HospitalInspections.org

Based on review of medical records, policy and procedures, contracted services Service Agreement, Quality Improvement Plan, Quality Committee meeting minutes, Governing Body meeting minutes and staff interviews, it was determined that the facility failed to maintain an organized and effective Governing Body with the overall responsibility of the quality of care provided in the facility.

Findings included:

Cross reference A-0015 as it relates to the facility's failure to ensure that patients' rights were protected and respected when three of (P#1, P#4, P#5) of five (P#1, P#2, P#3, P#4, P#5) sampled patients were not discharged in a safe and effective manner.

Cross reference A-0083 as it relates to the facility's failure to ensure that contracted services were furnished in a manner that ensured the facility was compliant with Conditions of Participation when the Behavioral Health Unit (BHU), managed by a contracted service, failed to report performance measures and data to the facility-wide Quality Improvement Committee.

Cross reference A-0799 as it relates to the facility's failure to ensure that an effective and efficient discharge planning process was implemented when three of (P#1, P#4, P#5) of five (P#1, P#2, P#3, P#4, P#5) sampled patients were not discharged in a safe and effective manner.

Based on review facility policies and procedures, contractor service agreement, Governing Board Meeting Minutes, Quality Council Meeting Minutes and interviews, it was determined that the Governing Body failed to ensure that contracted services were furnished in a manner that permitted the facility to comply with all applicable conditions of participation and standards for the contracted services. Specifically, the governing body failed to take actions through the hospital's QAPI program to: assess the services furnished either directly or indirectly by the behavioral health management contracted service, identify quality and performance areas of concern, implement appropriate corrective or improvement activities, and ensure the monitoring and sustainability of those corrective or improvement activities.

Findings included:

Review of the " Patient Grievance/Complaint Process " policy, effective 8/28/07, last reviewed 9/21 revealed the Governing Board had approved the grievance policy and delegated the responsibility of review to the Quality Management Council. Patients would be informed that they had a right to express any concerns, complaints, or grievances regarding any aspect of patient care while at the facility. Patients would be encouraged to discuss concerns with the charge nurse, supervisor, or Patient Liaison. If the issue was resolved in the department, it would not be considered a grievance. If a verbal complaint could not be resolved by the appropriate staff person present, the staff member taking the complaint would notify the Patient Liaison to discuss the issue with the patient or family. If the Patient Liaison was not able to resolve the problem, the complaint would become a grievance. A written complaint was always considered a grievance. Telephone complaints, allegations of abuse/neglect, or non-compliance with CMS requirements would be considered grievances. The Patient Liaison would discuss the complaint with the appropriate department to reach a resolution. If the problem was resolved, the concern would be logged into the Complaint Logbook. If a complaint was not resolved, the complaint would be sent to the delegated committee of which the facility administrator was a member. If the facility administrator could not resolve the situation, the complaint would be directed to the governing board representative. The facility would strive to provide the patient with a written response in 7-10 days and a resolution letter within 30 days. The policy further revealed that all verbal or written expressions of dissatisfaction would be addressed by the department involved. The Patient Liaison would assist in investigating and resolving the situation as needed and would send a written response to the patient within 7-10 days. The hospital would provide written notice of the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

A review of Page 11 of the BHU 'Patient Handbook' revealed that patients were encouraged to " Grievance Procedure " (no date) revealed that patients were encouraged to discuss any concerns, problems, or complaints that might arise while a patient was in the facility. The patient would request to see the charge nurse or supervisor to report a concern or complaint. If a satisfactory solution was reached, the concern would be documented as having been resolved. If the complaint could not be resolved by the appropriate staff person present, the Patient Liaison would be notified. If the Patient Liaison could not resolve the problem, then the complaint would become a grievance. The Patient Liaison would discuss the complaint/concern with the appropriate department supervisor in attempt to reach a resolution. Continued review of Page 12 of the handbook revealed a copy of Patient Rights.

