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Based on interview and record review, the hospital failed to assure that 2 of 2 discharged patients with home care referrals out of a patient sample of 9 were presented with a list of Home Health Agencies available to the patient, that are participating in the Medicare program, and failed to document regarding their freedom to choose among participating Medicare providers (#1 & 2).

Findings:

1. Record review of patient #1's record revealed a 46 year old male admitted to the facility on 6/01/15 and discharged on 6/12/15. There were no therapist notes available for review.
An "Inpatient Discharge Instructions" form documented a named Home care agency "referral sent."

A "Home Healthcare Order Fax Referral" form was seen with the name of the home care agency, address, and phone number. It contained patient information and orders for registered nurse (RN) assessment, and medical social worker with clinical findings and homebound status. The form was signed by the physician and dated 6/12/15. The form was not a hospital/facility form, and documented the name of the home care agency with a phone number and the name of the account executive at the bottom.

There was no documentation seen that the patient was given a list of home health agencies available to the patient, that are participating in the Medicare program, and failed to document regarding their freedom to choose among participating Medicare providers.


2. Record review of patient #2's record revealed a 63 year old male admitted to the facility on 7/01/15 and discharged on 7/24/15. A therapist note dated 7/23/15 documented "Therapist spoke with a name of home care agency and they have reviewed the (patient name) clinicals and have approved him for services."

A "Physician Discharge Orders" form 4505INPT.FM5-Creation/Revision Date 3/31/08", was signed by a physician on 7/24/15 and did not document a home care order.

An "Inpatient Discharge Instructions" form 4702CADM.FOR-Creation/Revision date of 4/15/08" documented a home care agency with a telephone number and an appointment date of 7/24/15 at 12:30 PM at group home.

A "Home Health Fax Referral" form was seen with the name of the home care agency, address and phone number. It contained patient information and orders for skilled nurse, medical social worker and occupational therapy. The form was signed by the physician and dated 7/23/15. The form was not a hospital/facility form, and documented the name of the home care agency's licensed clinical social worker (LCSW) at the bottom of the form.

There was no documentation found that the patient was given a list of home health agencies participating in the Medicare program, and failed to document the patients' freedom to choose among participating Medicare providers.

At 3:40 PM on 7/28/15, the therapist who finalized the patient's discharge plans related he did not document that a home health agency choice list was given to the patients and that he did not inform them of their freedom of choice among participating Medicare providers of post-hospital care services. The therapist related the facility uses specific agencies that would service their patient needs. Therefore, he filled out a named home care agency referral form and faxed it to them upon the patient's discharge. He said the "FAX Referral Form" belonged to the home care agency and was not an official hospital facility form.