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Based on staff interview and document review, it was determined the hospital failed to ensure each plan for physical and/or occupational therapy was implemented. Additionally, the hospital failed to ensure that changes in the plan of care were implemented in accordance with the hospital's policies and procedures as required at 42CFR §409.17(d) in three (3) of four (4) applicable medical records reviewed. Medical record #'s 3, 8, and 10.

Findings:

Ten (10) medical records were reviewed in the survey sample with the Quality Coordinator assisting in the navigation of the electronic records. Four (4) of the records reviewed contained orders for physical (PT) and/or occupational therapy (OT).

The medical record for patient #3 contained documentation of a PT evaluation on 02/06/22 that indicated the patient would receive PT at least three times a week. The next PT visit was documented as a PT reassessment on 02/14/22. The reassessment contained no documentation related to the patient receiving none of the ordered PT sessions the previous week. The reassessment established a continued PT frequency of at least three times per week. No further PT visits were documented. The patient was discharged 02/16/22. The medical record contained documentation of an OT evaluation done 02/05/22 that indicated a frequency of three times per week. No further OT visits were made until discharge on 02/16/22.

The medical record for patient #8 contained documentation of a PT evaluation conducted 05/25/22 that indicated the patient was to receive PT at least 3 times per week. The record contained documentation that PT was attempted 05/26/22, but the patient was not seen. No subsequent PT visits after the evaluation were documented in the medical record. The patient was discharged 05/30/22. The record contained no documentation of why the ordered frequency of PT was not met. The medical record contained documentation of an OT evaluation completed 05/23/22 that indicated the patient would receive OT at a frequency of at least three times per week. No further OT visits were documented in the medical record. The record contained no documentation of why the ordered OT frequency was not met.

The medical record for patient #10 contained physician orders for PT and OT to evaluate the patient. A PT evaluation was conducted on 04/23/22 and a care plan developed indicating the patient would receive PT at least 3 times per week. The patient received PT only once on 04/27/22. The patient was discharged 05/2/22. The record contained no documentation of why physical therapy was not performed at the frequency indicated in the plan of care. The record contained documentation that OT evaluated the patient on 04/26/22 and developed a care plan for OT at least three times a week. No further OT visits were documented in the patients record. The record failed to contain documentation for the reason why OT was not performed at the ordered frequency.

The surveyor requested policies related to therapy care planning to include frequencies and addressing changes to the plan of care. The surveyor was presented with a document, EBCD Clinical Documentation that did not address what action a clinician should take if the plan of care was changed or could not be implemented as ordered. The surveyor was also provided with a document, Occupational/Physical Therapy Treatment Frequency Guidelines that did not address changes to the plan of care.

An interview was conducted with a physical therapist (staff member #11) and the Inpatient Therapy Director (staff member #3) on 06/14/22 at 1:30 PM. The staff members were asked what the expectation was for documentation/notification if the ordered therapy frequency could not be met. Staff member #11 stated that the hospital had to triage patients according to need, and sometimes not all patients would be seen. The Therapy Director stated all attempts should be documented in the medical record. The staff members were asked for policies related to changes in the plan of care/not meeting the frequency in the plan of care and they confirmed no such policies existed.