A review of a Services Agreement between the facility and the behavioral health management company signed 8/5/16 revealed the Behavioral Health unit (BHU) consisted of 12 geropsychiatric inpatient and eight adolescent/child psychiatric inpatient beds. The agreement provided for administrative services and did not include contracting with physicians. Section III, Covenants of Hospital, subsection (m) revealed that the hospital was to maintain a hospital-wide quality improvement system that met accreditation and CMS Conditions of Participation and provide Utilization Review process that met CMS Conditions of Participation. Section IV, Covenants of Horizon, subsection (b) revealed that the contracted entity determined, implemented, and provided appropriate programs and services to carry out treatment plans, subject to hospital approval. Daily patient care including diagnosis, treatment plan development, changes to treatment plan and discharge planning was determined by the licensed physician on the hospital staff. Section V, Operation of the Program, subsection (c) revealed that the Program Director was responsible to the Hospital administration and functioned in a department head capacity. The Program Director complied with all reporting requirements to administration and was accountable to the administrator. Subsection (d) the medical staff committees of the hospital, such as quality improvement, utilization review and coordination of services was responsible for the medical services. Subsection (f), Horizon conducted activities in compliance with all rules, policies and regulations of the hospital, hospital medical staff and applicable government regulations, statutes, and ordinances. Subjection (j): all medical records were property of the hospital and maintained in accordance with policies.

Review of the Board of Directors meeting minutes from April 2021 to September 2021 revealed the meetings were held monthly. Minutes for Quality Management were presented for review for the months the quality council met. There was no discussion of complaints/grievances or discharge planning at the meetings.

Review of the " Quality Management System, " policy #QM.01, effective 9/1995, revised 7/20/17, reviewed 7/21/21 revealed the program allowed for a systematic, coordinated, and continuous approach to improving performance by focusing upon the mission and values of the facility. The organization-wide program had the responsibility for monitoring every aspect of patient care. The policy revealed the Governing Board had overall responsibility for governance of the organization, quality improvement activities, and medical staff services. The Board delegated to the Quality Management Council the oversight of Quality and Patient Safety. The Governing Board would receive reports of organization-wide quality management activities monthly and would use the information to ensure compliance with the intent of the program and to evaluate the achievement of the organization ' s quality goals.

Review of the Quality Management Council minutes from January 2021 to November 2021 revealed the Quality Management Council met in January, February, April, May, July, and November 2021. No meetings were held in March, June, August, and September 2021 due to a Covid surge and staffing issues. Discharge Planning was discussed in January, April, July, and October 2021, and was limited to readmissions and completion of discharge summaries within 30 days. Review of the minutes failed to reveal that incident reports, complaints, or grievances were discussed at the Quality Management Council meetings. Review of the Quality Management Council meeting minutes revealed that Behavioral Health reported to the council in February 2021 regarding the fall rate, patient smokers, patient satisfaction score, physician verbal orders, staff education, and group notes regarding treatment. Patient rights concerning restraint/seclusion data was presented. Review of the minutes from March-November 2021 failed to reveal quarterly reports from the Behavioral Health Unit to the Quality Management Council.

Review of the Medical Staff Bylaws revealed the medical staff would agree to conduct themselves as a Medical Staff in conformity with the Medical Staff Bylaws. The Administrator was appointed by the Governing Body as the chief executive officer to act on behalf of the Governing Body in the overall management of the facility. Functions delegated to the medical staff by the Board included effectively monitoring and evaluating the quality and efficiency of patient care.

An interview with Director of Nurses (DON) DD took place in the conference room on 11/22/21 at 12:00 p.m. DON DD explained that the facility used a contracted service for the management of behavioral health services. She further explained that the management, policies and procedures and day to day management was the responsibility of the contracted entity. The bedside staff were employed by the facility. The behavioral health unit currently had an interim Director and interim Manager that were employed by the contracting entity. DON DD further explained that the former Program Director (PD EE) was still employed by the contracting company but had assumed a new role. DON DD confirmed that the BHU maintained a separate complaint and grievance log and consulted the facility wide liaison if needed. She stated that the complaint/grievance procedures for BHU were completed by the BHU management.

