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Based on the complaint allegation ACTS Intake PR00000504 survey, review of thirty clinical record, policies/procedures interviews with staff, patients, and patients with the Utilization Coordinator (employee # 2),on 02/26/2013 from 8:30 am till 9:00 pm, it was determined that the Governing Body failed to carry out its responsibility for the operation and management of the hospital. It did not provide the necessary oversight and leadership as evidenced by the lack of compliance with: 42 CFR 482.43 Discharge Planning. (cross refer tags A799, A800, A806, A807, A810, A821, A823 and A843).

Based on the review of thirty clinical records and policies/procedures with the Utilization Coordinator (employee # 2), it was determined that the facility failed to have in effect a discharge planning process that applies to all patients which makes this Condition of Participation is Not Met (Please cross reference tags A800, A806, A807, A810, A821, A823 and A843).

Based complaint investigation PR00000504, review of clinical records, policies/procedures and interview with the Utilization Coordinator (employee # 2), it was found that the facility failed to establish the criteria to identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge, failed to ensure to have criteria for identifying risks within an early stage of hospitalization for the patient for discharge planning for 13 out of 30 records reviewed (R.R #2, #3, #4, #7, #8, #9, #10, #11, #12, #13, #16, #17 and #19 ) and failed to have a hospice rotation system.

Findings include:

1.During interview with the Utilization Coordinator (employee #2) on 2/26/13 at 8:45 am related to the discharge planning process, she stated that they did not have a discharge planning coordinator until February 4, 2013 because the discharge planning coordinator resign, however the facility design the responsibility to the social worker (employee #3) until February 18, 2013. On February 18, 2013 the utilization coordinator (employee #2) was designate discharge planning coordinator, however no evidence was found of job descriptions and functions on the employees' record. The director of the Information Management Department (employee #5) and the Utilization and Quality Director (employee #4) stated: ''The facility was working on a special model clinical team care coordinator and quality but at this moment the facility did not have specific indicator's for discharge planning and did not have a discharge planning director.''

The utilization coordinator (employee #2) was interview on 2/26/13 at 8:45 am., and she stated that the discharge planning was performed by seven utilization coordinators all of them are register nurses and they perform the discharge planning to all Medicare and Medicare Advantage patients and some patients have to be refer.

The Discharge planning director (employee #5) was interview on 2/26/13 at 9:30 am., and she stated: '' About less than a year the discharge planning program was incorporated under the same umbrella of the Information Management Department and as a new project was started and the initial interview for discharge planning was incorporated on the same interdisciplinary group assessment form. The person assigned to discharge planning tried to see all the cases, but if she was absent or was on vacations the social worker was the one that did the initial interview when a need of discharge planning was identified, then the discharge process was started and the team was integrated in the assessment. A personal was assigned from utilization to do the discharge planning. Each discipline will perform its ' evaluation as per their professional standard and will share information with the team. This personnel performs a daily screening for all admissions and census of admitted patients, then identifies the admitted patient per diagnosis and reviewed the physician progress notes from Monday through Friday, them if the patient has care needs, medical devises needs and if the patient have over 65 years old they performed the discharge planning according with the medical plan insurance, all Traditional Medicare patients and all Medicare Advantage. The utilization personnel evaluated the home care and hospice patients; however the facility did not have a register log of the patients evaluated by the utilization personnel. The patients who have the '' Medicaid health insurance plan (reforma de salud) have many problems because the medical plan denied the services in this case the physician tries directly with the plan and if the '' Medicaid plan continues to deny the patient services the facility provides charity services. The facility did not receive and official document related to the service denied per the medical plan; however the medical plan sends a denial letter directly to the patient. The facility designated seven utilization personnel to performed the patient discharge planning, at this moment there are a lot of things that are not well define but we are in the process of re-organize the department.''

2. On interview with the Social Worker ( employee #3) on 2/26/13 at 9:00 am she stated: '' The initial intervention related to discharge planning is performed by the nurse on the interdisciplinary assessment form, then is probable that the patient do not received the discharge planning initial assessment and re-assessment if it necessary because the physician ordered the discharge. The facility did not have discharge planning personnel on weekends, holidays and did not have on call personnel to perform the initial discharge planning assessment. I did not intervene with the hospital patient's related to the discharge planning process because I ' m working with the skill nursing patients.''

3. The facility's policies and procedures establish that Discharge Planning initial assessment is performed during the first 24 hours of admission on weekends and holidays is performed the next working day, however the discharge planning re-assessment do not established time frame to perform re-assessments after the initial assessment or referral as reviewed on 2/26/13 at 9:30 am.


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4. During the review of facilities policies and procedure related to Hospice Rotation listing on 2/26/13 at 11:30 am, it was found that the facility lack of a rotation system.

