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Based on document review and interview, it was determined that the Hospital failed to ensure an appropriate discharge planning. As a result, it was determined that the Condition of Participation for Discharge Planning 482.43 was not in compliance.

Findings include:

1. The Hospital failed to complete a referral, to ensure that the home health agency was appropriate to meet the patient's needs at home. See A-0806.

2. The Hospital failed to provide a comprehensive list of home health agency or SNFs (Skilled Nursing Facility) options. See A-0823.

3. The Hospital failed to ensure the discharge plan was reassessed to meet the needs of the patient. See A-0843.

Based on document review and interview, it was determined that for 1 of 3 (Pt. #1) clinical records reviewed for patients needing home health services, the Hospital failed to complete a referral, to ensure that the home health agency was appropriate to meet the patient's needs at home.

Findings include:

1. On 2/5/19 at approximately 12:30 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 6 year old female admitted to the Hospital (Hospital A) on 11/6/18 with a diagnosis of acute flaccid myelitis (A rare disease that affects the spinal cord and part of the nervous system. Symptoms include weakness in the arms or legs along with loss of muscle tone), now ventilator (breathing machine) dependent. The clinical record included:

- The Patient Information Sheet that included, "(Pt. #1) ... (Home Address) ... (State A) ..."

- The Physician's History and Physical dated 11/6/18 included, " ... History of Present Illness ... admitted to (Hospital B) on 9/15/18 with acute flaccid myelitis, now ventilator dependent ... (Pt. #1) had (upper respiratory infection) symptoms and intermittent fevers for 2 weeks prior to hospital presentation ... On the day of admission to acute care ... developed shallow breathing ... intubated, and the decision made to keep (Pt. #1) intubated given respiratory muscle weakness ... (Pt. #1) remained vent (ventilator) dependent and ultimately had tracheostomy (artificial airway) placed on 10/16/2018 ... Social Hx (history): Lives ... with both parents ... Current Functional Status: Dependent for all mobility and ADLs (Activities of Daily Living)... Impression and Plan ... Comprehensive ... PT (physical therapy)/OT (occupational therapy) ... Nursing ... to improve functional status, strength, endurance ... with goal of safe discharge ...Estimated length of stay: 8 weeks. Disposition: Home ..."

- The Care Management Initial Evaluation Note of E #1 (Care Manager) dated 11/8/18 included, " ... Patient lives in a home ... Adjustment to Disability ... Mom (Pt. #1's mother) states that she needs a lot of help in many areas of her life ... feels very overwhelmed currently with patients care ... Mom reports that she is interested in hiring a private sitter to assist with patient ... CM (Care Manager) will assist mom with this request ... Initial Discharge Plan ... Patient will return home with family. CM will assist with discharge planning and will also assist with other resources as necessary."

- The Weekly Interdisciplinary Team Conference Meeting Notes dated 12/24/18 included, " ... Nursing Summary ... Family has been participating in more patient care tasks and reinforcing a lot of nursing and therapy education... Mom has been participating in training and will provide 24/7 care starting Friday to make sure she is comfortable with providing all care in preparation for home ..."

- The Discharge Instructions for Pt. #1 dated 1/3/19 included, "(Hospital A's) Follow-Up Therapy and Care Instructions ... Community Referrals: (State Program A/A program that could assist with home health nursing) ...can assist with in-home nursing. Please follow-up with the program as soon as you are home. Services may take 4-6 weeks until they are in place... Private Duty Nursing: Until the nursing through (State Program A) is in place, you are working with (Home Health Agency A) on out of pocket PDN (private duty nursing) for about 44hrs/week ..."

- The clinical record lacked documentation that a referral (for Home Health Agency A) was completed.

2. On 2/6/19 at approximately 1:00 PM, the Hospital's document titled, "Patient LOS (Length of Stay) Protocol" (May 2018) was reviewed and included, "Objective: Streamline family training ... discharge options for pediatric patients ... Population: Pediatric Patients with new diagnosis of BI (Brain Injury) or SCI (Spinal Cord Injury) who will require trach (tracheostomy) and/or vent (ventilator) support upon DC (discharge) ... Within 4 weeks ... Care manager makes referral (s) to potential transition settings ..."