During an interview with the Patient Liaison (PL) HH on 11/23/21 at 10:52 a.m. in the Conference Room, PL HH said she had been the Patient Liaison for six years at the facility, and the Behavioral Health Unit (BHU) had never brought a complaint/grievance to the attention of PL HH; the complaints/grievances on the BHU were handled by the program manager of the BHU. PL HH said she would make rounds on the Medical/Surgical units, and the Emergency Department, Outpatient, and Obstetrics units would notify PL HH of any issues. PL HH said she would tally up grievances every quarter and provide a report to the Quality Improvement Coordinator and Credentialing director. The grievance report would also be discussed at the Quality Improvement Council meetings quarterly. Administration would be notified immediately of grievances, and administration would stay current during the grievance process. PL HH further said that if a repeated issue was identified, PL HH would try to identify and resolve the root cause. PL HH said there had been three grievances in 2021: two in February and one in May. There were no grievances concerning P#1. The quarterly report from the Patient Liaison did not include grievances from the BHU. PL HH said the program manager for the BHU should have an open line with the administrator to report complaints or grievances. The BHU would also give quarterly reports at the Quality Council meetings.

An interview took place with the Quality Improvement Coordinator (QI) II on 11/23/21 at 12:15 p.m. QI II said the hospital administrator was part of the Governing Body and attended the quality council meetings monthly. The Quality Council minutes were presented at the governing body meetings monthly. QI II said the Behavioral Health Unit (BHU) would give quarterly reports regarding falls, restraints/seclusion, smoking cessation, and safety, but the reports did not include complaints and grievances that involved the BHU.

On 11/23/21 at 12:45 p.m. during an interview in QI II's office, she confirmed that the BHU did not give a quarterly report to the quality council in the 2nd, 3rd, and 4th quarter of 2021 due to changes in the department leadership and missed Quality Council meetings due to COVID.

Based on a review of medical records, policies and procedures, and staff interviews, it was determined that the facility failed to promote and protect the rights of three (P#1, P#4, P#5) of five (P#1, P#2, P#3, P#4, P#5) behavioral health sampled patients by ensuring they were transported to the correct address and received appropriate follow-up care when:
1. P#1 was transported, despite the receiving facility's expressed refusal to admit P#1, and left outside of the facility at approximately 3:00 a.m. when the environmental temperature was reported to be below 35 degrees.
2. P#4 was transported and left to wait on the porch of a family member without confirmation that the family member agreed to and expected the patient.
3. P#5 was transported to the incorrect address and, on arrival P#5 provided the driver with the correct address.

Findings included:

Cross reference A-0131 as it related to the facility's failure to ensure that three (P#1, P#4, P#5) of five (P#1, P#2, P#3, P#4, P#5) sampled behavioral health patients and/or representatives were afforded informed consent about their respective discharge disposition in the discharge planning process.

Cross reference A-0816 as it related to the facility's failure to ensure that patients were provided choices in post-acute care and failure to ensure that patients rights to choose were protected when one (P#1) of five (P#1, P#2, P#3, P#4, P#5) sampled patients was discharged to a skilled nursing facility despite vocalizing that he did not wish to return to that particular skilled nursing facility and the record failed to reveal P#1 was provided alternatives in post-acute care.