Based on the review of policies and procedures related of the Discharge Planning twenty closed clinical record (RR) reviewed with the Utilization Coordinator (employee # 1), it was determined that the facility failed to ensure that discharge planning policies and procedures include provisions to comply with the discharge process for weekends and after hours and to provide the pamphlet with the "Important Message from Medicare" for 20 of 20 closed records reviewed. (RR #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19 and #20).
Findings include:

1. During the review of policies and procedures and medical records reviewed on 2/26/13 from 10:00 am till 7:00 pm with the Utilization Coordinator (employee # 1), the following was found:

a. The facility's policies and procedures establish that the "Important Message from Medicare" notification will be given to all patients who have Traditional Medicare, Medicare Advantage and Medicare as a secondary plan and double eligible admitted to the hospital. All admission personnel, emergency room personnel, social worker's, utilization personnel, nursing personnel, patient service personnel, quality and medical faculty is responsible to execute this policy however, the facility failed to designated the personnel responsible to given the '' Important Message'' to Medicare patients admitted at the hospital to assure that the message was given to Medicare patients. The policy established that the form will be signed, dated and kept the original and two additional copies in the patient medical record and provided a copy to the patient. A physician order was placed forty eight hours before the date of discharge planning. Twenty four hours before notify the discharge planning a '' Important Message from Medicare'' will be provided to the patient by the social worker personnel, however the facility failed to provide the '' Important Message from Medicare'' forty eight hours (48) before the patient discharge to home. A new signature must be taken to the patient or his representative. A sign and dated copy is safe in the clinical record.

b. Twenty out of twenty closed medical record reviewed (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20) provided evidence that the twenty four hours before discharge the patient pamphlet "Important Message from Medicare " were not given to patients and caregivers in order to make them aware of their rights to request a discharge plan or appeal


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2. During interview with the utilization staff (employee #2) and review of policies and procedure she state on 2/26/13 at 10:20 am that "the discharge planning officer only works from Monday through Friday from 8:00 am through 5:00 pm. It is not on-call for discharge planning. During the weekends, holidays and after hours the nursing personnel and the physician in charge of the patients intervene with the discharge planning, and if considered necessary they refer the patient to the social worker. Then the social worker prioritizes this referral in her next working day. The mechanism of evaluating patients in need of discharge planning on weekends and after hours is not included in the facility's policies and procedures. The discharge planning evaluations was performed for all patients Medicare and Medicare Advantage and referrals on Monday through Friday. Patients arriving the weekend are assessed on Monday. The non Medicare patients who need discharge planning were evaluated by the utilization personnel. The utilization personnel did not have authority to document their evaluation and intervention in patient medical record but they manage and performed intervention with patient discharge need".

However, no evidence was found in the patient medical records related to the intervention and management of the discharge planning.

Based on review of seven credential files (C.F) of the utilization coordinators, interview with the discharge planning director and record review (RR), it was determined that the facility failed to ensure that a qualified personnel develop evaluate the need of discharge planning for all patient for 15 out of 20 records reviewed (RR #1, #2, #3, #4, #5, #7, #9, #10, #11, #12, #13, #14, #15, #16 and #19 ) and to have a current credential file as required that contains job description for 7 of 7 utilization coordinators credential file (C.F #1, #2, #3, #4, #5, #6 and #7 ).

Findings include:

1. During the review of the seven credential files of the utilization coordinator's designated with discharge planning coordination on 2/26/13 at 12:50 pm with the Human Resource Director (employee #7) no evidence was found of the job descriptions.

2. During interview with the Human Resource Director (employee #7) related to the utilization coordinator's functions and responsibilities on the discharge planning process on 2/26/13 at 12:50 pm., she stated: '' The facility do not have a discharge planning coordinator on property at this moment, however the facility designated seven utilization coordinators to perform the discharge planning to the facility ' s patients, all of this personnel are register nurse and respond to the Medical Record Director. The utilization coordinator's personnel provide service from Monday through Friday from 8:00 am till 5:00 pm.''

During the month that the hospital did not have a discharge planning coordinator, the nursing staff was responsible to coordinate the discharge planning for all the patients. However, it was found that during this period of time that the hospital was without a discharge planning coordinator, fifteen out of twenty record reviews (#1, #2, #3, #4, #5, #7, #9, #10, #11, #12, #13, #14, #15, #16 and #19) do not provide evidence of coordination for discharge planning.

3. During the records review on 2/26/13 from 2:45 pm till 5:00 pm no evidence was found of a mechanism to ensure that the discharge planning process is complete assess and evaluated on a timely basis was not performed on 5 out of 20 closed clinical record reviews and on 5 active records reviewed the initial evaluation and assessment of discharge planning was not performed during the first 24 hours of admission as described in the facility policies and procedure (Closed records: R.R #7, #9, #13, #14 and #16) and (Active records: RR #21, #23, #24, #25 and #28).

a. R.R #7 is a 70 years old male admitted to the facility on 10/16/12 with a diagnosis of Jaundice and has a Tracheotomy, High Blood Pressure, Thyroid Disease and Depression. During the record review performed on 2/26/13 at 2:45 pm, on the interdisciplinary initial evaluation general information performed by the nurse lacks of information related to when the patient discharge, what services the patient needs, home care, hospice, medical equipment and supplies, transportation or other services and the nurse referred the patient to social worker for discharge planning services however, no evidence of social worker and discharge planning initial assessment or re-assessment during the patient hospitalization from 10/16/12 to 10/26/12 9 ( 10 days). On 10/25/12 at 11:15 am the physician ordered discharge planning to Hospice La Guadalupe. On 10/26/12 at 9:30 am a physician ordered call ambulance and discharge home. On 10/25/12 at 1:40 pm. the interdisciplinary progress note form performed by a nurse (employee #6) provided evidence that the patient case was given to '' Nieves Ambulance and La Guadalupe Hospice.'' The nurse discharge note for 10/26/12 at 9:00 am lacks information related to the name of the physician who ordered the discharge, no evidence of orientation related to the use of medications and the administration route and no evidence if the nurse verify if the patient have the necessary equipment at home before the discharge. No evidence was found of the revision of patients' needs according to patient changes during the hospitalization. No evidence was found of an ongoing mechanism to reassess its discharge planning process.

