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Based on an unannounced Complaint investigation ACTS Intake PR00000665 survey conducted on September 7, through September 8, 2022, review of twenty-seven medical records and policies, procedures, and interview with The Director of Case Management (employee #5) it was identified that facility failed to promote the right of each inpatient Medicare beneficiary to appeal the discharge process in advance. This deficient practice was identified in 7 out of 27 cases reviewed. (RR # 1, RR # 7, RR #13, RR#17, RR # 18, RR#20, RR#22, and RR#24)

Findings include:

1. During the review of twenty-seven cases during survey procedures on September 7, through September 8, 2022, from 8:30 AM through 3:00 PM with Director of Nursing (employee #1) and discussed with the Director of Case Management (employee #5) during this process the following was identified:

a. Inpatient Medicare beneficiaries (RR #1) did not receive the document "An Important Message from Medicare" (IM), " when admitted to the facility.

b. RR# 17 and RR# 22 medical record do not have evidence that facility provide the standardized notice, "An Important Message from Medicare" (IM), within 2 calendar days before the patient's discharge.

c. None of those medical record include IM signed and dated by the patient, relative or caregiver to acknowledge receipt.

d. Policy and procedure DO-07 Mensaje Importante de Medicare: Notificación a paciente sobre derecho de apelación last updated on 09/28/2021 was reviewed on 09/08/2022 at 11:00 AM and it was identified that did not establish a procedure guide the deliver the document "An Important Message from Medicare" (IM), within 2 calendar days before the patient's discharge.

During interview on 09/08/2021 at 10:05 AM Director of Case Management (employee #5) stated that facility had a mechanism (procedure) established to guarantee that the right of appeal the discharge of each inpatient Medicare beneficiary and that procedure is implemented when a patient disagrees with discharge process.


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e. Inpatient Medicare beneficiaries (RR #13, RR #18 RR#20, RR#24 and RR#25) medical record do not provide evidence that facility provides the standardized notice, "An Important Message from Medicare" (IM), within 2 calendar days before the patient's discharge.

Based on an unannounced complaint investigation ACTS Intake PR00000665, review of twenty seven closed and active records reviewed (R.R), policies/procedures review and interview performed to the Director of Case Management ( employee #5) on 09/08/2022 at 11:39 AM, it was determined that the facility failed to have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient ' s goals for care and his or her treatment preferences and ensure an effective transition of the patient from hospital to post-discharge care. All of which makes Discharge Planning (Condition ) 42 CFR §483.43 out of compliance. (Cross reference Tags A800, A805 and A814)

Based on a unannounced complaint investigation ACTS Intake PR00000665, review of twenty seven closed and active records reviewed (RR), policies/procedures review and interview performed to the Director of Case Management ( employee #5) on 09/08/2022 at 11:39 AM, it was determined that the facility failed to perform assessment at an early stage of hospitalization on those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation. This deficient practice was identified in 13 out of 27 records reviewed. (RR#1, RR# 3, RR #4, RR# 5, RR # 6, RR # 8, RR # 9, RR# 13, RR # 20, RR # 21, RR #22, RR # 24 and RR #25)

Findings include:

1.During the review of thirteen cases during survey procedures on September 7, through September 8, 2022, from 8:30 AM through 3:00 PM with Director of Nursing (employee #1) and discussed with the Director of Case Management (employee #5) during this process the following was identified:

a.RR #1 is a 71-year-old male patient admitted on 07/28/2022 with a diagnosis of Covid-19. When patient was admitted (07/28/2022) it was impossible to complete the nursing history and admission information because patient was disoriented. Nursing history and admission information was completed using medical record information on 08/01/2022 and during this process it was identified that patient came from an elderly home when admitted to the hospital.

Case was referred to discharge planning by nursing personnel on 08/01/2022 but was not evaluated by discharge planning department until 09/02/2022. There is evidence of a progress note on the medical record dated 09/02/2022 at 2:30 PM documented by a social worker in which it was explained that discharge planning services communicate by phone with a patient relative but did not obtain any answer or communication by patient relatives or caregivers.