Based on review of policies, meeting minutes, and interviews, the governing body failed take responsibility for a grievance process that included a mechanism for timely referral of behavioral care patient concerns regarding quality of care to the facility's Quality Improvement Council.
Review of the "Quality Management System," policy #QM.01, effective 9/1995, revealed the program allowed for a systematic, coordinated, and continuous approach to improving performance by focusing upon the mission and values of the facility. The organization-wide program had the responsibility for monitoring every aspect of patient care. The policy revealed the Governing Board had overall responsibility for governance of the organization, quality improvement activities, and medical staff services. The Board delegated to the Quality Management Council the oversight of Quality and Patient Safety. The Governing Board would receive reports of organization-wide quality management activities monthly and would use the information to ensure compliance with the intent of the program and to evaluate the achievement of the organization's quality goals.
Review of the Medical Staff Bylaws revealed an Administrator would be appointed by the Governing Body as the chief executive officer to act on behalf of the Governing Body in the overall management of the facility. Functions delegated to the medical staff by the Board included effectively monitoring and evaluating the quality and efficiency of patient care.
Review of the "Patient Grievance/Complaint Process" policy, effective 8/28/07, revealed the Governing Board had approved the grievance policy and delegated the responsibility of review to the Quality Management Council. Patients would be informed that they had a right to express any concerns, complaints, or grievances regarding any aspect of patient care while at the facility. The facility would strive to provide the patient with a written response in 7-10 days and a resolution letter within 30 days. The policy further revealed that all verbal or written expressions of dissatisfaction would be addressed by the department involved. The Patient Liaison would assist in investigating and resolving the situation as needed and would send a written response to the patient within 7-10 days. The hospital would provide written notice of the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.
Review of the Board of Directors meeting minutes from April 2021 to September 2021 revealed the meetings were held monthly. Minutes for Quality Management were presented for the board to review for the months the quality council met. The minutes failed to reveal discussion of complaints/grievances, incidents, or discharge planning concerns.
Review of the Quality Management Council minutes from January 2021 to November 2021 revealed the Quality Management Council met in January, February, April, May, July, and November 2021. No meetings were held in March, June, August, and September 2021 due to a Covid surge and staffing issues. Review of the minutes failed to reveal that incident reports, complaints, or grievances were discussed at the Quality Management Council meetings. Review of the Quality Management Council meeting minutes revealed that Behavioral Health reported to the council in February 2021 regarding the fall rate, patient smokers, patient satisfaction score, physician verbal orders, staff education, and group notes regarding treatment. Review of the minutes from March-November 2021 failed to reveal quarterly reports from the Behavioral Health Unit to the Quality Management Council.
An interview took place with the Quality Improvement Coordinator (QIC) (II) on 11/23/21 at 12:15 p.m. QIC II said the hospital administrator was part of the governing body and would attend the quality council meetings monthly. The Quality Council minutes would be presented at the governing body meetings monthly. QIC II said the Behavioral Health Unit (BHU) would give quarterly reports regarding falls, restraints/seclusion, smoking cessation, and safety, but the reports did not include complaints and grievances that involved the BHU.
During an interview with the Patient Liaison (PL) HH on 11/23/21 at 10:52 a.m. in the Conference Room, PL HH said she had been the Patient Liaison for six years at the facility, and the Behavioral Health Unit (BHU) had never brought a complaint/grievance to the attention of PL HH; the complaints/grievances on the BHU were handled by the program manager of the BHU. PL HH said she would make rounds on the Medical/Surgical units, and the Emergency Department, Outpatient, and Obstetrics units would notify PL HH of any issues. PL HH said she would tally up grievances every quarter and provide a report to the Quality Improvement Coordinator and Credentialing director. The grievance report would also be discussed at the Quality Improvement Council meetings quarterly. Administration would be notified immediately of grievances, and administration would stay current during the grievance process. PL HH further said that if a repeated issue was identified, PL HH would try to identify and resolve the root cause. PL HH said there had been three grievances in 2021: two in February and one in May. There were no grievances concerning P#1. The quarterly report from the Patient Liaison did not include grievances from the BHU. PL HH said the program manager for the BHU should have an open line with the administrator to report complaints or grievances. The BHU would also give quarterly reports at the Quality Council meetings.
On 11/23/21 at 12:45 p.m. in the Quality Improvement Coordinator's office, the Quality Improvement Coordinator confirmed that Behavioral Health did not give a quarterly report to the quality council in the 2nd, 3rd, and 4th quarter of 2021 due to changes in the department leadership and missed Quality Council meetings due to COVID.
Review of the Administrative Program Director job description revealed the functions of the position included but were not limited to developing and submitting an annual Quality Improvement Plan, implementing quality improvement goals and objectives on the Program in a timely fashion, providing feedback to the facility on an ongoing basis regarding concerns, improvements, changes, etc. Review of the personnel file for the interim BHU Program Director revealed the interim Program Director was a contracted position.

Based on a review of medical records, policy and procedures, and staff interviews, it was determined that the facility failed to promote and protect the rights of patients and/or representatives of informed decision making in the discharge process for three (P#1, P#4, P#5) of five sampled patients (P#1, P#2, P#3, P#4, P#5) when:

P#1 was discharged from Facility#1 to a receiving Facility#2 on 11/12/21 although Facility#2 had explicitly communicated to Facility#1 that they could not accommodate P#1. P#1 expressed his desire to be discharged to an alternative nursing facility. P#1 was transported to the Facility#2 via transportation service and dropped off at 3:00 a.m. when the environmental temperature was reported to be below 35 degrees.

