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Based on interview and record review, the facility failed to reassess a discharge plan for 1 of 3 sampled patients reviewed for discharge planning, Patient #1, as evidenced by discharging Patient #1 out of the hospital while a discharge appeal was in process.

The findings included:

Review of the facility policy, titled Addendum: Case Management/Discharge Planning, states in part, 'IV- Reassessment of the patient is done at least within the geometric length of stay. Reassessment is especially necessary in cases where patient's condition or situation may have changed and to ensure the medical necessity of service continues.'

Review of the clinical record for Patient #1 revealed she was admitted to the hospital on 01/30/19. The initial hospital course included admission to the intensive care unit with subsequent transfer to a telemetry unit on 02/05/19.

Review of the initial assessment Case Management Notes' dated 01/31/19, involving Patient #1's spouse as Patient #1 was unable to participate due to her medical condition, documentation by Case Manager (CM) 'A' stated the discharge plan was home health versus SNF (skilled nursing facility) pending clinical outcome. Review of the demographic sheet generated on admission, documented Patient #1's spouse as the next of kin and person to notify in case of an emergency.

Review of Case Management Notes dated 02/06/19 by CM 'A' document 'Transfer to (telemetry unit) on 02/05.'

Review of the next Case Management Note entry dated 02/11/19 at 1:30 PM by CM 'B' documents 'Discharge planning discussed with spouse, spouse agrees to send referrals to SNF in the insurance network, also patient's sibling wants to be updated, he can be reached at ....'

Review of the clinical record revealed no evidence of documentation the patient or the patient's spouse authorized this sibling to be involved in Patient #1's discharge planning.

Review of a Case Management Note entry dated 02/11/19 at 1:44 PM by CM 'B' documents 'Received call from sibling. Refuses SNF '1', awaiting on accepting facilities.' There is no evidence of documentation by CM 'B' that a referral was even sent to SNF '1'.

Review of a Case Management Note entry dated 02/11/19 at 3:41 PM by CM 'B' documents 'CM spoke with (insurance company representative) stated that he will authorize SNF if CM can find accepting facilities in insurance network in (County). If CM cannot find any, to send referrals to SNF '3' (outside of County). Referral were sent to SNF '3'. CM to follow.'

Review of a Case Management Note entry dated 02/12/19 at 2:35 PM by CM 'B' documents 'Call to family member in reference to SNF '2' accepting patient. Sibling notified.'

Review of a Case Management Note entry dated 02/12/19 at 2:43 PM by CM 'B' documents 'Call received from sibling, refuses SNF '2', insurance representative notified.'

Review of a Case Management Note entry dated 02/12/19 at 2:57 PM by CM 'B' documents 'SNF '3' accepting. Authorization pending. CM to follow.'

Review of a Case Management Note entry dated 02/12/19 at 3:38 PM by CM 'B' documents 'Sibling appealing discharge, sibling wants patient to stay in the hospital to receive therapy until ready to go home. Sibling notified that discharge orders in place, that patient has an accepting facility. QIO (Quality Improvement Organization) information provided with clear instruction to call CM with reference number. Copy of MEM (Important Message from Medicare) along with notification of discharge explained and provided to patient/family.'

Review of a Case Management Note entry dated 02/12/19 at 4:01 PM by CM 'B' documents ' Family file appeal, Reference # (123345...). CM to follow.

On 03/25/19 at 12:35 PM, during a tour of the telemetry unit, an interview was conducted with CM 'D' who stated the appeal process is initiated when the patient or responsible party does not agree with the discharge. She stated they give them the Medicare Information Message form to complete and advise them to call Medicare and file an appeal. She stated Medicare will take down the information and within 24 hours Medicare will call us to say there is an appeal pending. They will request 3 days' worth of clinical information that we fax to them and then within another 24 hours they will call with the determination.