Discharge planning process was performed on 09/07/2022 when discharge planning services personnel communicate with the personnel from the elderly home where the patient used to live. Personnel of the elderly home inform discharge planning services that when patient is discharge home it is going to return to this elderly home where they are going to be in charge of patient care.

b. RR #3 is a 87 years old female patient admitted on 09/04/2022 with a diagnosis of Pneumonia and Covid-19 (+), patient also had history of Lung Cancer. When patient was admitted was not referred to discharge planning services. Discharge planning evaluation was not performed until 09/08/2022 when patient was dependent of a mechanical ventilation. Facility failed to identify at an early stage of hospitalization these patients who are likely to suffer adverse health consequences due to his/her diagnosis.

c. RR # 4 is a 75-year-old female patient admitted on 08/27/2022 with a diagnosis of Non Stemi CHF, COPD and Covid-19. When patient was admitted, and nursing was performing the nursing history and admission process it was identified that patient also fell down three days ago; psychosocial assessment was not completed by nursing personnel and the case was not referred to discharge planning services. An initial assessment performed by discharge planning process was found documented however did not have the date when discharge planning personnel performed the assessment.

d. RR #5 is a 66-year-old male patient admitted on 09/01/2022 with a diagnosis of Abdominal Surgical Wound Infected and Covid-19 (+). When patient was admitted, and nursing was performing the nursing history and admission process identify patient must be referred to discharge planning services due to his admission diagnosis and document that the case was referred to discharge planning services for evaluation. However, there are no evidence that the case was referred.

Case was review with Director of Nursing (employee #1) on 09/08/2022 at 9:58 AM and the evidence of the referral could not be located. Facility failed to identify at an early stage of hospitalization this patient who is likely to suffer adverse health consequences due to her diagnosis. Patient was discharge home on 09/08/2022 the same day discharge planning services perform the initial assessment and evaluation.

e. RR #6 is an 81-year-old male patient admitted on 08/24/2022 with a diagnosis of Hypoxemia, Pneumonia and Covid-19. When patient was admitted, and nursing was performing the nursing history and admission process identify patient must be referred to discharge planning services and document that case was referred to discharge planning services.

Case was review with Director of Nursing (employee #1) on 09/08/2022 at 10:18 AM and the evidence of the referral could not be located. This case was not evaluated by discharge planning service until 09/07/2022. Facility failed to identify at an early stage of hospitalization these patients who are likely to suffer adverse health consequences due to his/her diagnosis.

f. RR #8 is a 91-year-old male patient admitted on 08/23/2022 with a diagnosis of Sepsis, Pneumonia and UTI. When patient was admitted, and nursing was performing the nursing history and admission process identify patient must be referred to discharge planning services and document that case was referred to discharge planning services.

Case was review with Director of Nursing (employee #1) on 09/08/2022 at 10:30 AM and the evidence of the referral could not be located. This case was not evaluated by discharge planning service until 09/07/2022. Facility failed to identify at an early stage of hospitalization these patients who are likely to suffer adverse health consequences due to his/her diagnosis.

g. RR #9 is an 86-year-old male patient admitted on 08/24/2022 with a diagnosis of Symptomatic Anemia. Patient was transferred to the Covid-19 unit on 09/04/2022 because came positive to Covid-19 while receiving treatment at facility. When patient was admitted, and nursing was performing the nursing history and admission process identify patient must be referred to discharge planning services and document that case was referred to discharge planning services.

Case was review with Director of Nursing (employee #1) on 09/08/2022 at 10:40 AM and the evidence of the referral could not be located. This case was not evaluated by discharge planning service until 09/07/2022. Facility failed to identify at an early stage of hospitalization these patients who are likely to suffer adverse health consequences due to his/her diagnosis.

h. RR #21 is a 89 years old female patient admitted on 07/26/2022 with a diagnosis of Transient Ischemic Attack-Acute CVA. When patient was admitted, and nursing was performing the nursing history and admission process did not identify that patient must be referred to discharge planning services.