On 2/23/21 P#4 was taken from Facility#1 via a transportation service to a family member's residence (FM #2) and left outside at the residence. Prior to discharge, Facility#1 failed to receive confirmation from FM#2 that P#4 would be discharged to that residence. FM#2 found P#4 on her front porch and notified the facility that she had not agreed to have P#4 stay with her.

On 6/2/21 the facilty failed to confirm the discharge address of P#5 who was taken by transportation service to the wrong address.

Findings included:

A review of Patient (P) #1 ' s medical record revealed that Facility#1's behavioral health unit (BHU) completed a pre-admission screening on 10/30/21 at 9:15 p.m. from a referral at Facility#3 emergency department. A review of the Pre-Admission Screening revealed that P#1 resided at Facility#2 and had been sent to Facility#3's emergency department for increased psychosis and assaultive behavior toward staff and other residents. The Emergency Department medically cleared P#1 for transfer on 11/1/21 at 5:52 p.m. P#1 was accepted for admission to Facility#1 and transported on 11/2/21. A review of the Psychiatric Evaluation dated 11/2/21 at 7:41 p.m. revealed that P#1 resided at a skilled nursing facility (Facility #2) and had a history of alcoholic dementia (dementia as a result of chronic alcohol use), stroke, and high blood pressure. P#1 had become more aggressive with staff and residents at Facility #2 and had auditory and visual hallucinations (seeing and hearing things/people that are not there). P#1 was agitated, labile and yelling on admit to Facility #1.

A review of the Interdisciplinary Treatment Plan dated 11/3/21 at 2:00 p.m. revealed that P#1's goals for treatment was to 'go somewhere else'. A review of a Psychosocial Assessment on 11/5/21 by Discharge Planner (DCP) AA revealed that P#1 would return to Facility#2. Continued review of the Psychosocial Assessment revealed that P#1 expressed his wish to 'go somewhere else' on discharge. A review of the Interdisciplinary Treatment Plan revealed that the discharge plan was for P#1 to return to a nursing home with outpatient behavioral health therapy and medication. Treatment team signatures included DCP AA, P#1, and RN CC on 11/10/21 at 2:00 p.m. A progress note written on 11/11/21 by physician (MD) BB revealed that P#1 appeared to be approaching psychiatric baseline and discharge was anticipated on Friday (11/12/21). Continued review of the medical record revealed that faxed copies of P#1 ' s medical notes and discharge medications were sent from Facility#1 to Facility#2 on 11/12/21 at 7:08 a.m.

A verbal discharge order was received on 11/12/21 at 9:00 a.m. to discharge patient home with Medicaid transportation. Continued review of the record revealed that P#1 signed a copy of discharge instructions on 11/12/21, no time noted. A review of Patient Progress Notes written by DCP AA on 11/12/21 at 4:00 p.m. revealed that Facility#2 had been notified of P#1 ' s discharge on 11/10/21. Facility#2 has now informed Facility#1 that P#1 ' s bed hold was up, and he cannot return to Facility#2. P#1 denied knowledge of Facility#2 ' s bed hold policy. A family member of P#1 was contacted and stated that Facility#2 had contacted him (family) earlier on 11/12/21 and requested that the bed hold fee be paid. Continued review of the note revealed MD BB " made aware of facility ' s attempt to not accept pt back " . MD BB instructed staff to continue transportation to " get the pt back to " Facility#2. " Medicaid transportation is expected to arrive around 1630 " . A review of Patient Progress Notes written 11/12/21 at 5:45 p.m. by Registered Nurse (RN) CC revealed that P#1 was cleared for discharge, denied any suicidal or homicidal thoughts and left Facility#1 at 5:45 p.m. with a Medicaid transportation company driver. Discharge medications had been called into Facility#2 at 1:00 p.m.

A Patient Progress Note written by DCP AA on 11/12/21 at 6:38 p.m. revealed that P#1 had completed the safety plan prior to discharge and was discharged to Facility#2 with Medicaid transportation. Continuing care information had been faxed to Facility#2 and P#1 voiced understanding of discharge instructions. Continued review of the medical record revealed that faxed copies of P#1 ' s discharge continuing care plan were sent from Facility#1 to Facility#2 on 11/12/21 at 7:06 p.m. A Patient Progress note written by DCP AA on 11/15/21 at 11:20 a.m. revealed that the Ombudsman had been made aware that Facility#2 reported that they could not accept P#1. Ombudsman informed DCP AA that Facility#2 had a history of trying to illegally dump residents. Ombudsman was aware that Facility#2 had beds available as she (ombudsman) had recently been to Facility#2. Ombudsman made aware that a staff member at Facility#2 had spoken with DCP AA and per Ombudsman, the staff member had a history of unprofessional behavior.

