Failure to Develop Person-Centered Speech Therapy Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for speech therapy (ST) services for one resident. The resident was admitted with diagnoses including parkinsonism and spasmodic torticollis, conditions associated with movement difficulties and muscle contractions. An order dated 11/7/2025 directed ST three times per week for four weeks for PO trials, education on aspiration precautions, and swallow compensatory strategies, and this order was discontinued on 12/6/2025. Review of ST notes showed the resident received ST services as ordered. However, review of the resident’s clinical documentation revealed no evidence of a person-centered care plan addressing ST services. During concurrent record review and interviews, the director of rehabilitation confirmed the resident received ST for four weeks and acknowledged there was no person-centered care plan for ST, stating that therapy staff should have developed and implemented one. The DON also confirmed the absence of an ST care plan and stated therapy staff should have developed and implemented a person-centered care plan when the resident received ST. The facility’s policy on comprehensive person-centered care plans requires the IDT, in conjunction with the resident and/or representative, to develop and implement a comprehensive, person-centered care plan for each resident, consistent with the resident’s rights to participate and receive services included in the plan of care.
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