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Based on record review, interviews, and policy review, the facility failed to develop an appropriate discharge plan based on the patient's physical level of function to ensure a safe discharge as well as the facility failed to conduct a reassessment of the appropriateness of the discharge plan to reflect the patient's capabilities and post discharge needs to ensure a safe discharge and prevent readmission for one of 20 sampled patients (Patient 14). This deficient practice had the potential to affect all 58 current patients who were receiving rehabilitation service at the facility.

Findings Include:

Review of the facility's policy titled, "Discharge Planning" effective 03/29/19 indicated, "The multidisciplinary team is also involved in assessing goals and potential barriers to discharge as part of their interdisciplinary assessment. And discharge planning process ...Throughout the patient's stay, the Case Manager works with the patient/caregiver to continue to develop a safe discharge plan based on the patient's physical, medical and cognitive behavioral needs as assessed by the team."

1. The facility failed to develop an appropriate discharge plan based on the patient's physical level of function to ensure a safe discharge and prevent readmission to the hospital. Refer to A-0806, Discharge Plans Needs Assessment.

2. The facility failed to conduct a reassessment of the appropriateness of the discharge plan when the patient's capabilities and post discharge needs warranted to ensure a safe discharge and prevent readmission to the hospital. Refer to A-0821, Reassessment of a Discharge Plan.

Based on record review, interviews, and policy review, the facility failed to develop an appropriate discharge plan based on the patient's physical level of function to ensure a safe discharge and prevent readmission for one of 20 sampled patients (Patient 14). This deficient practice has the potential to place patients at risk for unsafe discharge and unmet continuum of care needs.

Findings Include:

Review of the facility's policy titled, "Discharge Planning" effective 03/29/19 showed, "The multidisciplinary team is also involved in assessing goals and potential barriers to discharge as part of their interdisciplinary assessment. And discharge planning process ...Throughout the patient's stay, the Case Manager works with the patient/caregiver to continue to develop a safe discharge plan based on the patient's physical, medical and cognitive behavioral needs as assessed by the team. . .The physician, case manager, team and patient/ caregiver will refine or modify the preliminary plan as needed in accordance to patient's response to the rehabilitation program."

Review of Patient 14' s' medical record showed an admission date of 09/23/19 with diagnosis of multiple sclerosis (MS) and the use of a baclofen pump (a medical device used to deliver medications directly into the space between the spinal cord and the protective sheath surrounding the spinal cord). The medical record revealed a home health agency referral was made with a start of care date of 10/06/19. The prescription for home health services included a request for nursing, physical therapy, medical social worker, and occupational therapy.

Review of the "initial discharge assessment" dated 09/24/19, showed Staff H, Case Manager, Licensed Bachelor of Social Work (LBSW) documented Patient 14 was admitted on 09/23/19 with a diagnosis of MS and a baclofen pump, lives alone, had housekeeping services once a week, had home health services, and noted the patient intended to return home and resume those services upon discharge.

Review of the "interdisciplinary team (patient, physiatrist, case manager, physical therapist, occupation therapist, nurse, and speech therapist) notes" dated 09/27/19 and 10/03/19 showed that Patient 14 was capable of making his own healthcare decision and indicated that he needed assistance with most of his activities of daily living. The interdisciplinary team recommended to Patient 14 that he increase the "private help services" when he is discharged. The case manager documented that Patient 14 consented to recommendation "to increase the frequency of the private help if he thinks he needs it."

Review of the "physician discharge summary" dated 10/03/19 showed, "In therapy he could not ambulate, he was independent for eating function. He needed partial to moderate assistance for oral hygiene, totally dependent for upper body and lower body dressing. Independent for toilet hygiene. Totally dependent for toilet transfer. He needed partial moderate assistance for shower and bathing ...."

Review of "Education Narrative note" dated 10/01/19, showed Staff J, Physical Therapist documented, "Extensively educated pt. [patient] regarding recommendations for increased assist at home or transition to more supportive living environment. Elucidated [made clear] care needs and safety recommendations. Patient verbalized understanding."

Review of the "primary physical therapy discharge" note dated 10/04/19 showed, "Safety and weight bearing: Follow the safety instruction provided to you during your stay; Getting in and out of bed: you must have someone with you; On level surfaces indoors: you can walk or use wheelchair independently; On pavement outdoors: You can walk or use wheelchair independently: Curbs special instruction: No curbs, recommend ramp. Special instruction on stairs: No Stairs."

Review of the "discharge documentation" dated 10/04/19 by Staff H, LBSW, CM indicated that the Home Health Agency (HHA AA) refused to accept the referral for Patient 14's resumption of services, stating "they do not feel the patient is safe at home." The case manager referred the patient to Home Health Agency (HHA BB), and service start date was expected to be 10/06/19, the day following discharge.

