Failure to Provide Medically-Related Social Services for Discharge Planning
Penalty
Summary
The facility failed to provide medically-related social services to assist residents in achieving the highest possible quality of life, specifically by not facilitating discharge planning for two residents who wished to return to the community through the Money Follows the Person (MFP) program. One resident, with diagnoses including abnormal posture, spinal instabilities, and a sacral pressure ulcer, was cognitively intact and had a documented goal to return to the community. Despite this, the resident's care plan did not include a discharge plan, and there was no evidence of active discharge planning. Multiple interviews revealed that the facility lacked a Director of Social Work, and the available social worker was only present eight hours per week and was not familiar with the MFP process. Other staff, including the Administrator and Director of Rehabilitation, were unaware of any discharge plans, and the resident was not kept informed about MFP appointments or discharge meetings. A second resident, with diagnoses of atherosclerotic heart disease, COPD, and major depressive disorder, also expressed a desire to discharge using the MFP program. The care plan referenced MFP, but the resident reported being told that no one could assist with the request. Interviews with facility staff, including the DON and a regional clinical RN, revealed a lack of awareness of the resident's discharge wishes and the MFP process. The facility did not have a policy for MFP discharges, and the social worker confirmed that assistance with MFP paperwork and follow-up was not provided as required. The facility's own discharge policy indicated that social services should set up services and develop a discharge care plan, but this was not followed in these cases. Both residents experienced a lack of communication and support regarding their discharge planning, with staff either unaware of their wishes or unable to assist due to staffing shortages and lack of knowledge about the MFP program. The absence of a dedicated social worker and the lack of a clear policy or process for handling MFP discharges resulted in residents not receiving the medically-related social services necessary to facilitate their transition back to the community.