Failure to Provide Complete Discharge Information Delays Home Care Services
Penalty
Summary
The facility failed to ensure that all necessary resident information was conveyed to the home care agency at the time of discharge, resulting in a delay in the initiation of home care services for one resident. The resident, who had a history of right femur fracture, depression, muscle weakness, moderate cognitive impairment, and required significant assistance with activities of daily living, was scheduled for discharge with home care services. The discharge planning documentation indicated that arrangements should be made with community resources to support the resident's independence post-discharge. However, the home care agency did not receive all required documentation, including the resident's demographics and orders specifying needed disciplines, which prevented timely initiation of services. Interviews revealed that the facility typically sends discharge referrals two to three weeks before discharge, but the documentation is not maintained in the electronic medical record and is instead kept in paper form. The home care agency representative confirmed that only clinical information was received, and the absence of demographic and insurance information delayed the start of home care services. As a result, the resident's home care services were not initiated until several days after discharge, contrary to the usual practice of starting services within 48 hours.