On 10/05/19 at 12:35 PM, Staff D, RN provided discharge instructions to Patient 14 who signed the statement "I [patients name] received and understand the patient education materials/instruction and verbalize understanding." The document was signed by Patient14 but was not dated.

Review of the "home health agency home visit" document for Patient 14 on 10/06/19 showed, a nurse visit was conducted on 10/06/19 at 1:52 PM, "Patient stated I'm not doing well today; patient states he has not been able to get out of his electric wheelchair since he was dropped off from [name of hospital] yesterday. Patient states he is not able to change himself or provide the care he previously was able to do; states he has been sitting in a wet brief for 24 hours. Patient 14 states he currently has Agency CC, that come in once a week that he pays for out of pocket and does not think he [is] able to afford daily care."

The "home health agency nurse visit assessment findings and plan" dated 10/06/19 at 1:52 PM showed, "Objective findings from today: Patient sitting in wheelchair at dining table with a pillow in front of him where he slept last night. Patient is sitting in a urine filled brief TED hose (anti-embolic device) to BLE (bilateral lower extremities) with 3+ pitting edema. Patient has not taken his meds [medications]today or ate. Spoke with the [name of hospital] on call Admissions Director that patient will need to be sent back to the ER for placement. . . Plan: Transferred to [name]Hospital Emergency Room by secure transport for placement."

During an interview on 11/19/19 at 10:10 AM, Staff I, Speech Therapist (ST), stated that she had multiple encounters with Patient 14 from 09/23/19 to 10/05/19, providing memory training and to improve his speech. Staff I stated that there were concerns about Patient 14 being able to manage safely at home independently, but that [to go home] was the expressed desire of the patient. It was also explained that using the care tool "New Functional Nomenclature" released by the Centers for Medicare and Medicaid Services, not dated, suggested that patient [Patient14] was "somewhat independent."

During an interview on 11/19/19 at 10:25 AM, Staff H, LBSW, CM was unable to describe what services were being provided by the private help and whether it was finically feasible for the Patient 14 to sustain, when she encouraged him to increase those services upon his discharge. Staff H explained that the interdisciplinary team recommended that he [Patient14] consider assisted living or skilled nursing facility (SNF) but patient was unwilling to entertain those options and told Staff H that he [Patient14] was working with a lawyer to have his finances go to medical fund to cover his expenses.

During an interview on 11/19/19 at 10:40 AM, Staff J, primary Physical Therapist (PT) for Patient 14, stated that based on her involvement with Patient 14, "he could not safely function independently; needs straps for upper body while in sitting position." Staff J stated that when she discussed Patient 14's discharge plan to go home with him, he stated that he had "social and financial barriers to going to a SNF."

During an interview on 11/19/19 at 12:20 PM, the Staff K, Occupational Therapist (OT), stated that Patient 14 had an unrealistic assessment of his abilities, could transfer independently from bed to motorized wheelchair but was unable to transfer from toilet to motorized wheelchair.

During an interview on 11/19/19 at 1:03 PM, Staff C, RN, who cared for Patient 14 during the most recent admission at MARH [MidAmerica Rehabilitation Hospital] stated that the patient needed some assistance and would occasionally experience urinary and fecal incontinence.

During an interview on 12/05/19 at 8:45 AM, Staff H stated she is responsible to review therapy's assessment during a patients stay and communicate with therapy about the patient's progress." Staff H stated she had concerns about the plan for the patient to be discharged to home due to the assistance he needed. Staff H was concerned about how he would care for himself when the home health agency staff were not in the home. Staff H stated she discussed the discharge concerns with Staff L, Director of Case Management (DCM) and was told, "Plan on discharge Saturday 10/05/19, so I did." Staff H stated she did not initiate a revision to the discharge plan based on the patient's level of function because the patient wanted to go home.

During an interview on 12/05/19 at 9:50 AM, Staff K stated the initial discharge goal was for the patient to go home. Staff K stated that he did not attend the team discussion, but provides his evaluation and input to the lead therapist who attends the meeting. Staff K stated, " I did discuss the limitations with the occupational therapy lead. I told her the patient [Patient14] was not reasonable about his abilities and level of care and discharge plan of home." Staff K stated, "I told [name] Staff H Patient 14 was unsafe to go home by self." Staff K stated he did not recall Staff H's response. Staff K stated the plan established for discharge home was not a realistic goal. Staff K stated he did not change the discharge plan based on his evaluation.