b. R.R #9 is a 92 years old female admitted to the facility on 10/28/12 at 3:45 pm. with a diagnosis of Decompensate Congestive Heart Failure, Hypertension and Diabetes Mellitus. During the record review performed on 02/26/13 at 3:15 pm on the interdisciplinary initial evaluation on the general information performed by the nurse lacks of information related to if the patient needs to referred at social worker or discharge planning services. The record provides evidence that the patient was observed hypoactive and disoriented required and needs assistance on daily ADL'S. No evidence of social worker and discharge planning initial assessment or re-assessment during the patient hospitalization from 10/28/12 to 10/30/12. No evidence was found of the revision of patients' needs according to patient changes during the hospitalization. No evidence was found of an ongoing mechanism to reassess its discharge planning process.
c. R.R #13 is an 82 years old male admitted to the facility on 10/08/12 at 10:30 pm. with diagnosis of Anemia with five grams of hemoglobin, Gastric Cancer, Alzheimer and High Blood Pressure. During the record review performed on 2/26/13 at 4:00 pm. on the interdisciplinary initial evaluation on the general information provide evidence that the patient did not needs to referred for social worker or discharge planning services, however provide evidence that the patient needs assistance and has limitation on ADL'S and on information related to when the patient discharge to home referred to ''Hospicio de Oeste and identify that the patient needs medical equipment, medical supplies, enteral machine and transportation on ambulance. On 10/10/12 at 10:11 am. a social worker consult for hospice service was request by the physician and no evidence was found of social worker answering the consult or intervention with the patient during hospitalization. No evidence was found of discharge planning initial assessment or re-assessment during the patient stay on the hospital per eight days from 10/8/12 to 10/16/12. The interdisciplinary plan of care place on the patient record but did not have the date, hour and signature of professional, did not identified the patient problems, the objective, the intervention, and re-evaluation of the problems. No evidence was found of the revision of patients' needs according to patient changes during the hospitalization. No evidence was found of an ongoing mechanism to reassess its discharge planning process.
d. R.R #14 is a 73 years old male admitted to the facility on 10/16/12 with a diagnosis of Anasarca. During the record review performed on 2/26/13 at 4:30 pm, provide evidence that the patient was admitted at telemetry at room number 609 B, accordance of discharge nurse note on 10/19/12 at 2:50 pm the patient refused intubation treatment and discharge to home with home services. Accordance of a physician order on 10/17/12 at 12:30 pm. the patient is refer to hospice services. On 10/19/12 at 11:55 am. the physician ordered discharge for home today to received hospice services; however no evidence was found of social worker and discharge planning intervention. The record provide evidence that the patient is discharge to a hospice service however no evidence was found on the patient record of the name of the ambulance company that offered the patient service. However no evidence was found of an ongoing mechanism to reassess its discharge planning process. No evidence was found that the patient was evaluated by the social worker and discharge planning coordinator during two days of admission.
e. R.R #16 is a 67 years old male admitted to the facility on 10/09/12 with a diagnosis of Osteomyelitis, Right Foot Infected Ulcer, Diabetes Mellitus and High Blood Pressure. During the record review performed on 2/26/13 at 5:00 pm and no evidence was found of initial assessment and during the patient hospitalization 10/9/12 to 10/24/12 (16 days). The patient receives services from San Lucas Home Care previous to the hospitalization however no evidence on the patient record of social worker discharge note for 10/24/12 related to if the discharge planning coordinator coordinated the patient discharge for 10/24/12 with home care service and ambulance service. No evidence was found of an ongoing mechanism to reassess its discharge planning process.
f. R.R #21 is a 70 years old female admitted to the facility on 2/24/13 with a diagnosis of Rectal Bleeding. During the record review performed on 2/26/13 at 5:10 pm no evidence was found that the patient was evaluated by the discharge planning coordinator during two days of admission and no evidence of initial assessment.
g. R.R #23 is a 91 years old male admitted to the facility on 2/25/13 with a diagnosis of Sepsis and Alzheimer. During the record review performed on 2/26/13 at 5:20 pm provide evidence that the patient was observed disoriented with Nasogastric Tube, totally depended on daily living and needs home care when discharge home. On the interdisciplinary initial evaluation performed by the nurse on 2/23/13 at 6:00 pm. provide evidence that the patient did not need a social worker or discharge planning evaluation. No evidence was found that the patient was evaluated by the discharge planning coordinator during four days of admission and no evidence of initial assessment.
h. R.R #24 is an 86 years old male admitted to the facility on 2/21/13 with a diagnosis of Chest Pain, Diabetes Mellitus. During the record review performed on 2/26/13 at 5:30 pm no evidence was found that the patient was evaluated by the discharge planning coordinator during five days (5) of admission and no evidence of initial assessment. .
i. R.R # 25 is an 81 years old male admitted to the facility on 2/22/13 with a diagnosis of Esophageal Structive Dehydration. During the record review performed on 2/26/13 at 5:40 pm. provide evidence that the patient presented Dysphagia consequent inability to adequately keep oral diet. No evidence was found that the patient was evaluated by the discharge planning coordinator during five days (5) of admission and no evidence of initial assessment.
j. R.R #28 is a 65 years old female admitted to the facility on 2/21/13 with a diagnosis of Pleural Effusion, High Blood Pressure, Diabetes Mellitus and Breast Cancer. During the record review performed on 2/26/13 at 5:45 pm. provide evidence that the patient was referred on 2/21/13 to Damas Home Care Services when discharge to home. No evidence was found that the patient was evaluated by the discharge planning coordinator during five days (5) of admission and no evidence of initial assessment. The interdisciplinary evaluation form was initiated by the nurse on 2/22/13 however the psychosocial and discharge planning information related to if the patient needs evaluation by the social worker or discharge planning coordinator is in blank.
The patient was interview on 2/26/13 at 6:00 pm and she stated: '' I ' m admitted at the hospital since five days, is probable that I stay seven days according of the physician because a CT Scan revealed I have water in my lungs, but I feel better even when I still have oxygen. I have not eaten because I do not like the food provided at this hospital but my husband brings food when he comes to visit me. The social worker has not visited me to know what equipment I will need when I ' m discharge. Before I was hospitalized I was receiving home care services because on December 21, 2012 I was hospitalized for a breast tumor and I received chemotherapy and radiotherapy to reduce the tumor. I live with my husband that always comes to visit me and is always looking if I need anything.''


