Failure to Ensure Home Health Services in Place Prior to Discharge
Penalty
Summary
The facility failed to ensure adequate discharge planning for a resident who was discharged home with the expectation of receiving home health services. The resident, who had a history of a right acetabulum and pubis fracture, Type 2 Diabetes Mellitus, and long-term insulin use, was discharged with arrangements for physical therapy, occupational therapy, and nursing services through a home health agency (HHA). Although the facility's social services staff faxed referral documents to the HHA, there was no evidence that the facility confirmed receipt of the referral or that services were in place prior to discharge. After discharge, the resident contacted the facility to report that he had not received the expected caregiver services and had already experienced a fall at home. Interviews with facility staff revealed that the social services department did not typically follow up with HHAs or discharged residents unless notified by the HHA of an issue. The HHA reported they had not seen the resident because they were awaiting VA authorization and had been unable to contact the resident. Documentation showed that the VA had not processed the authorization request in a timely manner, and the HHA had not received the necessary information to proceed. The facility's policy required social services to ensure continuity of care during discharge, but in this case, the lack of confirmation and follow-up resulted in the resident not receiving needed home health services.