F0745

D

Failure to Provide Adequate Social Services and Discharge Planning for Two Residents Discharged to Independent Living

Richmond, Virginia Survey Completed on 02-06-2026

Penalty

Fine: $16,820

Summary

Facility staff failed to provide medically related social services for discharge planning for two residents, resulting in discharges to independent living settings without adequate planning, IDT involvement, or guardian participation. For the first resident, who had multiple complex medical diagnoses including muscle wasting/atrophy, diabetes, CHF, atrial fibrillation, prior cerebral infarction, major depressive disorder, and moderately impaired cognition, the record showed the resident had lived in the facility for over three years and had been adjudicated incapacitated with a court‑appointed guardian authorized to make all decisions, including living arrangements. The MDS documented that the resident did not wish to be asked about returning to the community, and the comprehensive care plan last reviewed eight months before discharge indicated no plans to discharge. Despite this, the resident was discharged to what was documented as a "group home" without a documented discharge plan, without documented rationale for discharge, without a physician/provider order or basis for discharge, and without documented consent or involvement of the legal guardian.

Clinical and facility documentation for this resident showed that the psychiatric NP and LCSW noted the resident talking about moving to a group home, but the physician’s recertification shortly before discharge stated the resident was appropriate for nursing home care and required significant help with ADLs, with no mention of community discharge. The social worker documented brief notes indicating discussion of discharge with the resident and the "group home" and set a discharge date, but there was no evidence of IDT care plan review or a written discharge plan identifying post‑discharge care needs, services, or goals. The discharge summary listed a group home address, noted medication reconciliation, and assigned the resident responsibility for scheduling follow‑up with a primary care provider, but left the provider’s contact information incomplete and contained no documentation of education on self‑administration of Trulicity or any other medications, despite the resident not having been assessed or trained to self‑administer injections or other medications in the facility. There was no documentation addressing access to a phone, money management, or specific community supports. Interviews with the guardian, NP, LPN, and social worker revealed that the guardian was not notified or consulted, the NP and nursing staff believed the destination was a licensed group home with medication administration and structured services, and the social worker had not verified the level of care or services at the destination, had not visited the site, and had no written description of services provided.

Further investigation with the owner of the discharge destination for the first resident established that the setting was independent living apartments, not a licensed group home, and that residents were required to be independent with all ADLs, with no direct care or medication administration provided, only pill reminders and some meal prep if requested. The NP stated the resident required cueing for hygiene, assistance with medication administration, and could not effectively manage money, and that independent living was not appropriate. The guardian reported learning of the discharge only after being contacted by a hospital social worker when the resident was found on the street with belongings and brought to the ED, and stated she had never been contacted by the facility about the discharge and would have evaluated the location herself if informed. The administrator acknowledged that the guardian should have been involved and that there was no separate documented discharge plan beyond the discharge summary. The facility’s social worker job description, as reviewed by surveyors, required participation in discharge planning, development and implementation of the social care plan, involvement of the resident/family in planning goals, and regular review of discharge plans, which were not reflected in the documentation for this resident.

For the second resident, who had resided in the facility for approximately three and a half years, diagnoses included NSTEMI, hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes with proliferative diabetic retinopathy, cerebral infarction, need for assistance with personal care, gait and mobility abnormalities, and hypertensive CKD with stage 5 CKD/ESRD requiring dialysis. The care plan contained an active focus area indicating the resident wished to remain long‑term care at the facility. The NP’s discharge summary stated the resident was stable for discharge to a group home with home health PT/OT. However, the clinical record contained no documented discharge planning addressing the resident’s needs prior to discharge, no documentation of arrangements for medication administration post‑discharge, no evidence of medication education or training, and no documented plan for management of the dialysis access site/port. There was no documentation of medical equipment needs beyond later evidence of a hospital bed setup, no evidence that home health services referenced by the provider were actually arranged, and no IDT involvement in discharge planning other than a care plan meeting note on the day of discharge.

The only social services documentation for the second resident consisted of two brief notes: one indicating the resident was interested in discharging to a group home after meeting with a group home representative, and another postponing discharge to a later date, with no details on the destination, services, or identified needs. The only document listing the discharge address was an IDT care plan meeting review form on the day of discharge, which also indicated the level of care as long‑term care and showed only nursing and social services present with the resident. The owner of the receiving facility reported that the setting provided apartments and rooms as independent living, with no assistance with daily care, no medication administration, only medication reminders and some meal prep if requested, and that the facility was not licensed as any type of medical facility. Interviews with the social worker, NP, and LPN showed that the social worker stated the resident requested discharge and that she ensured dialysis transport and owner awareness, but could not provide documentation of broader discharge planning; the NP believed the resident was going to a group home described as a small nursing home with CNAs and nurses and stated she was not aware it was independent living and felt the resident needed a group home; and the LPN unit manager believed the resident was discharging to a group home with 24‑hour care. The Director of Social Services confirmed that discharge planning was a social work responsibility and should be documented in the clinical record, which was not evident for this resident.