On 03/25/19 at 2:22 PM, an interview was conducted with the Director of Case Management and an inquiry made about Patient #1' sibling being involved in the discharge process when there was no documentation in the clinical record authorizing this to which she stated sometimes families are big and everyone wants to get involved and the CM will speak to families if they call if the patient and/or spouse agree it is okay to do so. Further, she stated maybe the face sheet has not been updated and sometimes it does not get updated until after discharge or at the next hospital visit. The Director of Case Management confirmed there was no documentation in the clinical record stating Patient #1's sibling had any rights to be making discharge plan decisions and no explanation why the Patient's sibling filed a discharge appeal.

Review of a Case Management Note dated 02/14/19 at 10:32 AM documentation by CM 'C' states 'Received call from spouse he is in agreement for SNF '3', call to insurance representative.'

Review of the last Case Management Note entry dated 02/14/19 at 11:11, documentation by CM 'C' states 'Call to family and spoke to patient regarding transport time, they are in agreement for discharge to SNF '3' at 3 PM.'

Further review of the clinical record revealed no documentation of any follow up with the discharge appeal that was initiated by the Patient's sibling as documented by CM 'B' on 02/12/19; there was no documentation of any clinical records sent to the QIO; and there was no documentation of the status of the discharge appeal.

On 03/25/19 at 2:28 PM, an interview was conducted with CM 'C' who arranged the transfer of Patient #1 on 02/14/19. She stated she vaguely remembers the case and stated she remembered the Charge Nurse told her the following day the patient's spouse had called after hours around 4:30 PM asking for information and the spouse was told the patient was no longer there and was transferred to SNF '3'. CM 'C' stated the Charge Nurse told her the spouse was very upset but was not sure about what. An inquiry was made about the patient's sibling being involved in the discharge planning when there was no documentation of authorization to do so, to which she stated she never spoke to the sibling, only the spouse. CM 'C' reviewed the case management documentation and was not able to find any documentation that consent was given for involving the sibling in the discharge plans. An inquiry was made about the discharge appeal to which she stated the appeal was submitted by the sibling 2 days before the discharge and the patient was discharged to where the patient and spouse agreed to. An inquiry was made why would the spouse call the hospital around 4:30 PM to speak to the nurse if he was aware Patient #1 had been transferred to SNF '3' at 3 PM. No comment was forthcoming.

On 03/26/19 at 10:21 AM, a telephone interview was conducted with Patient #1's spouse and an inquiry made if Patient #1's sibling was authorized to be involved in the discharge decisions to which he stated they are very close and he relies on the support he and Patient #1 get. An inquiry was made if he was aware on 02/11/19 the sibling refused a referral to SNF '1' to which he stated that is where they wanted her transferred to but there were no beds available. He stated the case manager told him to check out different facilities so he went to SNF '2' which he did not like and to SNF '3', which was okay but very far away. He stated he called the hospital around 4:30 PM to speak to the nurse about bringing in some special drinks for Patient #1 and he was told Patient #1 was already gone to SNF '3' and he got very upset and called Patient #1's sibling right away as they were not aware she was being transferred. Patient #1's spouse confirmed a discharge appeal was in process but was not sure what the status was at the time of her discharge. Patient #1's spouse requested this surveyor contact the Patient's sibling, stating he can explain things better.

On 03/26/19 at 10:46 AM, a telephone interview was conducted with Patient #1's sibling who stated they were not aware she was being transferred to SNF '3' and they were very upset when they found out. He was apprised the patient's spouse stated SNF '1' was where they wanted to go to but there were no beds, however review of the case management notes documents on 02/11/19 SNF '1' was refused to which he stated their choice was SNF '4' not SNF '1', both of which have the name of the city in the facility names, however are 2 different entities. He stated they checked out SNF '2' which they did not like and his brother in law checked out SNF '3' which was okay but it was too far away and would take too long to get to to visit. He stated he filed a discharge appeal and called the hospital with the case number and was assured by the hospital that they would not transfer Patient #1 until the appeal decision. He stated when his brother in law called the hospital around 4:30 PM to ask the nurse about a special drink and was told Patient #1 was discharged an hour and a half ago that is when he called him. He stated Patient #1 had no mental capacity to agree to the transfer. He stated they did not agree to the transfer to SNF '3'. His brother in law checked the facility out and said it was okay, and when they called, they took okay to mean he agreed to the transfer but he was saying the facility was okay. Further, they were waiting on the appeal decision and ultimately they wanted a transfer to SNF '4' and maybe by that time a bed would be available.

