HospitalInspections.org

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to follow their established policies regarding providing the patient and/or family a listing of home health agencies for two of 11 patients discharged with home health care (MR1 and MR2).

Findings include:

Review on January 17, 2013, of the facility's "Home Health Care Referral" policy, last approved November 20, 2012, revealed "Purpose: To manage patient's needs under home health services when services are ordered by a physician and are appropriate for outpatient management. Procedure: Discuss home health care services with the patient and/or family, the estimated frequency of visits and insurance/financial coverage. Provide a list of home health care providers to patient and/or family. If the physician selects a provider, verify that the patient and/or family member are in agreement. After home health provider is chosen, have patient or family member sign the Patient Freedom of Choice e-form. ..."

Review on January 17, 2013, of the facility's "Patient Freedom Of Choice" e-from, no review date, revealed "... The medical center has shared with me a list of agencies that are located in my area of residence from which to choose from for my discharge needs. ... I have voluntarily selected the following agency/agencies to provide me with continuation of care upon my discharge from Schuylkill Medical Center. I have made this decision willfully on my own. Agency/Agencies chosen ... Patient / Family / Responsible Party Signature: ... If patient is unable to sign authorization form because of physical condition or age, complete the following: Patient is minor. Patient is unable to sign authorization because: ... Relationship. Witness Signature."

1) Review of MR1 on January 17, 2013, revealed a physician order for this patient to be discharged home with home health care. Review of MR1's case management documentation dated November 11, 2012, revealed the patient and family chose a home health care agency for MR1's discharge needs.

There was no documentation that MR1 or this patient's family signed a Patient Freedom Of Choice form, that the facility provided the patient and/or family a list of home health agencies to choose from, or that the choice of the home health agency for MR1's discharge needs was made voluntarily.

2) Review of MR2 on January 17, 2013, revealed a physician order for this patient to be discharged home with home health care. Review of MR2's case management documentation dated December 26, 2012, revealed the patient and family chose a home health care agency.

There was no documentation that MR2 or this patient's family signed a Patient Freedom Of Choice form, that the facility provided the patient and/or family a list of home health agencies to choose from, or that the choice of the home health agency for MR2's discharge needs was made voluntarily.

Interview with EMP1 and EMP2 on January 17, 2013, at approximately 11:00 AM confirmed MR1 and MR2's physicians ordered the patients to be discharge home with home health care, and case management documentation revealed the patients and families chose a home health care agency for the patients' discharge needs. Further interview with EMP1 and EMP2 confirmed there was no documentation MR1 and MR2 or their families signed a Patient Freedom Of Choice form. EMP1 and EMP2 also confirmed there was no documentation the facility provided a list of home health agencies for MR1 and MR2 and/or the families to choose from, or that the choice of the home health agency for MR1 and MR2's discharge needs was made voluntarily.