Failure to Arrange Ordered Home Health Services at Discharge
Penalty
Summary
The facility failed to ensure ordered home health services were arranged for a resident at discharge, resulting in the resident returning home without confirmed home health care. The resident had been admitted after knee replacement surgery, was cognitively intact, and required substantial to maximum assistance with activities of daily living. A comprehensive assessment documented these needs, and a physician’s order dated 01/30/26 directed discharge home with OT, PT, home health services, and DME including a standard walker. The Social Services Director reported that the resident’s discharge was initially delayed because the ordered walker had not been delivered, and stated she faxed the home health orders to an agency on 01/29/26 but did not obtain or document confirmation that services were accepted or scheduled. The resident reported in a phone interview nearly a month after discharge that she was still waiting to receive home health treatment, and record review showed no documentation regarding the status of home health arrangements or follow-up on the referral at the time of discharge. Record review and interviews confirmed that the resident was discharged home without verified home health services in place, and the facility’s documentation lacked any evidence of confirmation or tracking of the home health referral, despite the resident’s identified need for substantial assistance and ordered post-acute services.
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