Failure to Confirm Home Health Services Prior to Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure that home health (HH) services were confirmed and accurately reflected in discharge documentation prior to residents’ discharge. For Resident 1, who was admitted with a peritoneal abscess and required surgical wound dressing changes, there was an order for discharge with HH services for RN visits, wound care, and PT. The discharge summary and post-discharge plan of care identified a specific home health agency as arranged, and the resident was discharged with a wound VAC in place. However, the referral to that agency was not faxed until approximately 29 minutes after the resident had already left the facility, and the agency did not accept the referral. There were no progress notes documenting discharge planning prior to the social services assistant’s (SSA) notes four days after discharge. The resident later reported to a GACH that no nurse had come to his home and that he did not know how to care for his wound VAC. For Resident 2, admitted with difficulty walking and pneumocystosis, an order was written for discharge to home with HH services for RN and PT visits. A discharge progress note documented that a referral had been sent to a home health agency and was pending review and acceptance, yet the discharge summary and post-discharge plan of care stated that this same agency had been arranged to provide services. The resident was discharged home, and more than three hours after discharge, a discharge planning note documented that the agency did not accept the referral. Over 24 hours after discharge, the SSA documented that a different home health agency confirmed acceptance of the referral. The SSA later stated that the day she documented the acceptance was the day the second agency confirmed, which was the day after the resident’s discharge. For Resident 3, admitted with acute cholecystitis and artificial openings of the digestive tract, the discharge summary stated that HH services had been arranged with a specific home health agency. A discharge planning note documented that a referral had been made to that agency and was pending review and acceptance. The social services staff stated she sent the referral but did not hear back from the agency regarding acceptance and did not have a chance to follow up on the referral before or after the resident’s discharge. In interviews, the administrator stated that referrals to HH agencies should have been initiated as soon as the facility became aware of a resident’s discharge date, and the DON in training stated that HH agencies should have been confirmed prior to residents’ discharges. The facility’s own policy required that discharge needs be identified on admission and that a discharge plan be developed and implemented in a timely manner to effectively transition residents to post-discharge care.
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