Every finding on record at St Mary Medical Center Inc

This visit was for a Federal complaint survey of a Deemed Home Health provider. Survey Dates: 08/26/2025 and 08/27/2025 Complaint #2589023 was investigated; related deficiencies were cited. 12 Month Unduplicated Skilled Admissions: 2, 124 Abbreviations used in report: Plan of Care (POC), Start of Care (SOC), Physical Therapist (PT), and Physical Therapy Assistant (PTA). QR: 09/05/2025 A1

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the POC was individualized to include the treatments performed and equipment used in 1 of 2 active clinical records reviewed with PT services provided following a hip replacement in a total sample of 4 active clinical records with PT services. (Patient #1) The findings include: The clinical record for Patient #1 evidenced a visit note completed by PTA 1 dated 08/06/2025 which indicated the Patient completed 10 minutes on the restorator (a stationary bike used for therapy). The POC for the initial certification period 08/04/2025-10/02/2025 indicated the agency was to provide PT services to include transfer and gait training, range of motion and strengthening exercises, and development and implementation of the home exercise program. The POC failed to evidence the treatments and equipment including a restorator. On 08/27/2025 at 3:10 PM, the Administrator indicated the PTA should follow the exercises listed on the home exercise program that was developed by the PT. The Administrator indicated there was not a restorator listed on the POC. On 08/27/2025 at 3:51 PM, the Director of Therapy indicated the use of the restorator was individualized per patient. The Director of Therapy indicated the restorator was not included on the home exercise program.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the services provided by the PTA were directed by the POC as developed by the PT in 1 of 2 active clinical records reviewed with PT services provided following a hip replacement in a total sample of 4 active clinical records with PT services. (Patient #1) The findings include: A clinical record review for Patient #1 evidenced a POC for the initial certification period 08/04/2025-10/02/2025 which indicated the Patient had a right hip replacement, and the agency was to provide PT services to include transfer and gait training, range of motion and strengthening exercises, and development and implementation of the home exercise program. The POC failed to evidence the treatments and equipment including a restorator (a stationary bike used for therapy). The PT initial evaluation completed by PT 4 dated 08/04/2025 indicated the Patient had weakness in the right leg and failed to evidence the treatments provided by PT 4 included a restorator. The visit note completed by PTA 1 dated 08/06/2025 indicated the Patient completed 10 minutes on the restorator. On 08/27/2025 at 11:30 AM, the Director of Therapy indicated the restorator should not be used after a hip replacement if the patient had weakness in the hip due to limited muscle control to protect the hip. On 08/27/2025 at 2:34 PM, PT 4 indicated she did not use a restorator with Patient #1. On 08/27/2025 at 3:10 PM, the Administrator indicated the PTA should follow the exercises listed on the home exercise program that was developed by the PT. The Administrator indicated there was not a restorator listed on the POC.