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Based on a review of documentation and interview, it was determined the facility failed to ensure discharge planning included a list of (HHAs or) SNFs that are available to the patient, that are participating in the Medicare program, and (that serve the geographic area (as defined by the HHA) in which the patient resides, or ) in the case of a SNF, in the geographic area requested by the patient. The facility also 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.


Findings included:


Facility based policy entitled "Discharge Planning", stated in part, " The discharge planning process provides for timely and appropriate identification of discharge planning needs for patients/family, and facilitates a smooth transition through an interdisciplinary team approach. Discharge planning at Las Palmas Del Sol Healthcare is a direct service provided to patients to ensure their right to free access to assistance with discharge needs. Las Palmas Del Sol Health care endeavors to ensure continuous quality of care in the post-discharge phase. The Discharge Planning assessment done on admission includes the physical, emotional, medical, social, spiritual, and financial needs of the patient and family as well as any identified equipment needs and post discharge needs. "

"Responsibilities:

C. Case Management Team: Comprised of Case Managers and Social Workers. Participate in interdisciplinary team meetings, high risk screenings, and assist with coordinating complex discharge plans and alternate placements....

* 1. Case Management Team works closely with the patient and family to coordinate the appropriate resources for the discharge plan and post-acute care incorporating the needs of the patient and family, medical necessity, financial capabilities, and available community resources...

* 4. Social Worker assists patients, families, or guardians with psycho-social and financial issues, which impact continuity of care. Participate in interdisciplinary team meetings and facilitate placements and alternate levels of care along the continuum, including: adult foster care, home health, hospice support groups, rehabilitation, long term facilities."

The "CHOICE LETTER", when completed, is part of the patient medical records, it was signed by Patient #1 on 04/21/2015, it states in part: "Your physician has recommended the following services after you leave the hospital." Out of seven options, "Skilled Nursing- VHHCC is hand written and "Inpatient Rehabilitation- DSMC" (hand written)". Also, stated in part: "You have the right to select who provides and where you receive these services. It is your choice. If you need more information before making this decision, please ask our Case Management staff to assist and provide you with alternatives. If you require Home Health, a Skilled Nursing Facility, or Hospice, a list will be provided. The list will include those facilities/agencies that participate in the Medicare program and serve the geographic areas that you request or in which you reside. Managed Care patients will be given a list of providers that are in their plan network."

Five out of 10 medical records reviewed (Patients #1, 2, 3, 4, and 5) did not have documentation that the patient/family were provided with a list of Home Health, Skilled Nursing Facilities or Hospice, during discharge planning or prior to discharge from the hospital.

In an interview on 5/28/15, staff member # 3, the Director of Case Management confirmed the above findings.