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Based on thirty records reviewed, review of policies and procedures related to the Discharge Planning Program with the staff utilization (employee #2), it was determined that the facility failed to ensure that discharge planning personnel complete an evaluation and reassess the patients' needs on a timely basis for post-hospital care and are made before discharge to avoid unnecessary delays with the discharge for 19 out of 30 records reviewed (R.R #1, #2, #3, #5, #7, #9, #10, #11, #12, #13, #14, #15, #16, #19, #21, #23, #24, #25 and #28).

Findings include:

1. A mechanism to ensure that the discharge planning process is complete assess and evaluated on a timely basis was not performed nor followed as found on 2/26/13 from 9:00 am till 6:30 pm: nine out of thirty clinical record reviews the initial evaluation and assessment of Discharge planning (R.R #1, #2, #3, #5, #10, #11, #12, #15 and #19).

a. R.R #1 is a 74 years old male admitted to the facility on 11/04/12 with a diagnosis of Septicemia, Sub Endocardial Infarct Initial, Heel and Mid Foot Ulcer, Gangrene first toe left foot, Diabetes Mellitus and Cancer. During the record review performed on 2/26/13 at 5:15 pm, it was found that the nursing initial assessment performed on 4/11/12 at 10:15 am, identified need of discharge planning services. The physician order on 11/18/12 at 4:22 pm says social worker consultation Hospicio Del Oeste. The patient was evaluated by discharge planning on 11/20/12 at 8:05 am, sixteen days after admission. The discharge planning identified needs of hospice, medical equipment, wheel chair and ambulance transportation. The patient is referred to hospice services and discharge home on 11/27/12.

b. R.R #2 is a 79 years old female admitted to the facility on 11/11/12 with a diagnosis of Acute Cerebro Vascular, Diabetes Mellitus, High Blood Pressure and Ulcer. During the record review performed on 2/26/13 at 3:44 pm, it was found that the patient was evaluated by discharge planning on 11/24/12 at 11:00 am, thirteen days after admission. The initial assessment identifies needs of hospice services and ambulance transportation. The patient is referred to hospice services and discharge home on 11/24/12. No evidence was found to reassess. No evidence was found of an ongoing mechanism to reassess its discharge planning process.

c. R.R #3 is an 85 years old female admitted to the facility on 11/03/12 with a diagnosis of High Blood Pressure, Myasthenia Gravis and Fever. During the record review performed on 2/26/13 at 3:10 pm, it was found that the physician order on 11/04/12 at 3:00 pm says Social work evaluation and hospice care. The physician order on 11/06/12 at 11:15 am says Social work evaluate for discharge planning. The patient was evaluated by discharge planning on 11/07/12 at 10:50 am, four days after admission. The initial assessment identifies needs of home services and ambulance transportation. The patient is referred to hospice services and discharge home on 11/08/12.

d. R.R #5 is a 94 years old male admitted to the facility on 10/14/12 with a diagnosis of Bronchopneumonia, Aspiration Pneumonia, Respiratory Failure Mechanical Ventilation and Sacral Ulcer type II. During the record review performed on 2/26/13 at 2:40 pm, it was found that the patient was not evaluated by the discharge planner. The nursing initial assessment performed on 10/15/12 at 5:00 pm, identified need of discharge planning services. The physician order on 10/19/12 at 11:30 am says discharge planning for tomorrow (ambulance). The physician order on 10/30/12 at 10:20 am says discharge planning with hospice care. In the discharge summary on the disposition it says, hospice care, diet low fat, low salt, diabetic diet and activity as tolerated. In the form intervention on 10/30/12 at 1:00 pm says, in process of discharge. Order says order Caribe Ambulance, service requested of hospice San Lucas. The patient is referred to hospice services and discharge home on 10/31/12.

e. R.R #10 is an 89 years old female admitted to the facility on 1/31/13 with a diagnosis of Upper GI Bleeding, Diabetes Mellitus, Breast Cancer and Ulcer Grade IV. During the record review performed on 2/26/13 at 2:15 pm, it was found that the patient was not evaluated by the discharge planner. The physician order on 2/1/13 at 11:35 am says consult social work for hospice. In the discharge summary in disposition says, hospice care, diet low fat, low salt, diabetic diet and activity as tolerated. The patient is referred to hospice services and discharge home on 2/11/13.