3. On 2/6/19 at approximately 3:45 PM, the Hospital's policy tiled, "Continuity of Care" (dated 8/15/18) was reviewed and included, "It is the responsibility of care managers to coordinate referrals to home health agencies for inpatients at the time of discharge. The treatment team should make recommendations regarding home health care prior to discharge... When care managers are asked to make recommendations regarding Home Health Agencies or asked to choose the agency for a patient, they should consider the patient's demographic location...and the patient's clinical needs..."

4. On 2/5/19 at approximately 2:15 PM, an interview was conducted with E #1/Care Manager). E #1 stated that it was recommended for patients who are dependent on technology (e.g. ventilator and tracheostomy) to have home health nursing because of high respiratory need. E #1 stated, "It is always a recommendation we make...Mom felt they have the ability to hire a caregiver ... Asked me for assistance ... Provided mom information about (Home Health Agency A) while in the Hospital." E #1 stated that, prior to Pt. #1's discharge, Pt. #1's mother arranged for the home health nursing service, since the recommendation to have home health nursing did not change. E #1 stated, "I did not make arrangement .... (Pt. #1's mom) made the arrangements with (Home Health Agency A)." E #1 could not provide documentation that Home Health Agency A could appropriately provide home health nursing services in (State A, where Pt. #1 was discharged to).

5. On 2/5/19 at approximately 3:30 PM and on 2/6/19 at approximately 11:47 AM, interviews were conducted with E #2 (Director of Inpatient Care Coordination). E #2 stated that patients who are technology dependent (ventilator and tracheostomy) are recommended to have home health nursing services. To verify that a home health agency could meet the needs of a patient after discharge, E #2 stated that a referral is made using the (Medicare Database A/Online search for participating home health agencies) considering the patients' demographic location, as well as insurance, and needs. E #2 stated that a referral for home health agency for Pt. #1 was not made.

6. On 2/6/19 at approximately 10:00 AM, an interview was conducted with MD #1 (Pt. #1's Attending Physician). Regarding discharge plan, MD #1 stated, "Generally, we work with the team ... we have plan, an 8 week protocol ... that includes equipment ordering ... In case of ventilator dependent patients, a referral to agencies for in-home nursing support." MD #1 stated, "It is no doubt that this type of patient needs home health nursing ..."

Based on document review and interview, it was determined that for 2 of 7 (Pt. #1 and Pt. #6) closed records reviewed for discharge planning, the Hospital failed to provide a comprehensive list of home health agency or SNF (Skilled Nursing Facility) options.

Finding include:

1. On 2/5/19 at approximately 12:30 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 6 year old female admitted to the Hospital (Hospital A) on 11/6/18 with a diagnosis of acute flaccid myelitis (A rare disease that affects the spinal cord and part of the nervous system. Symptoms include weakness in the arms or legs along with loss of muscle tone), now ventilator (breathing machine) dependent. The clinical record included:

- The Physician's History and Physical dated 11/6/18 included, " ... Current Functional Status: Dependent for all mobility and ADLs (Activities of Daily Living)... Impression and Plan... Nursing ... to improve functional status, strength, endurance ... with goal of safe discharge ...Estimated length of stay: 8 weeks. Disposition: Home ..."

- The Care Management Initial Evaluation Note of E #1 (Care Manager) dated 11/8/18 included, " ... Patient lives in a home ... Adjustment to Disability ... Mom (Pt. #1's mother) states that she needs a lot of help in many areas of her life ... feels very overwhelmed currently with patients care ... Mom reports that she is interested in hiring a private sitter to assist with patient ... CM (Care Manager) will assist mom with this request ... Initial Discharge Plan ... Patient will return home with family."

- The Weekly Interdisciplinary Team Conference Meeting Notes dated 12/24/18 included, " ... Nursing Summary ...Mom has been participating in training and will provide 24/7 care starting Friday to make sure she is comfortable with providing all care in preparation for home ..."

- The Discharge Instructions for Pt. #1 dated 1/3/19 included, " ... (Hospital A's) Follow-Up Therapy and Care Instructions ... Community Referrals: (State Program A/A program that could assist with home health nursing) ...can assist with in-home nursing. Please follow-up with the program as soon as you are home. Services may take 4-6 weeks until they are in place... Private Duty Nursing: Until the nursing through (State Program A) is in place, you are working with (Home Health Agency A) on out of pocket PDN (private duty nursing) for about 44hrs/week ..."