Review of the Case Management Notes revealed no evidence of documentation of the families' preference for discharge to SNF '4'.

On 03/26/19 at 1:47 PM, a telephone conference call commenced with the hospital Director of Case Management, CM 'C', Vice President of Regulatory Compliance and Quality and Quality Manager and an inquiry made what the process was for discharging a patient if they have submitted an appeal and would the discharge be on hold while waiting for the appeal decision. The Director of Case Management stated they would wait for the determination or if the family or patient are agreeable to discharge that would negate the appeal decision at which time they would fax a document to the QIO notifying them the patient was agreeable to the transfer and to revoke the appeal. A request was made to provide evidence of documentation of the fax that was sent to the QIO, to which the Director of Case Management stated they do no keep any of that documentation and do not keep a copy of the appeal either. An inquiry was made would that not be considered a part of the patient's medical record to which she had no comment.

On 03/26/19 at 1:52 PM, an inquiry was made to CM 'C' if she followed up with the status of the discharge appeal prior to transferring Patient #1 to SNF '3' to which she stated she did not ask any questions or follow up with the appeal status because she was 100% certain the patient and spouse agreed to the transfer therefore the appeal would no longer apply. She stated looking at her documentation on 02/14/19, she documented she spoke to the spouse and the patient and they agreed to the transfer. The conference call attendees were apprised of the conversation conducted with the patient's spouse and sibling, clarifying the spouse thought he was saying SNF '3' was okay as a facility as he had toured it, but he was not saying okay consenting to the discharge to SNF '3'. The attendees were apprised the family was waiting on the appeal decision before making the final discharge arrangements. Further, in reviewing the Case Management Notes, revealed there was no documentation of the family touring facilities and no documentation of the family preference for SNF '4'. It was pointed out CM 'B' documented SNF '1' was refused however after the conversation with Patient #1's sibling, it was discovered the family preference was for SNF '4' which coincidently had the same name of the city in the facility name however are 2 separate entities.

On 03/26/19 at 4:44 PM, during the exit conference with the Vice President of Regulatory Compliance and Quality and Quality Manger, the issues were discussed to include not following hospital policy; no documentation of any follow up with the discharge appeal; no documentation of any records sent to the QIO; no documentation of a fax sent to the QIO; no documentation the patient/family revoked the discharge appeal; and no documentation the QIO was informed of a revocation if there was one. Further, there was no documentation of the family's preference for SNF '4' and not SNF '1', which had been refused with no clarification of the names of the facilities. An inquiry was made if CM 'B' was aware they were 2 different facilities, which coincidently had the same name of the city in their names. The attendees could not speak to whether CM 'B' was aware SNF '1' and SNF '4' were not one in the same.

Review of the facility policy for Utilization Management Plan documents in part, 'If the beneficiary chooses to appeal the discharge decision, Case Management/Social Worker (CM/SW) will be responsible for providing the Detailed Notice of Discharge to original Part A Medicare beneficiaries only within the required timeframes. A copy of the notice will be maintained in the medical record. CM/SW will copy, fax and/or overnight deliver all documentation requested by the QIO in the required timeframe.'

Review of the facility Discharge Planning, Interdisciplinary Clinical Practice Manual policy states in part, 'Discharge planning is a systematic, coordinated program designed to bring about the timely discharge of a patient from a hospital to the next appropriate level of care or to return them to their normal living situation. It is an ongoing process that is continually refined in coordination with the patient and/or family representative or guardian, to meet the anticipated needs of the patient.'