Health inspection·April 9, 2025

§483.65 Specialized rehabilitative services. §483.65(a) Provision of services. If specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as set forth at §483.120(c), are required in the resident’s comprehensive plan of care, the facility must— §483.65(a)(1) Provide the required services; or §483.65(a)(2) In accordance with §483.70(g), obtain the required services from an outside resource that is a provider of specialized rehabilitative services and is not excluded from participating in any federal or state health care programs pursuant to section 1128 and 1156 of the Act. § 72301. Required Services. (d) Written arrangements shall be made for obtaining all necessary diagnostic and therapeutic services prescribed by the attending physician, podiatrist, dentist, or clinical psychologist subject to the scope of licensure and the policies of the facility. If the service cannot be brought into the facility, the facility shall assist the patient in arranging for transportation to and from the service location. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. California Code of Regulations, Title 22, Section 72523 § 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 2/20/2024 at 9:35 a.m., the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care and treatment, rehabilitation services, and resident rights. As a result of the investigation, the CDPH determined the facility failed to ensure resident 4 received Physical Therapy (PT, specialized rehabilitative service that helps you improve how your body performs physical movements) and Occupational Therapy (OT, specialized rehabilitative service that helps you improve your ability to perform daily tasks) services as indicated in Resident 4’s plan of care. These failures had the potential for Resident 4 to not attain, maintain or restore Resident 4’s highest practicable level of physical, mental, functional and psycho-social well-being. A review of Resident 4's Admission Record indicated the facility admitted Resident 4, a 57-year-old male, on 8/31/2024, with diagnoses including traumatic subarachnoid hemorrhage (SAH, a type of bleeding in the brain), acute respiratory failure (when the lungs can't get enough oxygen into the blood), and dysphagia (difficulty swallowing foods or liquids). A review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 12/20/2024, indicated Resident 4 was severely impaired in cognitive skills (ability to make daily decisions). The MDS indicated Resident 4 was dependent on staff for toileting, oral, and personal hygiene, dressing, and bathing. A review of Resident 4’s physician orders, untitled, indicated the following therapy orders for Resident 4: Occupational Therapy Evaluate and Treat as Indicated, dated 11/14/2025 Physical Therapy Evaluate and Treat as Indicated, dated 11/14/2025 OT eval completed awaiting authorization. Once authorized OT clarification of order for skilled services QD (every day) six times a week for four weeks (wks) for tx (treatment) …, dated 11/15/2025 PT clarification order for Skilled Physical Therapy Services QD six times a week for four wks (awaiting auth from insurance…), dated 11/15/2025 During a concurrent interview and record review on 2/25/2025, at 11:27 a.m., The Director of Rehabilitation (DOR) reviewed Resident 4’s OT Initial Evaluation (OT Eval), dated 11/15/2024 and PT Initial Evaluation (PT Eval), dated 11/15/2024. The OT Eval indicated Resident 4’s rehab potential was good. The OT eval indicated Resident 4 had a treatment plan to be conducted six times a week for four weeks with OT. The OT Eval indicated Resident 4 only receive one session of OT on 11/15/2024 and did not receive four weeks of treatment. The PT Eval indicated Resident 4 had a treatment plan to be conducted six times a week for 4 weeks with PT. The PT Eval indicated Resident 4 only receive one session of PT on 11/15/2024 and did not receive treatment six times a week for four weeks. The DOR confirmed OT and PT both indicated Resident 4 would benefit from OT and PT. The DON stated Resident 4 did not receive the OT and PT treatment plan because the facility was waiting for Resident 4’s insurance to authorize the OT and PT services. The DOR stated Resident 4’s insurance did not approve Resident 4 to receive OT and PT. During a concurrent interview and record review on 2/25/2025, at 12:40 p.m., with the DOR, Resident 4’s care plan titled “Resident requires skilled physical therapy…,” dated 10/11/2024 was reviewed. The care plan indicated Resident 4 required PT due to decreased strength and endurance. The care plan indicated the goal for Resident 4 was to have an increase in strength to both legs. The care plan indicated Resident 4 would receive therapeutic activities. The DOR stated the care plan was appropriate for Resident 4. The DOR stated Resident 4 still needed PT. During an interview on 2/25/2025 at 1:05 p.m., with the DON, the DON stated the decision to provide OT and/or PT to residents (in general) was not dependent on the residents’ insurance authorization. The DON stated if the resident’s OT eval and/or PT eval indicated the resident would benefit from OT and/or PT then the resident should receive OT and/or PT. The DON stated if the care plan indicated the resident needed OT and/or PT the resident should be provided OT and/or PT. A review of the facility's policy and procedure (P&P) titled, "Functional Impairment - Clinical Protocol," revised September 2012, indicated, upon admission to the facility, at any time a significant change of condition occurs, and periodically during a resident's stay, the physician and staff will assess the resident's physical condition and functional status. The P&P indicated, …A physician, nurse or therapist may initiate screening for the potential to benefit from rehabilitative services such as physical and occupational therapy…Following the screening, the therapist will document whether the resident may benefit from a more detailed rehabilitation evaluation or from unskilled therapy (e.g., restorative nursing services that can be provided by caregivers or exercises with which family members can assist)…If a potential to benefit from rehabilitation therapies (either skilled or unskilled) is identified, the attending physician will order a relevant therapy evaluation (for example, by a physical or occupational therapist)…. In conjunction with the physician and staff, therapists will propose a rehabilitation or restorative care plan that provides an appropriate intensity, frequency and duration of interventions to help achieve anticipated goals and expected outcomes efficiently using available resources…Based on a review of available information (including results of the evaluation), the physician will determine if a resident meets the criteria for skilled therapy services…The physician will order therapy services based on the above considerations and the therapist's recommendations. The facility failed to ensure resident 4 received PT and OT services as indicated in Resident 4’s plan of care. These failures had the potential for Resident 4 to not attain, maintain or restore his highest practicable level of physical, mental, functional and psycho-social well-being. These violations jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 4.