Failure to Implement Ordered Home Health Services at Discharge
Penalty
Summary
The deficiency involves the facility’s failure to implement a resident’s post-discharge plan of care by not arranging ordered home health (HH) services. The resident was admitted with diagnoses including difficulty in walking and muscle weakness. The discharge summary/Post Discharge Plan of Care dated 11/10/25 documented that the resident was independent in bed mobility and transfers, required supervision for ambulation with a front-wheeled walker, was independent with wheelchair use, and was to continue with home health services. A physician assistant note dated 11/12/25 indicated time spent to discharge the patient, review medications, and order PT/OT and needed equipment, with medications ordered to an outpatient pharmacy. The case manager’s note on 11/12/25 stated the patient would be discharging home with HH, including rehab PT/OT. Despite these documented plans, the facility’s discharged resident list showed the resident was discharged home with no home health services. A family member reported that at the time of discharge they were told they would be contacted about HH services, but no HH visit occurred after discharge. The family member also stated they attempted to call facility staff but did not receive a call back. Review of the clinical record by the ADON confirmed that home health was marked on the discharge summary/Post Discharge Plan of Care, but there was no documentation of any HH referral. Interviews with facility staff revealed confusion and lack of follow-through regarding responsibility for initiating the HH referral. The social services staff member stated she did not know about the HH referral and indicated the case manager knew more about HH referrals. The case manager stated that normally HH is set up before discharge based on rehab recommendations and that referrals are faxed or emailed, but acknowledged she did not send a referral for HH and stated that usually social services handles HH referrals. The ADON, DON, and Administrator each confirmed that HH was indicated in the discharge documentation and that either social services or the case manager was responsible for HH referrals, but their statements reflected vague and overlapping duties. This confusion resulted in no referral being sent to a home health agency and the resident being discharged home without any home care services, contrary to the documented post-discharge plan of care.
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