Failure to Arrange Timely Home Health Referral Prior to Discharge
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective discharge planning process to ensure timely referral for home health services prior to a resident’s discharge home. The resident had diagnoses including a displaced fracture of the right second metatarsal, cerebral palsy, and muscle weakness, and required assistance or supervision with several ADLs. The 5‑day MDS documented that the resident was cognitively intact, receiving PT and OT, and had an overall discharge goal of returning to the community with active discharge planning noted. However, the resident’s care plan dated 01/10/2025 contained no information related to discharge planning, and progress notes from 01/07/2025 through 01/31/2025 contained no documentation of discharge planning activities. Therapy documentation showed that the resident exhausted therapy benefits on 01/25/2025 and would require home health OT and PT upon discharge. An order dated 01/28/2025 directed discharge home with home health PT, OT, and case management services. The OT and PT discharge summaries indicated that the interdisciplinary team was to coordinate a discharge that included home health services. A nurse practitioner documented a face‑to‑face encounter on 01/30/2025, certified the resident as homebound, ordered home health PT and OT, and indicated that required home health documentation was reviewed and communication with the home health agency occurred. Despite these orders and certifications, there was no evidence in the record that a referral to home health was actually sent before the resident left the facility. The resident was discharged home on 01/31/2025, with the discharge/transfer plan of care stating that she was to be set up with home health PT, OT, and case management prior to discharge and that she left by car with a friend. The resident later reported that the social worker had told her home health services would be arranged before she went home, but she did not hear from home health until several days after discharge and relied on friends for help in the interim. Home health records and interview confirmed that the referral paperwork, which included a home health order dated 01/28/2025, was first received by the home health agency on 02/01/2025, after the resident had already been discharged. A fax confirmation from the facility also showed the referral was sent on 02/01/2025, and there was no evidence of any earlier referral, demonstrating that the facility did not complete the home health referral prior to discharge as planned.
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