During an interview on 12/05/19 at 10:30 AM, Staff J, stated she told Staff A, physiatrist, the patient was unsafe to complete slide board transfers and she recommended a mechanical lift transfer. Staff J stated she told Staff A that the patient [Patient14] should not go home alone. Staff A stated she knew the patient was at that "level of function" and she knew him from previous stays and would talk to him. Staff J stated she provided the case manager the same information. Staff J stated, "I made it clear on evaluation, two weeks would not allow him [Patient14] to achieve safe slide board transfers independently." Staff J stated, "I was part of the team discussion through my reports. Discharge with caregiver assistance was needed. The patient [Patient 14] needed 24/7 [24 hour] care or a higher level of care such as an assisted living or skilled nursing. This was my recommendation from the onset." Staff J did not know why the discharge plan was not developed based on the patients function level.

During interview on 12/05/19 at 11:45 AM, Staff L, DCM, stated if a patient does not meet the goals established on the initial discharge plan the facility discusses the barriers and communicates with the patient that the team feels they need to meet a specific level of function. We tell them "they are not there" and we recommend increase level of care. Staff L stated, the facility discussed with the patient [Patient14] that he did not meet the goals for discharge, but the discharge plan was not revised because Patient 14 wanted to go home. Staff L stated, "We continued to work with the initial discharge plan. We responded to the patient's wishes." Staff L stated Staff H told her the team was recommending increase level of care but the patient [Patient14] was refusing. Education was provided to Patient14 and he continued to say he wanted to go home. In that case we try to set up as safe of a discharge as possible. Staff L stated, "When as a team we feel patient is unsafe, we need to document our recommendations and have the patient sign." Staff L was unable to provide documentation that Patient 14 was provided the education and recommendations. Staff L stated Patient14 wanted to go home and the discharge plan developed by the hospital had to follow his patient right and wishes.

During an interview on 12/05/19 at 12:30 PM, Staff A stated she expressed concerns about the discharge plan because the patient [Patient14] was deteriorating with MS. Staff A stated, "I would have sent him to skilled unit but he said he had private duty caregiver." Staff A said the private duty caregiver was not included as a part of the documented discharge plan and she did not confirm the service was in place. Staff A stated, "I did bring up the concern he is living by self." Staff A stated she did not initiate a revision of the preliminary discharge plan because the patient was able to make decisions and his wishes were to go home.

Based on record review, interviews, and policy review, the facility failed to conduct a reassessment of the appropriateness of the discharge plan when the patient's capabilities and post discharge needs warranted to ensure a safe discharge and prevent readmission for one of 20 sampled patients (Patient 14). This deficient practice has the potential to place patients at risk for unsafe discharge and unmet continuum of care needs.

Findings Include:

Review of the facility's policy titled, "Discharge Planning" effective 03/29/19 showed, "The multidisciplinary team is also involved in assessing goals and potential barriers to discharge as part of their interdisciplinary assessment. And discharge planning process ...Throughout the patient's stay, the Case Manager works with the patient/caregiver to continue to develop a safe discharge plan based on the patient's physical, medical and cognitive behavioral needs as assessed by the team. . .The physician, case manager, team and patient/ caregiver will refine or modify the preliminary plan as needed in accordance to patient's response to the rehabilitation program."

Review of Patient14's medical record showed an admission date of 09/23/19 with diagnosis of multiple sclerosis (MS) and the use of a baclofen pump (a medical device used to deliver medications directly into the space between the spinal cord and the protective sheath surrounding the spinal cord). The medical record revealed a home health agency referral was made with a start of care date of 10/06/19. The prescription for home health services included a request for nursing, physical therapy, medical social worker, and occupational therapy.

Review of the "initial discharge assessment" dated 09/24/19, showed Staff H, Case Manager, Licensed Bachelor of Social Work (LBSW) documented Patient 14 was admitted on 09/23/19 with a diagnosis of MS and a baclofen pump, lives alone, had housekeeping services once a week, had home health services, and noted the patient intended to return home and resume those services upon discharge.

Review of "physician discharge summary" dated 10/03/19 showed, "In therapy he could not ambulate, he was independent for eating function. He needed partial to moderate assistance for oral hygiene, totally dependent for upper body and lower body dressing. Independent for toilet hygiene. Totally dependent for toilet transfer. He needed partial moderate assistance for shower and bathing ...."

Review of "Education Narrative note" dated 10/01/19, showed Staff J, Physical Therapist documented, "Extensively educated pt. [patient] regarding recommendations for increased assist at home or transition to more supportive living environment. Elucidated [made clear] care needs and safety recommendations. Patient verbalized understanding."

Review of the "primary physical therapy discharge note" dated 10/04/19 showed, "Safety and weight bearing: Follow the safety instruction provided to you during your stay; Getting in and out of bed: you must have someone with you; On level surfaces indoors: you can walk or use wheelchair independently; On pavement outdoors: You can walk or use wheelchair independently: Curbs special instruction: No curbs, recommend ramp. Special instruction on stairs: No Stairs."

Review of "discharge documentation" dated 10/04/19, showed Staff H, LBSW, CM documented, the home health agency that was providing services to Patient14 refused to accept the referral to resume services stating, "they do not feel the patient is safe at home." The case manager referred the patient to a sister home health agency (HHA BB) with the start of care date of 10/06/19, the day following discharge.

