Failure to Provide Restorative Therapy During Medicare Appeal Process
Penalty
Summary
The facility failed to provide restorative therapy to maintain or improve range of motion (ROM) and activities of daily living (ADLs) for a resident with multiple complex medical conditions, including Alzheimer's disease, Parkinson's disease, congestive heart failure, and pulmonary hypertension. The resident had been receiving occupational, physical, and speech therapy during a rehabilitation stay, but therapy was discontinued after the facility was notified that Medicare coverage was ending and the first level appeal was denied. According to facility policy and the Notice of Medicare Non-Coverage (NOMNC), therapy services should have continued during the appeal process. However, due to miscommunication between the therapy department and social services, therapy was not continued while a second level appeal was being pursued by the resident's Power of Attorney for Healthcare (POAHC). The Therapy Director was unaware that a second level appeal was in progress and did not continue therapy, as the Social Worker did not inform the therapy department, believing the resident was being discharged to an assisted living facility. The Social Worker based this decision on a phone conversation with the POAHC and the presence of assisted living staff assessing the resident, but there was no documentation of the conversation. The resident remained in the facility for several days after therapy was stopped and did not discharge until later. The lack of communication and documentation resulted in the resident not receiving restorative therapy during the appeal period, contrary to regulatory requirements and facility policy.