Failure to Continue Therapy Services After Insurance Denial
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.
Penalty
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The facility failed to provide ordered speech therapy services for two residents with dysphagia and post‑cerebral infarction speech and swallowing deficits. Both had physician orders to continue existing speech therapy plans of care under a new provider, with one to receive therapy twice weekly and the other three times weekly over a defined certification period, targeting improved swallow function, diet tolerance without aspiration signs, and better communication and speech intelligibility. Medical records for each resident showed only a single 23‑minute speech therapy session during that entire period. A therapy regional manager confirmed that services under the new contractor started after the prior contractor was terminated, that these two residents received speech therapy only once, and that available telehealth speech therapy was not utilized.
A resident with multiple medical conditions did not receive physical and occupational therapy at the frequency specified in their care plan. Therapy sessions were missed over several periods due to delays in insurance authorizations, as confirmed by the Rehab Director. The facility lacked a formal policy for therapy services, though it was expected that therapies would be delivered as ordered.
A resident with multiple diagnoses and a recent fall was discharged from OT with a recommendation for a restorative program focused on ADLs, including personal hygiene, dressing, and grooming. While a restorative ambulation program was implemented following PT recommendations, the ADLs restorative program was not initiated, as confirmed by staff interviews and record review.
A resident with significant communication impairments did not receive speech therapy as frequently as prescribed in their treatment plan due to the lack of a full-time speech therapist. Documentation and interviews revealed inconsistent therapy sessions, unclear caregiver training, and absence of recommended communication tools, resulting in ongoing communication difficulties and frustration for the resident.
A resident with multiple medical conditions and a need for rehabilitation did not receive timely PT, OT, and ST services as recommended, due to the facility's inability to verify insurance and obtain necessary billing information. Therapy was delayed until the payor source was confirmed, despite the resident's expressed interest and clinical need.
A resident with a history of stroke, dysphagia, and tube feeding was not offered or provided SLP services after readmission, despite hospital recommendations for ongoing evaluation and subsequent cognitive improvement. The facility lacked a Speech Therapist and did not document any SLP follow-up or treatment.
Failure to Provide Ordered Speech Therapy Services
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered speech therapy services for two residents requiring specialized rehabilitative care. One resident, admitted with diagnoses including dysphagia, dementia, and rheumatoid arthritis, had an MDS indicating severe cognitive impairment and a need for supervisory support with eating, positioning, and transferring, while remaining independently mobile in a manual wheelchair. Physician orders directed continuation of the resident’s existing speech therapy plan of care under a new provider effective 02/01/26, with a treatment plan calling for speech therapy twice weekly for four weeks during the certification period 02/01/26–02/28/26. The short-term goals included tolerating a mechanical soft diet without signs or symptoms of aspiration and performing oral-motor strength exercises to improve swallow function. Record review showed only one 23‑minute speech therapy session on 02/20/26, with no other speech therapy visits documented during the certification period. The second resident, admitted with a history of cerebral infarction, dysphagia following cerebral infarction, and other speech and language deficits following cerebral infarction, had an MDS showing moderately impaired cognition, a need for supervisory support with eating, and dependence on staff for positioning and transferring, while also being independently mobile in a manual wheelchair. Physician orders similarly required continuation of this resident’s speech therapy plan of care under a new provider effective 02/01/26, with a plan of treatment specifying speech therapy three times weekly for four weeks during the same certification period. Short-term goals included improving communication and speech intelligibility and tolerating a regular texture diet without signs or symptoms of aspiration. Documentation revealed only one 23‑minute speech therapy session on 02/20/26, with no additional visits recorded. In an interview, the Therapy Regional Manager stated that rehabilitative therapy services began on 02/02/26 after termination of the previous therapy contractor, confirmed that both residents received speech therapy only on 02/20/26, and acknowledged that although telehealth speech therapy was available, it was not used.
Failure to Provide Prescribed Therapy Services Due to Authorization Delays
Penalty
Summary
The facility failed to ensure that a resident received specialized rehabilitative services, specifically physical therapy (PT) and occupational therapy (OT), as outlined in the resident's plan of care. The resident was admitted with multiple diagnoses, including a lumbar vertebra fracture, dementia, muscle weakness, and difficulty walking. The care plans for both PT and OT specified therapy services to be provided three to five times per week for various therapeutic interventions. However, medical record and therapy service log reviews revealed multiple periods in October and November during which the resident did not receive the prescribed therapy sessions. Interviews with the Rehab Director confirmed that the therapy frequencies were not met as written in the plan of care. The Rehab Director attributed the missed therapy sessions to delays in obtaining insurance authorizations from the corporate office, which resulted in interruptions in therapy services. Additionally, it was noted that the facility did not have a formal policy regarding therapy services, though it was expected that therapies would be provided according to the care plan.