This case was not evaluated by discharge planning service until 08/15/2022. Facility failed to identify at an early stage of hospitalization these patients who are likely to suffer adverse health consequences due to his/her diagnosis.

i. RR #22 is a 76-year-old female patient admitted on 08/19/2022 with a diagnosis of Complicated Urinary Tract Infection, Sepsis patient had history of Alzheimer, Sacral Ulcer and Chronic Kidney Disease. When patient was admitted, and nursing was performing the nursing history and admission process did not identify that patient must be referred to discharge planning services. This case was not evaluated by discharge planning service until 08/25/2022. Facility failed to identify at an early stage of hospitalization these patients who are likely to suffer adverse health consequences due to his/her diagnosis.

The facility policy for discharge planning process and policy (revised in July 2015) was review on 09/07/2022 at 2:35 PM at with Director of Case Management (employee #5) while medical record review was performed. This policy establish that discharge planning process must begin since admission to the facility to every patient admitted receiving services.

Policy also establishes that the process must be continuous and that the discharge planning process's make priorities based on guidance established by discharge planning services. Guidance establishes a series of diagnosis and procedures used to prioritize patient assessment of needs for discharge planning arrangements.

Accordingly with discharge planning process the initial evaluation must be performed during the first 24 hours after the admission of a patient to the facility. This policy also establishes high risk criteria that must be considered to maintain a dynamic and more aggressive involvement of discharge planning services to manage situations of those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning.

Some of those criteria include patients with 75 years or older who lives alone, cases where it could be anticipated considering the need rehabilitation, patients who are not able to manage their condition and need supervision or tutoring

During interview on 09/08/2022 at 11:25 AM the Director of Case Management (employee #5) stated that discharge planning process must be perform accordingly with policies and procedures established. She also stated that based on the characteristics and morbidity of patients who receive services at facility it is very difficult to perform the process only with 7 social workers who are on duty to cover for services 7 days a week.


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j. RR # 13 is an 80-year-old female patient admitted on 07/02/2022 with a diagnosis of Covid-19, Pneumonia due to coronavirus disease 2019, Urinary tract infection site not specified and Type 2 Diabetes Mellitus with Hyperglycemia. When patient was admitted was not referred to discharge planning services. MD order discharge planning on 08/05/2022 and 08/06/2022. Discharge planning evaluation was not performed until 08/06/2022. Facility failed to identify at an early stage of hospitalization these patients who are likely to suffer adverse health consequences due to his/her diagnosis.

k. RR #20 is an 80-year-old female patient admitted on 07/27/2022 with a diagnosis of Cerebral Vascular Accident (CVA) and Covid 19. When patient was admitted was referred to discharge planning services. MD order discharge planning on 07/27/2022. Discharge planning evaluation was not performed until 08/04/2022. Facility failed to evaluate patient for discharge planning in the first 24 hours of the patient refer.

l. RR #24 is a 70-year-old female patient admitted on 05/13/2022 with a diagnostic of CVA. When patient was admitted was referred to discharge planning services. MD order discharge planning on 05/13/2022. Discharge planning evaluation was not performed during the patient admission. Facility failed to evaluate patient for discharge planning in the first 24 hours of the patient refer.

m. RR #25 is an 86-year-old male patient admitted on 07/21/2022 with a diagnosis of Pressure Ulcer Stage 4. The facility did not provide evidence of the patient referred to discharge planning services. Discharge planning evaluation was performed om 08/12/2022. Facility failed to evaluate patient for discharge planning in the first 24 hours.

Based on an unannounced complaint investigation ACTS Intake PR00000665, review of twenty-seven closed and active records reviewed (RR), policies/procedures review and interview performed to the Director of Case Management (employee #5) on 09/08/2022 at 11:39 AM, it was determined that facility failed to assure that discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge. This deficient practice was identified in 6 out of 27 records reviewed (RR#4, RR #5, RR#13, RR#20, RR#24 and RR#25).

Findings include:

1.RR # 4 is a 75-year-old female patient admitted on 08/27/2022 with a diagnosis of Non Stemi CHF, COPD and Covid-19. When patient was admitted, and nursing was performing the nursing history and admission process it was identified that patient also fell three days ago; psychosocial assessment was not completed by nursing personnel and the case was not referred to discharge planning services.

An initial assessment performed by discharge planning process was found documented however did not have the date when discharge planning personnel performed the assessment.