f. R.R #11 is a 69 years old male admitted to the facility on 11/18/12 with a diagnosis of Hemorrhagic Stroke, High Blood Pressure and Diabetes Mellitus. During the record review performed on 2/26/13 at 4:27 pm, it was found that the physician order on 11/28/12 at 4:17 pm says discharge planning for hospice care. The patient was evaluated by discharge planning on 11/30/12 at 10:35 am, twelve days after admission. The discharge planning identified needs of hospice, medical equipment, wheelchair, bed position, oxygen and feeding therapy. The physician order on 12/03/12 at 9:00 am says hospice care. The physician order on 12/06/12 at 5:30 pm says consult social work for discharge planning tomorrow to La Paz Hospice. The physician order on 12/07/12 at 9:30 am says discharge to hospice La Paz. The patient is referred to hospice services and discharge home on 12/07/12.

g. R.R #12 is a 63 years old female admitted to the facility on 11/17/12 with a diagnosis of Acute Respiratory Failure, Acute Renal Failure, Diabetes Mellitus, High Blood Pressure. During the record review performed on 2/26/13 at 6:13 pm, it was found that the patient was evaluated by discharge planning on 11/27/12 at 2:15 pm, ten days after admission. The discharge planning identified needs of hospice, wheelchair, position bed, glucometer, suction equipment and ambulance transportation. The physician order on 12/05/12 at 7:00 am says discharge planning. The physician order on 12/06/12 at 7:00 am says social worker re-evaluation (nursing home will not take with central line). The patient is referred to hospice services and discharge home on 12/07/12.

h. R.R #15 is a 62 years old male admitted to the facility on 10/14/12 with a diagnosis of Cerebro Vascular Accident. During the record review performed on 2/26/13 at 7:08 pm, it was found that the physician order on 11/18/12 says social work evaluation for hospice. The patient initial assessment for discharge planning was no perform. One Discharge note of intervention in process of discharge on 11/18/12 at 1:33 pm, four days after admission say Hospicio La Providencia and Caribean Ambulance transportation. The patient is referred to hospice services and discharge home on 1/04/13. No evidence was found or reassessment. No evidence was found of an ongoing mechanism to reassess its discharge planning process.

i. R.R #19 is a 90 years old female admitted to the facility on 12/22/12 with a diagnosis of Acute Gastrointestinal Bleeding, Anemia and Coumadin Intoxication. During the record review performed on 2/26/13 at 6:46 pm, it was found that the physician order on 12/28/12 at 10:40 am says discharge planning (hospice evaluation). The patient was evaluated by discharge planning on 12/28/12 at 11:19 am, six days after admission. The discharge planning identified needs of hospice and ambulance transportation. The physician order on 1/04/13 at 10:35 am says discharge home with hospice services. The patient is referred to hospice services and discharge home on 1/04/13.

2. No evidenced was found on 2/26/13 at 2:00 pm, of the polices and procedure to canalized referrals for discharge planning.

5. A mechanism to ensure that the discharge planning process and the plan of care for discharge planning is reassessed on an on-going basis was not performed nor followed as found on 2/26/13 from 2:45 pm till 5:00 pm: five out of thirty clinical record reviews did not reveal a re-assessment before discharge (R.R #7, #9, #13, #14 and #16).

a. R.R #7 is a 70 years old male admitted to the facility on 10/16/12 with a diagnosis of Jaundice and has Tracheotomy, High Blood Pressure, Thyroid Disease and Depression. During the record review performed on 2/26/13 at 2:45 pm, on the interdisciplinary initial evaluation and on the general information performed by the nurse lacks of information related to when the patient was discharge home, what of these services the patient needs, home care, hospice, medical equipment, supplies, transportation or other services and the nurse referred the patient to social worker or discharge planning services however, no evidence of social worker and discharge planning initial assessment or re-assessment during the patient hospitalization from 10/16/12 to 10/26/12 9 ( 10 days). On 10/25/12 at 11:15 am the physician ordered discharge planning to Hospice La Guadalupe. On 10/26/12 at 9:30 am a physician ordered call ambulance and discharge home. On 10/25/12 at 1:40 pm. the interdisciplinary progress note form performed by a nurse (employee #6) provided evidence that the patient case was given to'' Nieves Ambulance and La Guadalupe Hospice.'' The nurse discharge note for 10/26/12 at 9:00 am lacks information related to the name of the physician who ordered the discharge, no evidence of orientation related to the use of medications and the administration route and no evidence if the nurse verify if the patient have the necessary equipment at home before the discharge. No evidence was found of the revision of patients' needs according to patient changes during the hospitalization. No evidence was found of an ongoing mechanism to reassess its discharge planning process.

