telehealth services provided by therapists located remotely. The rehabilitation director confirmed that therapy was limited to one or two sessions per week due to staffing constraints, and that recommendations for more frequent therapy were changed to match what the facility could provide. Residents expressed disappointment and frustration with the telehealth format and the limited frequency, with some stating that their progress was slower than expected or that they were not making improvements. Two residents chose not to participate in physical therapy after learning it would be conducted via telehealth. Documentation reviews showed that initial therapy recommendations for higher frequency were altered by facility staff to reflect the reduced availability. Staff interviews confirmed that prospective residents and their families were not informed about the telehealth delivery or session limitations prior to admission, and that hospital case managers were also unaware. The facility's own policy emphasized residents' rights to be informed and participate in care planning, but this was not upheld in practice for the sampled residents.

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