- The clinical record lacked documentation that a list of participating home health agency options were provided.


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2. On 2/6/19 at approximately 10:30 AM, the clinical record of Pt. #6 was reviewed. Pt. #6 was a 77 year old male admitted on 12/14/18 with a diagnosis of traumatic brain injury. Pt. #6 clinical record included a physician's order dated 1/12/19 at 10:00 AM included "Discharge Patient...Destination Extended care Facility (SNF).

- Pt. #6's "Care Management Initial Evaluation" dated 12/16/18 at 8:04 PM was reviewed and included "...per wife plan is to d/c (discharge) to home...

- Pt. #6's "Inpatient Team Conference Care Notes" from 12/14/18 to 1/12/19 were reviewed. and included "...CM (Case Management) reports due to current care needs...family to pursue SNF D/C (discharge) prior to returning home with family support..." These notes lacked documentation that a list of skilled nursing facilities was provided.

3. The policy titled, "Admission, Continued Stay and Discharge Criteria" (reviewed by the Hospital on 1/2013) was reviewed on 2/6/18 and included, "(The Hospital) determines the appropriate level of care for patients...and discharge upon the (Hospital) Utilization Review Committee Plan, regulations and guidelines from applicable federal..."

4. The policy titled, "Discharge Planning" (revised 12/2008) was reviewed on 2/6/19 and included, "Discharge planning requires an understanding of available resources... within the community... Decisions regarding discharge disposition are ultimately the responsibility of the patients, their caregivers... These individuals have the opportunity to receive counseling regarding their discharge decisions and are fully informed regarding options available to them..."

5. On 2/6/19 between 10:40 AM and 11:47 AM, the Director Inpatient Care Coordinator (E #2) was interviewed. E #2 stated that the clinical record did not include that a comprehensive list of SNF was provided to Pt. #6. E #2 could not provide documentation that a list of participating home health agency options were given to Pt. #1's caregiver.

Based on document review and interview, it was determined that for 1 of 7 (Pt. #1) closed records reviewed for discharge planning, it was determined that the Hospital failed to ensure discharge plan was reassessed to meet the needs of the patient.

Findings include:

1. The clinical record of Pt. #1 was reviewed on 2/5/19. Pt. #1 was a 6 year old female admitted 11/6/18 with a diagnosis acute flaccid myelitis (A rare disease that affects the spinal cord and part of the nervous system. Symptoms include weakness in the arms or legs along with loss of muscle tone). Pt. #1 was discharged on 1/3/19 under the care of the mother. The clinical record indicated that Pt. #1 was ventilator (breathing machine) dependent and needed total assistance with eating, bathing and grooming. The clinical record also included:

- The Discharge Instructions for Pt. #1 dated 1/3/19 included, " ... (Hospital A's) Follow-Up Therapy and Care Instructions ... Community Referrals: (State Program A/A program that could assist with home health nursing) ...can assist with in-home nursing. Please follow-up with the program as soon as you are home. Services may take 4-6 weeks until they are in place... Private Duty Nursing: Until the nursing through (State Program A) is in place, you are working with (Home Health Agency A) on out of pocket PDN (private duty nursing) for about 44hrs/week ..."

- The clinical record did not include a follow up after discharge was attempted. Pt. #1 was discharged home on 01/03/19 under the care of the mother.

2. The policy titled "Admission, Continued Stay, and Discharge Criteria (reviewed by the Hospital on 1/2013) reviewed on 2/6/19 and included ""(The Hospital) determines the appropriate level of care for patients...and discharge upon the (Hospital) Utilization Review Committee Plan, regulations and guidelines from applicable federal...Discharge from inpatient level of care is indicated when the patient...6. has an appropriate discharge plan, which may include but not limited to ...therapeutic and supportive services."

3. On 2/5/19 at approximately 2:15 PM, the Case Manager (E #1) was interviewed. E #1 stated that it is the Case Management department process to follow up with patient/or patient's representative 2 days after discharge. E #1 stated she did not follow-up with Pt. #1's mother because she (E #1) was sick. E #1 was not aware if another case manager had attempted to contact Pt. #1's mother after discharge. E #1 stated that it is documented if contact was made in another software and not in the patients clinical record. E #1 was not able to provide documentation that a follow up contact with Pt. #1's mother to assess the discharge plan occurred.