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F0745
D

Failure to Provide Safe Discharge Planning and Medically Related Social Services

Leesburg, Virginia Survey Completed on 05-21-2025

Penalty

Fine: $5,712
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to provide medically related social services for one resident, specifically by not developing a safe discharge plan. The resident in question had a history of Parkinson's disease and alcoholism, with multiple clinical notes documenting ongoing alcohol abuse, aggressive behavior, and repeated intoxication upon returning from outings. Despite these documented issues, the discharge planning process did not adequately address the resident's substance abuse or ensure a safe and stable discharge destination. The discharge process was marked by a lack of clear communication and coordination among facility staff. The social worker assigned to the case was instructed by an administrative staff member to find placement for the resident due to nonpayment, with the facility offering to pay for a few nights in a hotel if necessary. The social worker expressed discomfort with discharging the resident to a hotel and attempted to find a shelter, eventually locating one in an adjacent state. However, the discharge notification letter provided to the resident did not specify a discharge date or destination, and there was no evidence in the record of when the resident received this notice. The social worker also reported being kept out of the loop until the final days of discharge planning and was unaware of the resident's alcohol dependency, which was not addressed in the discharge plan. Interviews with facility staff, including the director of social services and the administrator, confirmed that the discharge plan lacked essential details such as the discharge location and did not address the resident's ongoing substance abuse issues. The facility's own job descriptions for social services staff emphasize the importance of comprehensive discharge planning, including assessment of medical, social, and emotional needs, and coordination of community resources. In this case, the discharge plan did not meet these standards, as there was no clear evidence of a safe and appropriate discharge arrangement or follow-up for the resident's substance abuse.

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