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F0627
D

Failure to Ensure Safe Discharge with Home Health Services

Portland, Oregon Survey Completed on 09-08-2025

Penalty

No penalty information released
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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

A resident with a fibular fracture was admitted to the facility and had a discharge care plan indicating an anticipated return home, with arrangements to be made for home health (HH), caregiver support, physical therapy (PT), and occupational therapy (OT). Physician and social services notes confirmed the need for these services, and a referral to a home health agency was initially sent. However, when the home health agency attempted to complete the referral, facility staff informed them to cancel it, as the resident was reportedly no longer planning to discharge at that time. Despite this, the resident was ultimately discharged home without a completed home health referral or the necessary support services in place. The resident reported being without caregiver supports until arranging services independently through their physician, and a family member had to quit two jobs to provide care until home health services were established. Facility leadership acknowledged that the resident was discharged without the required home health, PT, and OT services.

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