The "home health agency nurse visit assessment" findings and plan" document dated 10/06/19 at 1:52 PM showed, "Objective findings from today: Patient sitting in wheelchair at dining table with a pillow in front of him where he slept last night. Patient is sitting in a urine filled brief TED hose (anti-embolic device) to BLE (bilateral lower extremities) with 3+ pitting edema. Patient has not taken his meds today or ate. Spoke with the [name of hospital] on call Admissions Director that patient will need to be sent back to the ER for placement because he did not have a change in condition and was just. . . Plan: Transferred to [name]Hospital Emergency Room by secure transport for placement."

During an interview on 11/19/19 at 10:10 AM, Staff I, Speech Therapist (ST), stated that she had multiple encounters with Patient14 from 09/23/19 to 10/05/19, providing memory training and to improve his speech. Staff I stated that there were concerns about Patient 14 being able to manage safely at home independently.

During an interview on 11/19/19 at 10:40 AM, Staff J, primary Physical Therapist (PT) for Patient 14, stated that based on her involvement with Patient 14, "he could not safely function independently; needs straps for upper body while in sitting position." PT stated that when she discussed Patient 14's discharge plan to go home with him, he stated that he had "social and financial barriers to going to a SNF [Skilled Nursing Facility]."

During an interview on 11/19/19 at 12:20 PM, the Staff K, Occupational Therapist (OT), stated that Patient 14 had an unrealistic assessment of his abilities, could transfer independently from bed to motorized wheelchair but was unable to transfer from toilet to motorized wheelchair.

During an interview on 11/19/19 at 1:03 PM, Staff C, RN, who cared for Patient 14 during the most recent admission at [name of hospital] stated that the patient needed some assistance and would occasionally experience urinary and fecal incontinence.

During an interview on 12/05/19 at 8:45 AM, Staff H stated she is responsible to review therapy's assessment during a patient's stay and communicate with therapy about the patient's progress. Staff H stated, "My expectation was patient [Patient14] would care for himself at home until the home health agency arrived the next day." Staff H stated she had concerns about Patient 14's discharge to home due to the assistance he needed. Staff H was concerned about how he would care for himself when the home health agency staff were not in the home. Staff H stated she discussed the discharge concerns with Staff L, Director of Case Management (DCM) and was told, "Plan on discharge Saturday 10/05/19, so I did." Staff H stated she was not aware of the facility policy stating the team will refine or modify the preliminary discharge plan if the patient does not reach the rehabilitation goals.

During an interview on 12/05/19 at 10:30 AM with Staff J, stated she told Staff A, Physiatrist, the patient was unsafe to complete slide board transfers and she recommended a mechanical lift transfer. Staff J stated she told Staff A that the patient [Patient14] should not go home alone. Staff A stated she knew the patient was at that "level of function" and she knew him from previous stays and would talk to him. Staff J stated she provided the case manager the same information.

During interview on 12/05/19 at 11:45 AM, Staff L, DCM, stated if a patient does not meet the goals established on the initial discharge plan the facility discusses the barriers and communicates with the patient that the team feels they need to meet a specific level of function. We tell them "they are not there" and we recommend increase level of care. Staff L stated, the facility discussed with the patient [Patient14] that he did not meet the goals for discharge, but the discharge plan was not revised because Patient 14 wanted to go home. Staff L stated, "We continued to work with the initial discharge plan. We responded to the patient's wishes." Staff L stated Staff H told her the team was recommending increase level of care but the patient [Patient14] was refusing. Education was provided to Patient 14 and he continued to say he wanted to go home. In that case we try to set up as safe of a discharge as possible. Staff L stated, "When as a team we feel patient is unsafe, we need to document our recommendations and have the patient sign." Staff L was unable to provide documentation that Patient 14 was provided the education and recommendations. Staff L further stated refining the preliminary discharge plan did not pertain to Patient14 because he wanted to go home and the hospital had to follow his patient right and wishes.

During an interview on 12/05/19 at 12:30 PM, Staff A stated she expressed concerns about the discharge plan because the patient [Patient 14] was deteriorating with MS. Staff A stated, "I would have sent him to a skilled unit, but he said he had private duty caregiver." Staff A stated that the private duty caregiver was not include as a part of the documented discharge plan and she did not confirm the service was in place. Staff A stated, "I did bring up the concern he is living by self." Staff A stated she did not initiate a revision of the preliminary discharge plan because the patient was able to make decisions and his wishes were to go home.

Review of the medical record did not show documentation that barriers for Patient 14 to go home were used to revise the discharge plan. Documentation did not identify, per the facility policy, the discharge plan was revised based on Patient 14's level of function and care needs to ensure a safe discharge.