b. R.R #9 is a 92 years old female admitted to the facility on 10/28/12 at 3:45 pm. with a diagnosis of Decompensate Congestive Heart Failure, Hypertension and Diabetes Mellitus. During the record review performed on 02/26/13 at 3:15 pm on the interdisciplinary initial evaluation on the general information performed by the nurse lacks of information related to if the patient needs to be referred to social worker or discharge planning services. The record provides evidence that the patient was observed hypoactive and disoriented required and needs assistance on daily ADL'S. No evidence of social worker and discharge planning initial assessment or re-assessment during the patient hospitalization from 10/28/12 to 10/30/12. No evidence was found of the revision of patients' needs according to patient changes during the hospitalization. No evidence was found of an ongoing mechanism to reassess its discharge planning process.
c. R.R #13 is an 82 years old male admitted to the facility on 10/08/12 at 10:30 pm., with diagnosis of Anemia with five grams of hemoglobin, Gastric Cancer, Alzheimer and High Blood Pressure. During the record review performed on 2/26/13 at 4:00 pm. on the interdisciplinary initial evaluation and the general information provide evidence that the patient did not need to be referred to social worker or discharge planning services, however provide evidence that the patient needs assistance and has limitation on ADL'S and on information related to when the patient discharge home referred to ''Hospicio de Oeste and identify that the patient needs medical equipment, medical supplies, enteral machine and transportation on ambulance. On 10/10/12 at 10:11 am., a social worker consult for hospice service was request by the physician and no evidence was found of social worker answering the consult or intervention with the patient during hospitalization. No evidence was found of discharge planning initial assessment or re-assessment during the patient stay on the hospital per eight days from 10/8/12 to 10/16/12. The interdisciplinary plan of care place on the patient record but did not have the date, hour and signature of the professional, did not identified the patient problems, the objective, the intervention, and re-evaluation of the problems. No evidence was found of the revision of patients' needs according to patient changes during the hospitalization. No evidence was found of an ongoing mechanism to reassess its discharge planning process.
d. R.R #14 is a 73 years old male admitted to the facility on 10/16/12 with a diagnosis of Anasarca. During the record review performed on 2/26/13 at 4:30 pm, provide evidence that the patient was admitted at telemetry at room number 609 B, accordance to the discharge nurse note on 10/19/12 at 2:50 pm the patient refused intubation treatment and discharge home with home services. Accordance to the physician order on 10/17/12 at 12:30 pm. the patient is referred to hospice services. On 10/19/12 at 11:55 am., the physician ordered discharge home today to received hospice services, however no evidence was found of social worker and discharge planning intervention. The record provide evidence that the patient is discharge to a hospice service however no evidence was found on the patient record of the name of the ambulance company that offered the patient service. Also no evidence was found of an ongoing mechanism to reassess its discharge planning process. No evidence was found that the patient was evaluated by the social worker and discharge planning coordinator during two days of admission.
e. R.R #16 is a 67 years old male admitted to the facility on 10/09/12 with a diagnosis of Ostheomyelitis, Right Foot Infected Ulcer, Diabetes Mellitus and High Blood Pressure. During the record review performed on 2/26/13 at 5:00 pm and no evidence was found of initial assessment and during the patient hospitalization 10/9/12 to 10/24/12 (16 days). The patient receive services from San Lucas Home Care previous to the hospitalization however no evidence on the patient record of social worker discharge note for 10/24/12.related to if the discharge planning coordinator coordinated the patient discharge for 10/24/12 with home care service and ambulance service. No evidence was found of an ongoing mechanism to reassess its discharge planning process.


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Based on thirty medical records reviewed (R.R) with the utilization staff (employee #2) and review of policies/procedures, it was determined that the facility failed to ensure that ongoing reassessments are performed, re-assessment of the plan of care and documentation of patient ' s needs for factors that may affect continuing care for 13 out of 30 patients admitted to the facility (R.R #1, #2, #3,#7, #9, #11, #12, #13, #14, #15, #16, #17 and #19).

Findings include:

During interview with the utilization staff (employee #2) and review of policies and procedure it state on 2/26/13 at 10:20 am that the discharge planning evaluations was performed for all patients Medicare and Medicare Advantage and referrals on Monday through Friday. Patients arriving the weekend are assessed on Monday. The non Medicare patients who need discharge planning were evaluated by the utility personnel. The utility personnel did not have authority to document their evaluation and intervention in patient medical record but they manage and performed intervention with patient discharge need.

" I search for the daily census list, from the Departments and perform the assessment needs. Some patients have to be referred by the physician or nurse to be evaluated by the discharge planning coordinator. The letter Important Message from Medicare is given to the patient at the time of admission and I not know who is in charge of providing the information 48 hours before discharge. The discharge planning officer only works from Monday through Friday from 8:00 am through 5:00 pm. There is no on-call for discharge planning. During the weekends, holidays and after hours nursing personnel and the physician are in charge of the patients and intervene with the discharge planning, and if considered necessary they refer the patient to the social worker. Then the social worker prioritizes this referral in her next working day. The mechanism of evaluating patients in need of discharge planning on weekends and after hours is not included in the facility's policies and procedures " .

2. The facility policies and procedure related the discharge planning re-assessment failed to define the time frame to perform reassessments after the initial assessment or referral.

3. A mechanism to ensure that the discharge planning process is reassessed on an on-going basis was not performed nor followed as found on 2/26/13 from 11:00 am till 7:30 pm: eights out of thirty clinical record reviews did not reveal a re-assessment before discharge (R.R #1, #2, #3, #11, #12, #15 #17 and #19).