A review of email correspondence from DCP AA to a staff member at Facility#2 on 11/10/21 at 11:37 a.m. revealed that clinical notes on P#1 were attached and discharge was anticipated for 11/12/21.

A review of email correspondence from Facility#2 to DCP AA at 11/11/21 at 3:49 p.m. revealed that P#1 exhausted his bed hold days with Facility#2 on 11/9/21 and based on review of psychological notes, Facility#2 cannot provide for his needs at this time.

A review of email correspondence from DCP AA to Facility#2 on 11/11/21 at 4:17 p.m. revealed that DCP AA explained that there were no psychological concerns noted in P#1 ' s progress notes and P#1 had demonstrated stability for days. " We will still set up transportation to get him to " Facility#2 " on tomorrow " . " Once he is there, I am sure that you all can work out a plan from there " .

A review of email correspondence from Facility#2 to DCP AA on 11/12/21 at 8:47 a.m. revealed that P#1 was ' no longer on (our) census ' . ' Per Administrator we cannot meet (P#1) needs. " His family has been contacted and are picking up his belongings today " . An email response from DCP AA to Facility #2 on 11/12/21 at 9:15 a.m. revealed that DCP AA had been unable to contact P#1 ' s family. DCP AA informed Facility#2 that she would contact an ombudsman to assist P#1 and questioned if P#1 had been made aware of the bed hold policy.

Facility #2 replied via email on 11/12/21 at 10:49 a.m. that P#1 had been notified of the bed hold policy. The family member had been contacted and was unable to provide financial support to hold P#1 ' s bed. Facility#2 was unable to provide one on one care and therefore unable to meet P#1 ' s psychological needs.

DCP AA replied to Facility#2 on 11/12/21 at 11:21 a.m. and explained that Facility#1 had a private transport set up for P#1 to return to Facility#2. " Your staff can get {P#1} back to your local ED if you feel as if you cannot accept him back. Your facility has failed to follow proper protocol for dismissing a resident " .

Facility#2 replied to DCP AA on 11/12/21 at 11:42 a.m. " We are unable to accept him back. He will be sent back. The family has been made aware. We are not a psych facility. He is a danger to other residents and our employees. You are more than welcome to contact whomever. "

A review of the medical record for P#4 revealed that he was admitted to the facility on 2/16/21 at 5:55 p.m. with a diagnosis of schizophrenia. P#4's home address was listed on the Record of Admission form. In addition, P#4 had an additional emergency contact address listed for Family Member (FM) #2. A review of a Psychosocial Assessment dated 2/18/21 at 8:00 p.m. revealed that P#4 had been residing with FM#2 for the past month. FM#1 was the primary caregiver but could not care for P#4 due to an illness. A review of the Behavioral Unit Discharge Instruction dated 2/23/21 revealed that P#4's discharge address matched P#4's address indicated on the Record of Admission form. A review of a Patient Progress Note revealed that FM#1 was made aware of P#4's discharge from the facility. A facility therapist could not reach FM#2 of P#4's departure from the facility. P#4 was discharged on 2/23/21 to FM#2 residence via transport service.

A review of the medical record revealed that P#5 had two Records of Admissions. Both Records of Admissions revealed an admission date of 5/19/21 with a diagnosis of Major Depression with Suicidal Ideation and included the same home address and date of birth. A continued review revealed that the two Record of Admission documents included different hospital numbers and admission times. The discharge address on the Behavioral Unit Discharge Instructions dated 6/2/21 was different from the address on the Record of Admissions form. P#5 was discharged on 6/2/21 via transport service to the incorrect address on the discharge instructions.

