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Based on record review and interview, the hospital failed to ensure arrangements for post-discharge care or equipment needs were finalized before discharge for 3 of 3 patients (Patients# 1, 2, and 3) reviewed for discharge planning.

The findings included:

Review of the hospital's Policy and Procedure titled Discharge Planning, review date 02/01/18, documents under Policy "The discharge planning function focuses on meeting the patient's continuing healthcare needs after discharge... The purpose of discharge planning is to identify the patient's continuing physical, emotional, social, housekeeping, transportation, and safety needs and to arrange services to meet those identified needs" and documents under Procedure "All patients will receive the initial discharge planning interview by Case Management within 72 hours of admission. The Case Management staff will coordinate discharge planning efforts by all disciplines for those patients... All pertinent information shall be documented and placed within the medical record." The Policy and Procedure does not document that arrangements should be finalized before the patient leaves the facility.

1) Review of the record revealed Patient #1 was admitted to the hospital on 01/11/19 and discharged on 01/23/19 at 3:30 PM. Patient #1's Case Management Inpatient Rehabilitation Initial Assessment dated 01/12/19 documents she lives with her spouse who works nights and had no medical equipment in the home.

Patient #1's Physician Orders include an order dated and timed 01/19/19 at 2:07 PM "Patient requires shower chair upon discharge" (sic).

Patient #1's Occupational Therapy Inpatient Rehabilitation Discharge Summary dated 01/22/19 at 11:30 AM documents she needed a walker and bedside commode in order to toilet herself, and needed a tub bench.

Patient #1's Physician Orders include a handwritten telephone order dated "01/23/18" (sic) by the Case Manager "D/C home Wed (Wednesday, that same day) 1/23/2019 with Home Health PT (Physical Therapy) /OT (Occupational Therapy) /RN (Registered Nurse) eval for skin check and vital signs, DME (Durable Medical Equipment) shower bench, rolling walker, 3:1 (3-in-1) commode." The order was marked as checked off 01/23/19 at 3:00 PM.

Patient #1's discharge information sheet titled Congratulations From Your Rehabilitation Team documents under Equipment Needs, Company "Y" (name of supplier redacted), with no indication of what equipment she was to get or whether it was ordered or issued, and, under Home Services, Home Health Agency "X" (name redacted) for PT and OT. There was no documentation that the patient's safety was discussed or addressed for her first night home since her spouse worked nights and equipment delivery was not confirmed. There was also no evidence of documentation whether Home Health Agency "X" had accepted the patient or was notified when she went home, or when they would make the first visit to the patient.

During interview on 02/26/19 from 2:41 PM to 3:50 PM, the Case Manager stated that during his initial assessment he verifies the patient's contact information and also stated "nobody leaves without equipment." The Case Manager was asked for evidence that equipment was delivered or confirmed for Patient #1's discharge. Within the same interview the Case Manager then stated the hospital will discharge patients without equipment if the equipment will be delivered that night, but he does not verify equipment delivery arrangements because the companies call patients directly, and that the nurses can ask him if they don't see equipment in the patient's room. The Case Manager stated that Company "Y" often causes delays to get equipment so he has to order from them in advance. In regards to home health the Case Manager stated he "usually" only puts the name of the Home Health Agency in the record after they have accepted the patient and confirm they will visit within 24 hours. When asked within the same interview for evidence that Home Health Agency "X" had accepted Patient #1 before discharge, the Case Manager explained for (Patient #1's insurance company) the hospital discharges the patient when insurance coverage ends and may send the patient home without confirming that home health services will be provided and staffed, but tell the patient/family/representative to call if they don't hear from a Home Health Agency in 24 hours.

The patient's phone number of record was called on 02/27/19 at 09:33 AM but went to a long-standing local place of business. No other phone number was found in the record and the spouse phone number was listed as the same. This was verified by a second call with Staff "A" on 02/27/19 at 3:49 PM.