a. R.R #1 is a 74 years old male admitted to the facility on 11/04/12 with a diagnosis of Septicemia, Sub Endocardial Infarct Initial, Heel and Mid Foot Ulcer, Gangrene first toe left foot, Diabetes Mellitus and Cancer. During the record review performed on 2/26/13 at 5:15 pm, it was found that the nursing initial assessment performed on 4/11/12 at 10:15 am, identified need of discharge planning services. The physician order on 11/18/12 at 4:22 pm says social worker consultation for Hospicio Del Oeste. The patient was evaluated by discharge planning on 11/20/12 at 8:05 am, sixteen days after admission. The discharge planning identified needs of hospice, medical equipment, and wheelchair and ambulance transportation. The patient is referred to hospice services and discharge home on 11/27/12. No evidence was found of reassessment. No evidence was found of an ongoing mechanism to reassess its discharge planning process.
b. R.R #2 is a 79 years old female admitted to the facility on 11/11/12 with a diagnosis of Acute Cerebro Vascular, Diabetes Mellitus, High Blood Pressure and Ulcer. During the record review performed on 2/26/13 at 3:44 pm, it was found that the patient was evaluated by discharge planning on 11/24/12 at 11:00 am, thirteen days after admission. The initial assessments identify needs of hospice services and ambulance transportation. The patient is referred to hospice services and discharge home on 11/24/12. No evidence was found to reassess. No evidence was found of an ongoing mechanism to reassess its discharge planning process.
c. R.R #3 is an 85 years old female admitted to the facility on 11/03/12 with a diagnosis of High Blood Pressure, Myasthenia Gravis and Fever. During the record review performed on 2/26/13 at 3:10 pm, it was found that the physician order on 11/04/12 at 3:00 pm says Social work evaluation and hospice care. The physician order on 11/06/12 at 11:15 am says Social work evaluate for discharge planning. Patient was evaluated by discharge planning on 11/07/12 at 10:50 am, four days after admission. The initial assessment identifies needs of home services and ambulance transportation. The patient is referred to hospice services and discharge home on 11/08/12. No evidence was found to reassess. No evidence was found of an ongoing mechanism to reassess its discharge planning process.
d. R.R #11 is a 69 years old male admitted to the facility on 11/18/12 with a diagnosis of Hemorrhagic Stroke, High Blood Pressure and Diabetes Mellitus. During the record review performed on 2/26/13 at 4:27 pm, it was found that the physician order on 11/28/12 at 4:17 pm says discharge planning for hospice care. The patient was evaluated by discharge planning on 11/30/12 at 10:35 am, twelve days after admission. The discharge planning identified needs of hospice, medical equipment, wheelchair, bed position, oxygen and enteral machine. The physician order on 12/03/12 at 9:00 am says hospice care. The physician order on 12/06/12 at 5:30 pm says consult social work for discharge planning tomorrow to La Paz Hospice. The physician order on 12/07/12 at 9:30 am says discharge to hospice La Paz. The patient is referred to hospice services and discharge home on 12/07/12. No evidence was found to reassess. No evidence was found of an ongoing mechanism to reassess its discharge planning process.
f. R.R #12 is a 63 years old female admitted to the facility on 11/17/12 with a diagnosis of Acute Respiratory Failure, Acute Renal Failure, Diabetes Mellitus, High Blood Pressure. During the record review performed on 2/26/13 at 6:13 pm, it was found that the patient was evaluated by discharge planning on 11/27/12 at 2:15 pm, ten days after admission. The discharge planning identified needs of hospice, wheelchair, position bed, glucometer, suction equipment and ambulance transportation. The physician order on 12/05/12 at 7:00 am says discharge planning. The physician order on 12/06/12 at 7:00 am says social worker re-evaluation (nursing home will not take her with central line). The patient is referred to hospice services and discharge home on 12/07/12. No evidence was found to reassess. No evidence was found of an ongoing mechanism to reassess its discharge planning process.
f. R.R #15 is a 62 years old male admitted to the facility on 10/14/12 with a diagnosis of Cerebro Vascular Accident. During the record review performed on 2/26/13 at 7:08 pm, it was found that the physician order on 11/18/12 says social work evaluation for hospice. The patient was not assessed with an initial discharge planning. A note found of intervention in process of discharge on 11/18/12 at 1:33 pm, four days after admission say Hospicio La Providencia and Caribbean Ambulance transportation. The patient is referred to hospice services and discharge home on 1/04/13. No evidence was found to reassess. No evidence was found of an ongoing mechanism to reassess its discharge planning process.
g. R.R #17 is a 90 years old female admitted to the facility on 12/05/12 with a diagnosis of Bronchopneumonia, Anemia, High Blood Pressure and Alzheimer. During the record review performed on 2/26/13 at 11:00 am, it was found that the physician order on 11/19/12 at 10:50 am says consult Social work for hospice care discharge. The patient was evaluated by discharge planning on 12/06/12 at 9:30 am, one day after admission. The discharge planning identified needs of hospice and ambulance transportation. The patient is referred to hospice services and discharge home on 12/19/12. No evidence was found to reassess. No evidence was found of an ongoing mechanism to reassess its discharge planning process.
h. R.R #19 is a 90 years old female admitted to the facility on 12/22/12 with a diagnosis of Acute Gastrointestinal Bleeding, Anemia and Coumadin Intoxication. During the record review performed on 2/26/13 at 6:46 pm, it was found that the physician order on 12/28/12 at 10:40 am says discharge planning (hospice evaluation). The patient was evaluated by discharge planning on 12/28/12 at 11:19 am, six days after admission. The discharge planning identified needs of hospice and ambulance transportation. The physician order on 1/04/13 at 10:35 am says discharge home with hospice services. The patient is referred to hospice services and discharge home on 1/04/13. No evidence was found to reassess. No evidence was found of an ongoing mechanism to reassess its discharge planning process.
4. A mechanism to ensure that the plan of care for discharge planning is reassessed on an on-going basis followed was found on 2/26/13 from 11:00 am till 7:30 pm: seventeen out of thirty clinical record reviews did not reveal a re-assessment of the plan of care (R.R #1, #2, #3, #5, #7, #8, #9, #11, #12, #13, #14, #15, #16, #17, #18, #19 and #20)