Failure to Implement Recommended ADLs Restorative Program After OT Discharge
Penalty
Summary
The facility failed to implement a recommended restorative program for activities of daily living (ADLs) for a resident following discharge from occupational therapy (OT) services. The resident, who had diagnoses including orthopedic care, left femur fracture, high blood pressure, spinal stenosis, and dementia, was readmitted after a fall incident. Upon readmission, therapy evaluations were recommended, and both physical therapy (PT) and OT assessments were completed. The PT evaluation resulted in a restorative program for ambulation, which was implemented and documented as being followed daily. However, although the OT evaluation recommended a restorative program for ADLs such as personal hygiene, dressing, and grooming, this program was not implemented. Staff interviews confirmed that the resident never participated in an ADLs restorative program, and the Assistant Director of Nursing acknowledged that the evaluation for the ADLs program was not reviewed or acted upon after it was completed and locked by OT. This omission resulted in the resident not receiving the specialized rehabilitative services as required.
Failure to Provide Prescribed Speech Therapy Services
Penalty
Summary
The facility failed to provide a resident with the specialized rehabilitative services of speech therapy as required by the resident’s plan of treatment. The resident, who had a history of encephalopathy, aphasia, dysarthria, cerebral infarction, dysphagia, hemiplegia, and cognitive impairment, was admitted with significant communication challenges. The speech therapy plan called for treatment five times a week for six weeks, but documentation showed inconsistent delivery of services, with the resident receiving therapy fewer times than prescribed in several weeks. The speech therapy discharge summary included recommendations for ongoing strategies and caregiver training to support the resident’s communication needs. However, interviews with the Rehabilitation Director revealed uncertainty about what specific training was provided to caregivers, which caregivers received it, and whether any visual aids or communication tools were supplied to the resident. The Rehabilitation Director also confirmed that the lack of a full-time speech therapist led to irregular therapy sessions, as services were only provided when a therapist was available. The resident expressed ongoing frustration and difficulty with communication, both with family and caregivers, and indicated a need for additional speech therapy. Observations during interviews confirmed the resident’s communication struggles and emotional distress related to these challenges. The deficiency was identified during a complaint investigation and affected one resident reviewed for therapy services.
Failure to Provide Timely Rehabilitation Services Due to Insurance Verification Delays
Penalty
Summary
A resident admitted with diagnoses including type II diabetes mellitus, bipolar disorder, and depression was identified as needing physical, occupational, and speech therapy upon admission. The resident's comprehensive assessment showed intact cognition, limited range of motion in both lower extremities, and dependence on staff for transfers and toileting. Physician orders and therapy evaluations recommended therapy services to address mobility and strength. Despite these recommendations, the resident did not receive the prescribed therapy services in a timely manner. The delay in providing therapy was due to the facility's inability to confirm the resident's insurance information, which prevented the initiation of rehabilitation services. Staff interviews confirmed that therapy was not started because the facility could not verify the resident's payor source and did not have the necessary insurance documentation. As a result, the resident did not receive therapy as recommended until the facility resolved the billing issue, despite the resident expressing a desire to participate in therapy and improve mobility.
Failure to Provide Required Speech/Language Pathology Services
Penalty
Summary
The facility failed to provide or offer Speech/Language Pathology (SLP) services as required for a resident with significant medical needs. A resident with a history of cerebral infarction with left hemiplegia, aphasia, ischemic cardiomyopathy, obesity, congestive heart failure, and chronic kidney disease was readmitted to the facility after a hospital stay for a stroke. Upon readmission, the resident had orders for NPO status and continuous tube feedings due to dysphagia, and had previously received SLP services in the hospital, including recommendations for ongoing SLP evaluation. Despite these recommendations and the resident's subsequent improvement in cognition, the facility did not provide SLP services because they had not had a Speech Therapist on staff since October 2024. The Director of Rehab confirmed that although the resident would have benefited from SLP services after cognitive improvement, no such services were offered or provided. The facility's practice in cases of swallowing concerns was to obtain a modified barium swallow evaluation and follow dietary recommendations, but no ongoing SLP evaluation or treatment was documented for this resident.
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