Failure to Continue Therapy Services After Insurance Denial
Penalty
Summary
The deficiency involves the facility’s failure to provide ongoing specialized rehabilitative services to ensure a resident maintained the highest practicable level of physical and functional mobility. The resident was admitted with malignant neoplasm of the cerebellum and right lung, congestive heart failure, and COPD, and the admission MDS showed modified independence in decision making, substantial/maximal assistance needed for toilet hygiene, and dependence for bed mobility and transfers. The resident initially received PT, OT, and ST per physician orders, and the care plan included PT/OT evaluation and treatment. OT, PT, and ST evaluations were completed, and subsequent OT and PT discharge summaries documented that the resident had not met therapy goals and would benefit from continued therapy for functional mobility, ADLs, transfers, safety, and for ongoing cognitive/communication and dysphagia needs. However, PT and ST services were discharged due to insurance exhaustion and loss of appeal, and the resident remained in the facility without further therapy. Interviews confirmed that after skilled insurance coverage ended, the resident was removed from the therapy caseload and had not received therapy services since the discharge date, while Medicaid status was still pending and Part B coverage had not yet been verified. The resident reported that therapy had stopped a few weeks earlier when insurance ended, that she had applied for Medicaid, and that her goal was to return home once she became stronger and more independent. She stated that when she was in therapy she could stand and transfer with one staff member, but currently nursing staff only used a mechanical lift and did not assist her to stand. An STNA corroborated that when the resident was on therapy she could transfer with one staff assist, but nursing staff now used a mechanical lift for all transfers and had not been informed by therapy that manual assistance was possible. The PT and Director of Rehab acknowledged that the resident would benefit from therapy, that services had been discontinued due to insurance denial, that Part B coverage had not been verified, and that the facility did not have restorative programs, despite a facility policy stating that therapy services are to help residents reach maximum functional performance and transition to restorative nursing when appropriate.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.