Based complaint investigation PR00000504, review of facility policies/procedures and interview with the staff utilization (employee #2), it was found that the facility failed to include a complete list of Home Care (HHA), Hospice and Skilled Nursing Facilities (SNFs) that are available to the patient, in a geographic area in which the patient resides and failed to provide to patients with Advantage medical insurance a list of available Home Cares post-hospital extended care services that have a contract with the Advantage medical insurance and failed to document in the patient's medical record that the list was presented to the patient or to the individual acting on the patient's behalf for 18 of 20 closed records reviewed. (R.R #1, #2, #3, #5, #6, #7, #8, #9, #10, #11, #13, #14, #15, #16, #17, #18, #19 and #20).

Findings include:

1. During interview with the staff utilization (employee #2) and review of policies and procedure its state on 2/26/13 at 10:20 am that the discharge planning evaluations was performed for all patients Medicare and Medicare Advantage and referrals on Monday through Friday. Patients arriving the weekend are assessed on Monday. The non Medicare patients who need discharge planning were evaluated by the utility personnel. The utility personnel did not have authority to document their evaluation and intervention in patient medical record but they manage and performed intervention with patient discharge need. " I search the list of daily census, and then under the Departments and perform the assessment needs. Some patients have to be referred by the physician or nurse to be evaluated by the discharge planning coordinator. The letter Important Message from Medicare is given to the patient at the time of admission and I do not know who is in charge of providing the information 48 hours before discharge. The discharge planning officer only works from Monday through Friday from 8:00 am through 5:00 pm. The facility lack of on call personnel of discharge planninge. During the weekends, holidays and after hours nursing personnel and the physician in charge of the patients intervene with the discharge planning, and if considered necessary they refer the patient to the social worker. Then the social worker prioritizes this referral in her next working day. The mechanism of evaluating patients in need of discharge planning on weekends and after hours is not included in the facility's policies and procedures".

2. The facility policies and procedure provided evidence related to a list of six home cares, cero Skilled Nursing, cero medical equipment companies, seventeen ambulances companies and twelve Hospices that provide post-hospital care services to patient with traditional Medicare medical insurance. However, no evidence was found that this list was provided to the patient. No evidence was provided on 2/13/13 at 11:30 am related to a list of Home Care, Hospice and medical equipment company that have contract with the different Advantage medical insurance. The facility lack of a list of Home Care, Medical Equipment and Skilled Nursing Facilities that the patient or their relatives can choose the preferred agency for them. No evidence was found on eighteen (18) out of twenty (20) close records reviewed who choose the agency that is going to provide services to the patient. (R.R #1, #2, #3, #5, #6, #7, #8, #9, #10, #11, #13, #14, #15, #16, #17, #18, #19 and #20).

Based on the review of documents and policies/procedures and interview with the medical director of medical record (employee #4), it was determined that the facility failed to ensure that its discharge planning process is reassessed on an on-going basis.

Findings include:

1. The hospital's discharge planning process is integrated into its Quality Assessment and Performance Improvement Program as reviewed on 2/26/13 at 6:30 p.m., however, they only report statistics related to percent services that needs ambulance, equipment and mental health services at home at discharge. Another indicator is a coordination of services for patients who needs services for mental health.

2. No evidence was found on 2/26/13 at 6:40 p.m., of an ongoing mechanism to reassess its discharge planning process.

3. The facility failed to establish a mechanism of screening according to risk criteria as reviewed on 4/7/11 at 10:45 am. The Discharge planning services failed to perform surveillance of issues which need to be assessed to ensure the quality of care offered to patients. The data was not presented as indicators or information obtained in order to present facility approach of quality improvement and patient health outcomes as the result of the care provided by the service.

Based on review of seven credential files (C.F) of the utilization coordinators, interview with the discharge planning director and record review (RR), it was determined that the facility failed to ensure that a qualified personnel develop evaluate the need of discharge planning for all patient for 15 out of 20 records reviewed (RR #1, #2, #3, #4, #5, #7, #9, #10, #11, #12, #13, #14, #15, #16 and #19 ) and to have a current credential file as required that contains job description for 7 of 7 utilization coordinators credential file (C.F #1, #2, #3, #4, #5, #6 and #7 ).

Findings include:

1. During the review of the seven credential files of the utilization coordinator's designated with discharge planning coordination on 2/26/13 at 12:50 pm with the Human Resource Director (employee #7) no evidence was found of the job descriptions.

2. During interview with the Human Resource Director (employee #7) related to the utilization coordinator's functions and responsibilities on the discharge planning process on 2/26/13 at 12:50 pm., she stated: '' The facility do not have a discharge planning coordinator on property at this moment, however the facility designated seven utilization coordinators to perform the discharge planning to the facility ' s patients, all of this personnel are register nurse and respond to the Medical Record Director. The utilization coordinator's personnel provide service from Monday through Friday from 8:00 am till 5:00 pm.''

During the month that the hospital did not have a discharge planning coordinator, the nursing staff was responsible to coordinate the discharge planning for all the patients. However, it was found that during this period of time that the hospital was without a discharge planning coordinator, fifteen out of twenty record reviews (#1, #2, #3, #4, #5, #7, #9, #10, #11, #12, #13, #14, #15, #16 and #19) do not provide evidence of coordination for discharge planning.