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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.56 Rehabilitation Services was out of compliance.

A-1134 - The provision of care and the personnel qualifications must be in accordance with national acceptable standards of practice and must also meet the requirements of §409.17 of this chapter. Based on document review and interviews, the facility failed to ensure staff providing therapy for patients followed the frequency as determined in the patient treatment plan in three of five medical records reviewed for the frequency of therapy provided to patients. (Patients #3, #4, and #5)

Based on document review and interviews, the facility failed to ensure staff providing therapy for patients followed the frequency determined in the patient treatment plan in three of five medical records reviewed for the frequency of therapy provided to patients. (Patients #3, #4, and #5)

Findings include:

Reference:

According to Guidelines for Provision of Therapy, when skilled therapy is reasonable and necessary, frequency of treatment should be established based upon recommendations for safe discharge to the next level of care and evidence-based practice. Attempts made to evaluate or treat patients should be documented, even when care was not provided.

1. The facility failed to provide rehabilitation services according to the designated frequency in the patient's treatment plan.

a. Medical record review of Patient #3 revealed the patient was admitted to the facility on 11/9/2022 for debility (physical weakness) and treatment for infected wounds. On 11/16/22 at 10:09 a.m., provider orders for physical therapy (PT) and occupational therapy (OT) were placed. The evaluation was completed by OT on 11/17/22 at 10:40 a.m. and the frequency of OT sessions was determined to be conducted six times per week. The evaluation was completed by PT on 11/18/22 at 4:40 p.m. and the frequency of PT sessions was determined to be conducted five times per week. Further medical record review revealed Patient #3 did not receive therapy sessions in compliance with the evaluations. For example:

i. During the week of 11/23/22 through 11/29/22, Patient #3 only received PT two times (11/24/22 and 11/29/22). During the same week, the patient only received OT one time (11/25/22). There was no documentation of additional attempts made to see the patient or if the patient refused services.

ii. During the week of 12/7/22 through 12/13/22, Patient #3 only received PT one time (12/13/22). Documentation on 12/9/22 revealed the patient was unavailable for a therapy session, but no documentation showing additional attempts to see the patient. During the same week, Patient #3 only received OT one time (12/13/22). Documentation on 12/7/22 revealed Patient #3 was unavailable. There was no documentation showing additional attempts to see the patient. Further documentation on 12/10/22 revealed the patient refused treatment.

b. Medical record review of Patient #4 revealed the patient was admitted to the facility on 2/23/23 for treatment of colon cancer. On 2/26/23 at 9:43 a.m., provider orders for PT and OT were placed. The evaluation was completed by PT on 2/26/23 at 2:07 p.m. and the frequency of PT sessions was determined to be conducted five times per week. The evaluation was completed by OT on 3/3/23 at 9:15 a.m. and the frequency of OT sessions was determined to be conducted six times per week. Further medical record review revealed Patient #4 did not receive therapy sessions in compliance with the evaluations. For example:

i. During the week of 3/5/23 through 3/11/23, Patient # 4 only received PT three times (3/6/23, 3/10/23, and 3/11/23). Documentation on 3/7/23 revealed the patient was unable to participate in therapy due to medical instability. There was no other documentation showing additional attempts to see the patient. During the same week, Patient #4 only received OT two times (3/6/23 and 3/10/23). Documentation on 3/7/23 revealed the patient was unable to participate in therapy due to medical instability. There was no other documentation showing additional attempts to see the patient.

ii. During the week of 3/12/23 through 3/18/23, Patient #4 only received PT three times (3/12/23, 3/15/23, and 3/16/23). Documentation revealed on 3/13/23 PT did not see the patient because PT needs were met by other therapy that day. There was no other documentation showing additional attempts to see the patient. During the same week, Patient #4 only received OT four times (3/23/23, 3/13/23, 3/15/23, and 3/16/23). There was no other documentation showing additional attempts to see the patient.

c. Medical review of Patient #5 revealed the patient was admitted to the facility 1/31/23 for treatment of sepsis. On 1/31/23 at 11:37 a.m., provider orders for PT and OT were placed. The evaluation was completed by PT on 2/4/23 at 2:43 p.m. and the frequency of PT sessions was determined to be conducted four times per week. Documentation revealed on 2/24/23 PT increased the frequency of sessions to five per week. The evaluation was completed by OT on 2/6/23 at 3:03 p.m. and the frequency of OT sessions was determined to be conducted four times per week. Documentation on 2/16/23 revealed OT increased the frequency to six sessions per week. Further medical record review revealed Patient #5 did not receive therapy sessions in compliance with the evaluations. For example:

i. During the week of 2/28/23 through 3/6/23, Patient #5 only received PT three times (2/28/23, 3/3/23, and 3/6/23). Documentation on 3/1/23 revealed the patient refused therapy and on 3/2/23, the patient was unavailable while on the unit. There was no other documentation showing additional attempts to see the patient. During the week of 2/28/23 through 3/6/23, Patient #5 only received OT two times (3/1/23 and 3/3/23). There was no documentation showing additional attempts to see the patient.

ii. During the week of 3/14/23 through 3/20/23, Patient #5 only received PT one time (3/17/23). Documentation by PT revealed on 3/15/23 that the patient needs were met by another therapy for this day. On 3/16/23, both PT and OT documented the patient was off the unit. Patient #5 was seen by OT two times (3/15/23 and 3/20/23). There was no documentation showing additional attempts to see the patient.

The instances of missed therapy sessions in the medical record reviews of Patients #3, 4, and 5 were in contrast with the facility's Guidelines for Provision of Therapy, which indicated the frequency of treatment should have been established based upon recommendations for safe discharge to the next level of care and evidence-based practice. Attempts made to evaluate or treat patients should have been documented, even when care was not provided.

d. On 3/22/2023 at 12:11 p.m., an interview with occupational therapist (Therapist) #2 was conducted. Therapist #2 stated she believed therapists were not required to meet the frequency of therapy sessions indicated in the treatment plan evaluation when seeing a patient. Therapist #2 explained sometimes the frequency was not met when therapists were short staffed or when the patient load was too big.

e. On 3/22/2023 at 12:41 p.m., an interview with physical therapist (Therapist) #3 was conducted. Therapist #3 stated therapists were not required to meet the recommended frequency. She stated therapists strived to do their best by attempting to make sure the patient was being seen by at least one therapy discipline (PT or OT). She stated there was no mandate in place to get the entire caseload completed each day and that it was possible to not meet the plan of care. Therapist #3 stated she was unsure if there was a requirement for meeting frequency goals with the hospital or national standards.

f. On 3/22/2023 at 1:16 p.m., an interview with the director of rehabilitation services (Director) #4 was conducted. Director #4 stated her expectations regarding frequencies of therapy were to assess the needs of the patient and determine whether or not those needs could be met. Director #4 explained there were times that supplementing one discipline (PT/OT) for another (PT/OT) was acceptable. She stated when a patient was unavailable for treatment, her expectations were for the therapist to move on to the next patient with the possibility of checking back in with the patient at a later time the same day if the patient had immediate needs. Director #4 stated the determined therapy frequencies documented in the initial evaluation for therapy were more like goals that could be met in ideal situations. Director #4 stated if therapy was attempted and not provided due to a patient's acute medical condition, the attempt was only required to be documented if it was determined by the therapist to be important to include in the patient's overall treatment progression. Director #4 stated there was not always time for the therapist to return to the patient once the patient was ready for a treatment session. Director #4 then stated the risk to the patient not receiving therapy as scheduled was the patient would have a longer hospital stay and not move to the next level of care.