F0825

D

Failure to Facilitate Insurance Coverage Resulting in Interrupted PT/OT Services

Los Angeles, California Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that a resident received necessary PT/OT services by not facilitating the use of the resident’s secondary insurance coverage, contrary to its Specialized Rehabilitative Services policy. The resident was admitted with diagnoses including spinal stenosis, acute kidney failure, and muscle weakness, and the MDS showed intact cognition, bilateral upper and lower extremity impairment, wheelchair dependence, and dependence on staff for ADLs. A PT evaluation and plan of treatment documented lower extremity strength deficits and the resident’s goal to walk again. PT services were provided for a limited period and then the resident was discharged to an RNA program in December, with the MDS later indicating no special treatments, procedures, or programs in the prior seven days.

The resident reported that a hospital physician had recommended at least 90 days of PT/OT, but therapy was discontinued after about a month because the primary insurance only covered 32 days, despite the resident having provided secondary insurance information to the facility. The DOR confirmed that the resident could have benefited from more PT/OT and that therapy did not continue due to limitations of the primary insurance and a technical issue between the business office and the secondary insurer. The resident, RNA staff, RN supervisor, and SS director all indicated that the resident wanted more therapy and could have benefited from additional PT/OT, while SS and the DON were unaware that therapy had been interrupted due to insurance coverage issues or that SS was responsible for obtaining additional resources. The facility’s policy required it to provide or obtain specialized rehabilitative services when required by the comprehensive care plan, but this was not carried out for this resident.