Review of the " Discharge -Transfer of Patients to Another Facility " policy #10.010, Effective 5/1/2017, last reviewed 6/1/21 revealed that patients must have been discharged from the behavioral health units, and all the customary practices and protocols for patient discharge would be performed. The discharge process provided for continuing care based upon the patient ' s assessed needs at the time of discharge. Acceptance of the patient by the physician at the receiving facility must precede the actual discharge of the patient. Clinical information would be exchanged with proper patient consent, and the transfer would be coordinated among the health care programs.

Review of the " Discharge Upon Completion of Treatment " policy #10.002, effective 5/1/2017, last reviewed 6/10/20 revealed that patients would be discharged from the program when deemed clinically suitable by the interdisciplinary team and the attending physician. The attending physician would sign and date the discharge order, complete the Discharge Form on Transfers from an appropriate facility, complete the psychiatric discharge note, and dictate the discharge summary. If a patient was transferred to another facility, the nurse would fill out the Patient Information and Transfer Form and give the forms to the accompanying family member or transportation driver. The social worker would review the continuing care/discharge plan and safety plan with the patient and family, write a discharge progress note addressing each problem, and forward the discharge plan to the outpatient provider or referral source.

Review of the " Discharge Planning and Continuing Care " policy #10.001, effective 5/1/2017, last reviewed 6/1/20 revealed that discharge planning would begin upon admission and would be the responsibility of the interdisciplinary team. The admission nursing assessment would note any barriers to discharge planning. Discharge Planning would be documented on the Master Treatment Plan. When specific therapeutic placement was ordered by the physician, the social worker would arrange placement involving the family as appropriate. The attending physician would write an order indicating the discharge date, medication, and condition of patient on discharge. The social worker would be responsible for the development and coordination of the discharge plan and safety plan. The social worker would coordinate with family and community resources to provide optimum implementation of the discharge plan. The discharge continuing care plan would be reviewed and education would be provided as needed with the patient and family. The policy further revealed that patients not returning home and being referred to other treatment facilities would be provided with ongoing treatment by that facility. The patient and family would participate in the decision-making process. Patient and family involvement would be coordinated by the social worker.

An interview with Discharge Planner (DCP) AA took place on 11/22/21 at 2:00 p.m. in the conference room. DCP AA recalled that she contacted Facility #2 and was informed that they would be accepting P#1 back at discharge. On 11/10/21, she emailed Facility #2 with P#1's medical notes and anticipated discharge date of 11/12/21. DCP AA recalled that she received communication from Facility #2 that they could not take P#1 back. DCP AA stated that she notified MD BB and was told to proceed with the discharge. DCP AA stated that she did not phone the facility prior to P#1 leaving but that the facility had received a fax containing his discharge information. DCP AA explained that she typically called Medicaid transportation companies in the morning between 8:00 a.m. and 8:30 a.m. and that the arrival time to pick patients up varied. She stated that the transportation company did not arrive until after 5:00 p.m. to pick up P#1 and did not drop him off at the nursing facility until after 2:00 a.m. She stated that it had been explained to her that the Medicaid transportation company does 'rideshare,' meaning that they pick up multiple patients during a trip, and the estimated time to the destination could not be predicted. DCP AA stated that Facility #2 initially agreed to take P#1 back but then provided several reasons they couldn't take him back, including lack of bed hold, staffing shortage, and being psychiatrically unstable. DCP AA recalled that the morning after P#1 was discharged, a nurse from Facility #1 phoned her at home, and she, in turn, spoke with a staff member at Facility #2. She stated that Facility #2 demanded that Facility #1 send transport to come back and 'get' P#1, and she explained that she could not arrange that. DCP AA stated that she attempted to get in touch with facilities and/or patients' families at the time of discharge to ensure that someone would be prepared when the patient arrived. She confirmed that an incident in February 2021 occurred when a private transporter dropped a patient off at a family member's residence, and there was no one at the home to meet the patient. She stated that she spoke with the transporter and explained that she (transporter) must ensure that patients can get into the house. She recalled that with this incident, she had phoned the home and left a message.

An interview with psychiatrist (MD) BB took place on 11/21/21 at 3:45 p.m. in the conference room. MD BB stated that he recalled P#1, and he had improved and had been ready for discharge back to the nursing facility. He explained that the facility did discharge planning Monday, Wednesday, and Friday. Information had been sent to Facility #2 about a pending discharge on a Monday, and questions were answered on Wednesday. P#1 was discharged and transported using Medicaid transportation. MD BB explained that he was not aware of Facility #2's refusal to take P#1 back until after transport had left with the patient. He further explained that the facility did not discharge patients unless they had a place to go.

