F0628

D

Failure to Coordinate Home Health Orders and Communicate PCP Limitations at Discharge

Providence, Rhode Island Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure appropriate communication of critical discharge information and coordination with a home care agency for a resident discharged with orders for skilled nursing and therapy. The resident, who had dementia, heart failure, and a BIMS score of 9 indicating moderate cognitive impairment, was admitted in January 2026 and discharged home on 2/15/2026 with medically necessary home health services ordered by the facility’s Medical Director. The facility’s social worker knew shortly after admission that the resident did not have a community PCP and arranged for a new PCP with an appointment scheduled for 2/26/2026. She also knew that this new PCP would not sign home health orders until the resident was seen in the office, but there was no documentation that this limitation was communicated to the home care agency.

The home care agency accepted the referral for services to begin at discharge and conducted an initial assessment on 2/17/2026. Agency records showed that when staff contacted the new PCP for signed orders, they were informed the PCP would not sign until the resident’s 2/26/2026 office visit. The agency then called the facility on multiple occasions, beginning on 2/18/2026, leaving voicemails for the facility social worker to request that the facility’s Medical Director sign the home care orders so services could start before the PCP visit. Progress notes from the agency documented additional voicemails on 2/26/2026 and 2/27/2026, but the facility did not return these calls until 3/5/2026. As a result, the resident did not receive the ordered skilled nursing and therapy services after the initial home care assessment on 2/17/2026.

The resident’s family member reported informing the facility a few days after admission that the resident had no PCP and later attempted to contact the social worker on three separate dates after discharge using the correct telephone number, without receiving a return call until 3/5/2026. The family member stated that the social worker had previously assured them that the new PCP had agreed to sign home care orders prior to the office visit, but the social worker could not provide evidence of such an agreement and denied receiving the calls, despite acknowledging the phone number used was correct. The Medical Director stated he had been told by facility staff that the new PCP would sign the orders at discharge and was unaware of the home care agency’s requests for his signature until early March; he indicated he would have signed the orders if he had known the PCP would not sign and that the resident was not receiving services. The record review confirmed there was no evidence the facility communicated to the home care agency that the PCP was new and would not sign orders before seeing the resident, and no timely response to the agency’s and family’s calls, leading to the interruption of ordered home health services following discharge.