Facility failed to evidence that it complies with their guidance who establish that patients who has COPD as one of the diagnoses it is used to prioritize patient assessment and needs for discharge planning arrangements.

Accordingly with discharge planning process the initial evaluation of patients with this condition must be performed during the first 24 hours after the admission of a patient with this diagnosis.

Patient was discharge home on 09/08/2022 the same day discharge planning services perform the initial assessment and evaluation.

2. RR #5 is a 66-year-old male patient admitted on 09/01/2022 with a diagnosis of Abdominal Surgical Wound Infected and Covid-19 (+). When patient was admitted, and nursing was performing the nursing history and admission process they identify patient must be referred to discharge planning services due to his admission diagnosis and document that the case was referred to discharge planning services for evaluation.

Accordingly with information documented on the nursing history, patient lives alone and had history of Cancer. However, there are no evidence that the case was referred.

Case was review with Director of Nursing (employee #1) on 09/08/2022 at 9:58 AM and the evidence of the referral could not be located.

Facility failed to comply with their guidance who establish infected wound as one of the diagnoses used to prioritize patient assessment of needs for discharge planning arrangements.

Accordingly with discharge planning process the initial evaluation must be performed during the first 24 hours after the admission of a patient with this diagnosis to the facility.

Patient was discharge home on 09/08/2022 the same day discharge planning services perform the initial assessment and evaluation.


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3. RR # 13 is an 80-year-old female patient admitted on 07/02/2022 with a diagnosis of Covid-19, Pneumonia due to Coronavirus Disease 2019, Urinary tract infection site not specified and Type 2 Diabetes Mellitus with Hyperglycemia. When patient was admitted was not referred to discharge planning services. MD order discharge planning on 08/05/2022 and 08/06/2022. Discharge planning evaluation was not performed until 08/06/2022. Facility failed to identify at an early stage of hospitalization this patient who are likely to suffer adverse health consequences due to his/her diagnosis.

4. RR #20 is an 80-year-old female patient admitted on 07/27/2022 with a diagnosis of Cerebral Vascular Accident (CVA) and Covid 19. When patient was admitted was referred to discharge planning services. MD order discharge planning on 07/27/2022. Discharge planning evaluation was not performed until 08/04/2022. Facility failed to evaluate patient for discharge planning in the first 24 hours of the patient refer.

5. RR #24 is a 70-year-old female patient admitted on 05/13/2022 with a diagnostic of CVA. When patient was admitted was referred to discharge planning services. MD order discharge planning on 05/13/2022. Discharge planning evaluation was not performed during the patient admission. Facility failed to evaluate patient for discharge planning in the first 24 hours of the patient refer.

6. RR #25 is an 86-year-old male patient admitted on 07/21/2022 with a diagnosis of Pressure Ulcer Stage 4. The facility did not provide evidence of the patient referred to discharge planning services. Discharge planning evaluation was performed om 08/12/2022. Facility failed to evaluate patient for discharge planning in the first 24 hours.

Based on an unannounced complaint investigation ACTS Intake PR00000665, review of twenty seven closed and active records reviewed (RR), policies/procedures review and interview performed to the Social Work and Discharge Planning Submanager (employee #6) on 09/08/2022 at 2:00 PM AM, it was determined that facility failed to demonstrate the effectiveness of the discharge planning process on an ongoing basis and the review of the discharge plan to ensure that are responsive to patient's discharge needs.

Findings include:

1.Facility provide evidence of the ongoing evaluation of the effectiveness of its discharge planning process (Quality Assessment Performance Improvement activities) related with post-acute care services of patients referred to Hospice Services.

Evidence of the evaluation of the effectiveness of its discharge planning process (Quality Assessment Performance Improvement activities) related with post-acute services of patients discharge home and referred for Home Health Agency services or transferred to a Skilled Nursing Facility SNF for post hospital extended care services or transferred to an Inpatient Rehabilitation Facility was not provided.

2. Social Work and Discharge Planning Submanager (employee #6) stated on 09/08/2022 at 2:00 PM that facility only perform evaluation of the effectiveness of its discharge planning process ( Quality Assessment Performance Improvement activities ) related with post-acute care services of patients referred to Hospice Services.