HospitalInspections.org

.
Based on Medical Record review, interview and document review, the Care Management Staff did not complete the Discharge Planning Evaluation within twenty-four (24) hours of admission, in three (3) of five (5) Medical Records as per facility Policy.

Findings:

Patient #11's Medical Record identified that the patient was admitted on 09/01/17 at 8:25PM. The Initial Discharge Evaluation was completed on 09/03/17 at 2:59PM, approximately forty-two (42) hours after admission. This was verified with Staff J (Care Management Department Manager) and Staff I (Information Specialist).

Patient #15's Medical Record identified that the patient was admitted on 06/02/17 at 9:06PM. The Initial Discharge Evaluation was completed on 06/04/17 at 4:14PM, approximately forty-three (43) hours after admission. This was verified with Staff Members I and K (Care Manager).

Similar findings were found for Patient #14, and confirmed with Staff Members I and K.

The facility Policy and Procedure titled "Discharge Planning" last reviewed 06/16/16 stated "Each patient admitted to, or placed on Observation at [facility], will have an initial screen and assessment completed by the patient's assigned Care Manager and/or Social Worker within 24 hours of admission or placement on Observation."
.

.
Based on Medical Record review, interview and document review, the Care Management Staff did not document discussing the results of the Evaluation with the patient or individual acting on his or her behalf in three (3) of five (5) Medical Records.

Findings:

Patient #15's Medical Record review identified a Care Management Note dated 06/15/17 which stated "...patient disclosed she is unable to read and write and requests that her daughter be included in conversations with hospital staff. SW [Social Worker] placed note on chart indicating patient's request. Verbal consent obtained at bedside of DOH-HIPPA [authorization for the release of medical information] forms allowing sharing of information with daughter and spouse; witnessed by [RN] ..." No evidence of communication with or inclusion of the patient's daughter in Patient 15's Discharge Planning was found through discharge on 06/24/17.

Patient #14's Medical Record review identified a Care Management Initial Evaluation dated 06/12/17. No documented evidence of Care Management discussion with the patient or representative regarding the Discharge Evaluation or Discharge Plan was found until fourteen (14) days after the Initial Evaluation on the day of discharge on 06/26/17.

Similar findings were found for Patient #12. All findings were confirmed with Staff H (Nurse Manager) and Staff I (Information Specialist).

The facility Policy and Procedure titled "Discharge Planning" last reviewed 06/16/16 stated "...The Care Management Department staff will work closely with the patient, appropriate community agencies and with the patient's permission, his or her family and/or significant others, designated caregiver in order to ensure continuity and quality transition of care."

The facility Policy and Procedure titled "Documentation in the Medical Record: Transition in Care" last revised 06/02/16, stated "...Caregivers shall be included in the discharge planning process and informed before the hospital patient is to be discharged..."
.

.
Based on document review, Medical Record review and interview, the Care Management Staff did not document reassessing the patients' Discharge Plan for factors affecting continuing care needs, or the appropriateness of the Discharge Plan, in four (4) of five (5) Medical Records.

Findings:

The facility Policy titled "Discharge Planning" last reviewed 06/16/16 stated "...The discharge plan will be regularly and systematically reviewed by the patient, the Care Manager and/or Social Worker (SW) and the interdisciplinary team. The discharge plan shall be periodically updated to reflect the evolving needs and preferences of the patients and the availability of resources in the community ..."

The facility Policy titled "Documentation in Medical Record: Transition in Care" last reviewed 06/02/16 stated "...the discharge plan shall be periodically reevaluated on an ongoing basis to provide for changes in the patient's condition or circumstances. The reassessment must include a review of the discharge plans to ensure that the plan will meet the patient's individualized discharge needs ..."

Review of Patient #13's Medical Record identified a Care Management Note dated 09/01/17 at 3:33PM which stated "Patient [#13] is a long-term patient at Affinity [Skilled Nursing Facility]. When medically stable patient will return to Affinity. CM will continue to follow for a safe appropriate discharge." As of the survey date 09/08/17, seven (7) days after the most recent Care Management Note, no documented evidence of Care Management follow-up or Discharge Plan Reassessment was found.

Patient #13's Medical Record review also identified the patient had a wound VAC (Vacuum Assisted Closure) placed on 09/01/17, and a change in Health Care Proxy on 09/05/17. A Physician's Note dated 09/07/17 stated Patient's [#13] new Health Care Proxy will "work closely with SW/CM to see if he can be moved to a facility closer to her home ..." This was verified with Staff K (Care Manager).

Interview with Staff Members K and J (Care Management Department Manager) on 09/08/17 at 10:55AM revealed that the Care Management Department was not aware of Patient #13's care changes and both Staff Members K and J confirmed that no Care Management documentation in seven (7) days was too long of a timeframe to reflect regular and periodic Discharge Plan review.

Review of Patient #15's Medical Record identified that the Initial Discharge Evaluation was completed on 06/04/17 and the patient was anticipated to return to home with Home Care Services vs. home pending hospital course. On 06/07/17, a Care Management Note indicated that the patient may require SAR (Sub-Acute Rehab) upon discharge. No documented evidence of Care Management Reassessment was found for five (5) days, from 06/08/17 to 06/13/17.

