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Based on policy review, medical record review, and staff interview the hospital staff failed to communicate discharge arrangements with the patient's chosen post-acute care service provider in 1 of 4 patients (Patient #2) related to discharge planning.

The findings included:

Review on 11/19/2019 of hospital policy titled "Referrals to Post-Acute Care Services" last revised 01/2019, revealed "Scope/Purpose: To ensure patients are provided an opportunity for choice in selecting their post-acute care services. Post-Acute Care Services include (but are not limited to) home health, hospice, durable medical equipment, and extended care facilities...PROCEDURE ...4. After obtaining consent from the patient/decision maker the appropriate case management team member will communicate demographic information and appropriate clinical information related to the patient's hospitalization and care needs to the selected agency to ensure that the agency is able to meet the patient's needs and for continuity of care. 5. Prior to discharge, the patient/decision maker is informed of any services arranged, provided with contact telephone number, and anticipated day and time of the initiation of services (if known). ..."

Closed medical record review on 11/19/2019 revealed Pt. (patient) #2 was admitted to the hospital 09/06/2019 through 10/31/2019. Pt. #2 was a 70-year-old female who was admitted with "Acute on chronic respiratory failure..." and other co-morbidities. Record review revealed prior to admission Pt. #2 lived in a Skilled Nursing Facility (SNF). Record review revealed on 09/07/2019 at 1239, MD #1 ordered an Inpatient consult to Case Management (CM). Record review revealed there were adjustments of disposition (SNF vs Home with Home Health Agency [HHA]), and adjustments to the destination disposition (family members home vs patient's home). Record review revealed, on 10/06/2019 the patient's HCPOA selected an HHA and conveyed that information to the CM team. Record review revealed on 10/31/2019 at 0745, MD #1 completed the "Discharge Summary" for Patient #2. Review revealed, on 10/31/2019, a printed "After Visit Summary" included the [Named] Home Health Services and [Named] Durable Medical Equipment Services with the address and telephone of each. Record review revealed on 10/31/2019 at 0916, CM #1 documented "...SW (Social Worker) discussed home health care agency options who could provide care and meet patient's needs in her geographic area. SW disclosed financial interest with [Named Home Care]. [Family member] reported that she would like to use [Named Home Care] and had no other agency choice." Review failed to reveal the case manager notified the HHA that the patient would be discharged and to verify when the HHA would assume post-acute care services for the patient after discharge.

Interview with CM #1 on 11/20/2019 at 1530, revealed the hospital would not discharge a patient unless there was confirmation of the home health agency acceptance of the patient. Interview revealed, "...Referrals are sent electronically and via telephone confirmation of home health agency received the referral. If the agency cannot accept the patient, they call back to the hospital to let us know that." Interview revealed that the Case Management team did not verify that a visit was planned for the discharged patient. Interview revealed while surveyors were onsite, Case Management called the assigned home health agency for Pt. #2. Interview revealed the home health agency did not make a home visit to the patient after discharge on 10/31/2019 as planned. Interview revealed, typically the chosen HHA would schedule a visit within 24-48 hours of the discharge of the patient. Interview with CM #1 revealed that the assigned home health agency perceived that another agency had obtained the booking for Pt. #2 at the time of discharge due to there being more than one agency assigned for care. Interview revealed, there were several agencies involved for medical equipment, oxygen services, and two seperate home health agencies to provide around the clock services for Pt. #2 at the time of discharge.

Interview with HHA #1 on 11/20/2019 at 1630, revealed the discharge notification for the named patient was in "pending discharge" status on 10/31/2019. Interview revealed the HHA data entry personnel viewed the Pt #2 as "pending discharge" status with another outside home health agency scheduled for assigned hours, which created confusion for which was the assigned home health agency. Interview revealed, there were several agencies involved for medical equipment, oxygen services, and two seperate home health agencies to provide around the clock services for Pt. #2 at the time of discharge.

Interview with CM #1, Admin (Administrator) #1, Admin #2 on 11/21/2019 at 0930 revealed, on 10/06/2019 the patient's HCPOA selected an HHA and conveyed that information to the CM team. Interview revealed a staff member of the chosen HHA had an office in the hospital and readily had access to the patient's medical record and the hospital Case Management team. Interview revealed the hospital conducted a record review during this survey to discover the contracted liaison staff of the HHA assigned to Pt.#2 did not release the information to schedule a visit for the home health agency on 10/31/2019, the discharge date. Interview revealed, the HHA did not visit the patient within 24-48 hours after discharge as planned. Interview revealed the hospital CM did not verify that the visit was planned for the named patient upon discharge.

NC00157918, NC00157163