the appellant’s argument that this 99-year old beneficiary had a significant decline in condition demonstrated by 4 hospital
admissions in the preceding three months and needed skilled monitoring and caregiver education. ALJ Decision in 1
275756951, at 10. The ALJ noted that the beneficiary had been allowed 13 SN visits after release from a previous hospital admission. Id. The ALJ concluded that the beneficiary and her family received sufficient instruction then on the disease
process, diet and safety and the current services were “general monitoring of a medically compromised but medically stable
beneficiary.” Id. at 11.
The recertification OASIS notes the repeated hospitalizations; records a primary diagnosis of thoracic spinal compression, with hypertension and dementia; notes SOB on walking more than 20 feet, memory deficit and impaired decision-making in a
beneficiary who is forgetful and disoriented; and rates ALJ levels at minimal to maximum assist. Case File in 1-275756951, Ex. 13 passim. She needs hospital bed, bedside commode, and wheelchair or walker for mobility. Id. at 7. No changes are identified from the previous period assessment (during which the 13 visits were allowed). Id.
The appellant argues that, far from being stable, the patient was in final decline and “actively dying,” and weekly SN visits were necessary to coordinate care for complications, monitor
skin integrity, and educate the family on her care. Patient Ex. 29. The beneficiary left home health to enter hospice care.
Case File in 1-275756951, Ex. 10, at 3; Ex. 11.
The patient is incontinent of bowel and bladder and nursing notes do reflect monitoring of skin integrity to forestall the risk of pressure sores. Case File in 1-275756951, Ex. 14
passim. The notes record provision of education but also note needs for continuing intervention and instruction. Id.
The documentation indicates that continuing weekly SN visits to the beneficiary was reasonable and necessary to forestall
further hospitalizations and maintain her skin integrity, given her fragile condition. We reverse the ALJ Decision.
W.W. (ALJ 1-275741690) - The beneficiary received 7 SN, 12 PT, 1
SW. Within the two weeks preceding SOC, the beneficiary
suffered a stroke with altered mental status and daily headaches and has a history of diabetes and cardiac problems. Case File in 1-275741690, Ex. 16, at 2, 5. The SOC OASIS records mental problems including hallucinations, agitation, forgetfulness, sleeplessness, impaired decision-making and paranoia. Id. at 11. He is at high nutritional risk having had a 30-pound recent weight change. Id. at 10. He has swollen and painful knees, poor conditioning and weakness. Id. at 11-12. His PLOF was independent with all basic ADLs, while he now needed assistive devices (cane) or minimal assist for dressing, bathing and
ambulating. Id. at 12-13, 15. He is assessed as unable to take medication unless administered by someone else. Id. at 14. The home health services were discontinued when the patient was
admitted to the hospital for a possible stroke. Case File in 1 275741690, Ex. 11, at 8.
The ALJ does not find that SN services were unnecessary or unreasonable for this beneficiary’s condition, but instead
concludes that the nursing notes do not document performance of the measures called for in the plan of care. ALJ Decision in 1
275741690, at 11. Specifically, he notes two blood pressure readings at a level which called for notifying the physician but no documentation of physician contact. Id. He points to the plan of care called for instruction by SN on breathing exercise, infection control and drug regimen, with several new
medications, and states that only one notation is made for administration of one drug and no notes show the required instruction in breathing and infection. Id.
There is evidence in the record that the nurse contacted the physician on several occasions, but not about the high blood pressure readings despite awareness of the risk of hypertension. Compare Case File in 1-275741690, Ex. 12, at 3-4, Ex. 18, at 3 with Case File in 1-275741690, Ex. 18, at 1-2 A nurse does advise the patient/caregiver to call a nurse or doctor for any blood pressure reading above 150/90. Case File in 1-275741690, Ex. 18, at 5. Further, while there is evidence of instruction on safety in ambulation and reduction of stress, none of the notes document the other interventions called for on the plan of care.
We conclude that the ALJ properly denied the coverage of the SN services after the initial assessment as not providing the
skilled level of services planned for. We therefore cover the initial visit and deny coverage of the remaining 6 SN visit. The ALJ denied coverage of the PT services on the grounds that the beneficiary did not have “good rehabilitation potential” and the therapy was merely “general exercises to promote overall fitness or flexibility and activities to provide diversion or general motivation.” ALJ Decision in 1-275741690, at 11. The PT notes certainly make clear that the patient had considerable difficulty with motivation and focus, and the PT therapist
records seeking input from his supervisor on dealing with the patient. Case File in 1-275741690, Ex. 19 passim. However, the notes also record that, with considerable encouragement, the patient was able to successfully improve his static and dynamic balance, functional endurance, and strength, to learn fall
recovery skills, and to reduce the level of assistance needed for his basic ADLs and move from a walker to a single point cane. Id. The notes show that the caregiver was trained to encourage a HEP and in safety precautions. Id. Given the impact these improvements have in reducing fall risk and regaining functionality, we cannot say that the therapist’s assessment in the PT evaluation of “good” rehabilitation
potential was erroneous from the point of view of the time the assessment was made. Case File in 1-275741690, Ex. 20, at 1.
We therefore reverse the ALJ on this service and cover the PT visits. The SW visit is also covered since a qualifying service is covered.
4. Physical therapy as only/primary service Physical therapy services are covered “if the inherent complexity of the service is such that it can be performed safely and/or effectively only by or under the general supervision of a skilled therapist” and if “reasonable and
necessary to the treatment of the patient's illness or injury or to the restoration or maintenance of function affected by the patient's illness or injury.” MBPM, Ch. 7, § 40.2.1.
Generally, there must be a reasonable expectation of material improvement or a need for skilled services to establish a maintenance program and the nature, amount, duration and
frequency of the services must be consistent with the patient’s medical needs. Id.