A Care Management Note dated 06/15/17 stated "...patient [#15] disclosed she is unable to read and write and requests that her daughter be included in conversations with hospital staff ...anticipated discharge 24-48 hours home with home care." No evidence of communication with, or inclusion of, Patient #15's daughter in the Discharge Planning was found through discharge.

No Care Management Reassessment documentation found for three (3) days from 06/16/17 to 06/19/17. A Care Management Note dated 06/19/17 stated "Discharge order dated 6/19/17 at 12:52pm ... patient will require home IV (Intravenous) Antibiotic therapy. Referral made to Coram Infusion, prescription and demographics faxed ... for insurance verification." From 06/20/17 to 06/24/17 Care Management documentation reflected difficulty in obtaining authorization from Patient #15's Insurance Plan for IV Infusion Therapy Services. Authorization for Infusion Services could not be obtained. Patient #15 was discharged home, on oral antibiotics, with Home Care Nursing and Therapy Services on 06/24/17. This lack of timely Discharge Planning Reassessment was confirmed with Staff H (Nurse Manager) and Staff I (Information Specialist).

Similar findings were found in Patient #14's Medical Record, which lacked Care Management Reassessment documentation for thirteen (13) days from 06/13/17 through discharge on 06/26/17; and Patient #12's Medical Record, which lacked Care Management Reassessment documentation for seven (7) days from 09/01/17 to 09/08/17. These were confirmed by Staff Members H and I and acknowledged by Staff G.
.

.
Based on observation, Medical Record review, interview and document review, the Care Management Staff did not: (A) Provide the patient and/or patient's representative with an appropriate list from which to choose a participating Skilled Nursing Facility (SNF) in one (1) Medical Record, and (B) Document that the list of available Home Health and post-hospital Extended Care Services was presented to the patient or the individual acting on the patient's behalf in four (4) of five (5) Medical Records.

Findings for A include:

Review of Patient #10's Medical Record identified that the patient was admitted on 09/03/17. A Care Management Note dated 09/03/17 at 9:45PM stated "D/C [discharge] plan discussed SAR [sub-acute rehabilitation] vs HC [home care]- first choice is BHCF [Brookhaven Health Care Facility] if SAR is the d/c plan. Pt has Elderplan Homefirst medicare HMO [health maintenance organization]". Patient #10 requested a specific Skilled Nursing Facility for post-acute rehabilitation if needed upon discharge.

During an interview with Patient #10 on 09/07/17 the patient indicated being very upset that she was given a list of five (5) Skilled Nursing Facilities to choose from only to be told on 09/07/17 that none of them participated in her Insurance, and that she would need to stay in the hospital until a facility was found.

During an interview with Staff F (Care Manager) on 09/07/17 in the presence of Staff H (Nurse Manager), Staff F stated that normally she would check first to see which Skilled Nursing Facility participated in a patient's Insurance before providing them with a list, but did not do so in this case.

The facility Policy and Procedure titled "Discharge or Transfer to Another Organization, Level of Care or Service" last revised 05/12/17, lacked directives for staff to limit the list of Skilled Nursing Facilities to those that participate in the Insurer's Network of Providers.

Furthermore, a list of Skilled Nursing Facilities last updated 06/17, that is usually provided to patients, had a disclaimer at the bottom inappropriately informing the patient that "This information is being provided for your convenience only". "To make an informed decision, it is strongly recommended that you confirm with your insurance company that the facility/agency you are interested in is covered by your plan."

Findings for (B) include:

Review of Patient #15's Medical Record identified that the patient was admitted on 06/02/17 and discharged home with Home Care Services on 06/24/17. A Care Management Note dated 06/24/17 at 12:55PM stated "...Brookhaven Home Care in place for RN (Registered Nurse) and PT (Physical Therapy) [services]". No documented evidence was found indicating that Patient #15 was offered the list of available Home Health Care Services. This was confirmed with Staff I (Information Specialist) and Staff H (Nurse Manager).

Review of Patient #14's Medical Record identified that he was a resident of a Skilled Nursing Facility), admitted 06/10/17 and discharged to the same Skilled Nursing Facility on 06/26/17. An Initial Care Management Note dated 06/12/17 at 8:40AM identified this patient as a Skilled Nursing Facility resident. The next Care Management Note dated 06/26/17 stated "Spoke with spouse, patient going back to SNF." No documented evidence that the patient, or the patient representative, were provided with a choice or list of other available Post-Hospital Extended Care Services was found. This was verified with Staff Members I and H.

Similar findings were found in the Medical Records of Patients #13 and #12, and verified with Staff Members I, J (Care Management Department Manager) and K (Care Manager).

The facility Policy and Procedure titled "Documentation in the Medical Record: Transition in Care" last reviewed 06/02/16 stated "Documentation in the medical record shall reflect that the Home Health Agency / Skilled Nursing Facility list is being provided to the patient / patient representative."


35332