A telephone call was placed on 02/27/19 at 9:38 AM to Company "Y" during which Company "Y"'s Representative "B" reported Patient #1's only equipment orders from this hospital were received on 01/23/19 but that they could not reach the patient since the phone number provided on the facesheet went to a place of business. Representative "B" stated the company called the Case Manager at the hospital the next day seeking a valid phone number, but the Case Manager denied having any other contact number for the patient. Therefore, Patient #1 could not have been called and arrangements made for delivery of the equipment, or to start home health, before her discharge on 01/23/19. Although Company "Y"'s Representative confirmed equipment was delivered by 01/25/19, 2 days after discharge, it is unknown whether Patient #1 ever received any home health services that were ordered since she could not be reached by phone. Without the benefit of confirming arrangements before Patient #1's discharge, the opportunity was missed to correct her contact information so she could receive the necessary services and timely equipment to ensure a safe discharge.

2) Review of the record revealed Patient #2 was admitted to the hospital on 02/07/19 after open heart surgery and discharged on 02/16/19.

Patient #2's Physical Therapy Inpatient Rehabilitation Discharge Summary dated 02/15/19 documented "continued Physical Therapy is recommended to address TE (Therapeutic Exercises), TA (Therapeutic Activities)." Patient #2's Occupational Therapy Inpatient Rehabilitation Discharge Summary dated 02/15/19 documented "continued Occupational Therapy is not recommended at this time due to: Goals have been MET." Patient #2's Physician Orders include an order dated and timed 02/15/19 at 3:15 PM for him to be discharged the next day, 02/16/19, with home health for Physical Therapy and a Registered Nurse evaluation for skin checks and vital signs.

Patient #2's discharge paperwork for 02/16/19 documented he would receive home health services from Home Health Agency "Z" for Nursing services, Physical Therapy and Occupational Therapy.

A telephone call was placed to Patient #2 on 2/27/19 2:03 PM during which he reported he was discharged on a Saturday but home health did not come out over the weekend; that he later learned from his insurance that home health had not been arranged. Home Health Agency "Z" did not work with his insurance, and another agency had to be arranged. Due to the patient's/family's own efforts, home health services started 3 days after discharge. He also reported medications were called to the pharmacy incorrectly, resulting in a 2-day delay to get medications after discharge.

On 02/27/19 at 3:22 PM the Director of Nursing said staff should confirm arrangements are made for equipment deliveries and home health before discharging the patient.

On 02/27/19 at 3:24 PM, Staff "A," who reported she was covering for, and regularly covers for, the Case Manager in his absence, stated she had set up Patient #2's home health with Home Health Agency "Z," as specified by the Case Manager according to the insurance coverage. A telephone call on 02/27/19 at 4:24 PM with Staff "A" to Patient #2's insurance company verified they do not work with Home Health Agency "Z." Without confirming the home health agency's acceptance of the patient, the hospital was unable to correct the inappropriate referral to arrange post-discharge care.

3) Review of the record revealed Patient #3 was admitted to the hospital on 12/18/18 and discharged on 01/29/19. Patient #3's Physician Orders include a handwritten order dated 01/29/19 to discharge home with home health for Physical Therapy, Occupation Therapy, Home Health Aide, and Registered Nurse services and with medical equipment to include a semi-electric bed with gel overlay mattress, 3-in-1 commode, tall hemi-walker, and wheelchair with elevated leg rests.

Patient #3's Physical Therapy Inpatient Rehabilitation Discharge Summary dated 01/27/19 documented continued Physical Therapy was recommended for gait and wheelchair training, therapeutic exercises and activities, neuro education, and patient family education. Patient #3's Occupational Therapy Inpatient Rehabilitation Discharge Summary dated 01/28/19 documented continued Occupational Therapy was recommended for transfer/balance/activities of daily living training, therapeutic exercises and activities, and patient education.

Patient #3's discharge paperwork for 01/29/19 documented he would receive home health services for Physical Therapy, Occupation Therapy, Home Health Aide, Social Work, and Registered Nurse services but provided no name or phone number of a home health agency or contact information to inquire about home health arrangements.

During telephonic interview on 02/26/19 at 11:09 AM, Patient #3's family member reported he was discharged with a borrowed wheelchair but never received any home health services or the walker and wheelchair that was ordered; that she was unable to safely assist him without the proper equipment and he'd had at least 7 falls at home since discharge. The family member stated she made several calls herself before receiving some of the other equipment, and that she called the hospital to check on home health but the hospital staff claimed insurance had not authorized it, whereas the insurance company denied receiving any orders for home health from the hospital.

On 02/27/19 at 4:52 PM, Staff "A" provided fax confirmation of an order for Patient #3's alternate pressure pad and pump (for a hospital bed) and reported she received a phone call from Patient #3's family member on the day of discharge that he had a bed and could be sent home. However, Staff "A" could provide no evidence that other equipment or home health were arranged for Patient #3.

Based on record review and interview, the hospital did not provide 2 of 3 patients (Patients# 2 and 3) a choice of Home Health Agencies that were available to them, and had no process in place to offer patients a choice of providers and disclose the hospital's financial interests in any of the agencies offered.

The findings included:

Review of lists of home health agencies and equipment companies, provided by Staff "A," revealed for each payor source listed, there was contact information to a "broker" utilized by the insurance company or to one Home Health Agency, if any, and/or an equipment company. For insurances that do not utilize a broker service, such as Medicare and Insurance "U," there was no evidence of lists of Home Health Agencies from which patients could choose, appropriate to their payor source. Staff "A" confirmed these were the the Case Manager's lists that they use to send referrals for home services and equipment.

1) Patient #2's record documented his payor was Insurance "V." Patient #2's discharge paperwork for 02/16/19 documented he would receive home health services from Home Health Agency "Z" for Nursing services, Physical Therapy and Occupational Therapy.

A telephone call was placed to Patient #2 on 02/27/19 2:03 during which he reported the home health never contacted him so, upon calling some days after discharge, he learned home health had not been set up and Home Health Agency "Z" did not accept Insurance "V."

On 03/27/19 at 3:24 PM, Staff "A," who reported she was covering for, and regularly covers for, the Case Manager in his absence, stated she had set up Patient #2's home health with Home Health Agency "Z," as the Case Manager directed according to the insurance coverage. A telephone call on 02/27/19 at 4:24 PM with Staff "A" to Patient #2's insurance company verified they do not work with Home Health Agency "Z." Without the benefit of efforts to identify participating providers that work with the patient's insurance, the hospital made an inappropriate referral instead of to the broker that Insurance "V" utilizes for all home health referrals.

2) Patient #3's record documents his payor was Insurance "U" and he was discharged with orders for home health services. However, there was no documentation that Patient #3 or his caregiver/family were provided a choice of home health providers since Insurance "U" works with multiple home health agencies in the area, as verified upon review of Insurance "U"'s website. Patient #3's discharge paperwork did not indicate which home health agency would provide services.

Patient #3's Inpatient Rehabilitation Discharge Summary, by the Case Manager the day after discharge, documented home health was "recommended" with initials for a home health agency, but without indication that the patient/family participated in the choice of agency, or that it was arranged.

On 02/26/19 at 2:41 PM the Case Manager explained that a lot of times a home health agency representative will come in to the facility and ask if he has any business for them, at which time he gives them names of patients for them to see. The Case Manager did not describe a process for patients to choose their own home health agency.

On 02/27/19 at 3:24 PM, Staff "A" was asked how she makes sure patients have a choice of home health providers and responded that she asks them if they had a home health agency before, in which case she would use the same agency, but if not staff would pick the agency. Upon inquiry for Medicare patients, Staff "A" stated they get Catholic Home Health Services, which is the hospital's affiliated agency. She denied awareness that patients must get a choice of available providers, this be documented in their record, and that financial interests in the providers must be disclosed.

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