An interview with Registered Nurse (RN) CC took place on 11/23/21 at 9:30 a.m. in the conference room. RN CC had been employed at Facility#1 for two years on the behavioral health unit. RN CC explained that nurses were generally not involved in discharge planning, DCP AA was primarily responsible. RN CC recalled that she was working on the day that P#1 was discharged. She recalled that she faxed a list of medications to Facility#2 but did not have any other communication with the facility. She explained that she did not phone Facility#2 to alert them that P#1 was en route because she ' forgot ' . RN CC stated that she had been under the impression that Facility#2 had agreed to take P#1 back. She recalled that P#1 voiced concerns about returning to Facility#2 because of the incidents that had taken place prior to his admission to Facility#1. RN CC stated that she did not call or speak with MD BB about P#1 ' s discharge. RN CC stated that the social worker generally verified the residence that a patient was discharged to prior to discharge. RN CC stated that P#1 did not exhibit any aggressive behaviors while admitted to Facility #1.

An interview with Former Program Director of the Behavioral Health Unit (PD) EE took place in the conference room on 11/23/21 at 9:44 a.m. in the conference room. Interim Director (ID) of BHU FF and Interim Manager (IM) of BHU were present for interview. PD EE explained that she was the Program Director of Facility#1's behavioral health unit for four years prior to her departure in June 2021. PD EE was still employed by the behavioral health management contractor. PD EE explained that she had developed several checklists and forms to assist with the discharge process. These forms had been in place for several years. She stated that these were operating procedures as the policy was broad. IM GG explained that she inquired about P#1's discharge status a couple of days prior to his actual discharge and was informed that he (P#1) was waiting on transport. She recalled that she received a call from a law enforcement detective a day or so after P#1's discharge inquiring about the conditions of P#1's discharge. ID FF stated that they (leadership) had started working on re-education for the staff on the discharge process. PD EE stated that MD BB would be contacted, and the discharge process would be discussed with him as well. PD EE stated that she had been aware of a couple of other incidents that had occurred previously around discharge transportation.

Based on review of records, policies and procedures and staff interview, it was determined that the facility failed to have an effective discharge planning process resulting in the facility's failure to ensure that three (P#1, P#4, P#5) of five (P#1, P#2, P#3, P#4, P#5) behavioral health sampled patients were transported to the correct address and received appropriate follow up care when:
1. P#1 was transported, despite the receiving facility's expressed refusal to admit P#1, and left outside of the facility at approximatley 3:00 a.m. with the environmental temperature below 35 degrees
2. P#4 was transported and left to wait on the porch of a family member without confirmation that the family member agreed to and expected the patient.
3. P#5 was transported to the incorrect address and on arrival provided the driver with the correct address.

Findings include:

Cross reference A-0802 as it related to the facility's failure to re-assess and adjust as needed the patients discharge plan.
Cross reference A-0816 as it related to the facility's failure to ensure that patients were provided choices in post-acute care and failure to ensure that patients rights to choose were protected.

Based on review of medical records, review of policy and procedures, staff interviews, and staff correspondence it was determined that the facility failed to re-assess the discharge plan and make appropriate changes for three (P#1, P#4, P#5) of five (P#1, P#2, P#3, P#4, P#5) sampled patients.

Findings included:

A review of Patient (P) #1's medical record revealed that Facility#1's behavioral health unit completed a pre-admission screening on 10/30/21 at 9:15 p.m. from a referral at Facility #3. A review of the Pre-Admission Screening revealed that P#1 resided at a skilled nursing facility (Facility#2) and had been sent to Facility#3's emergency department for increased psychosis and assaultive behavior toward staff and other residents. Facility #3 medically cleared P#1 for transfer on 11/1/21 at 5:52 p.m. P#1 was accepted for admission to Facility #1 and transported on 11/2/21. A review of the Psychiatric Evaluation dated 11/2/21 at 7:41 p.m. revealed that P#1 resided at a skilled nursing facility (Facility #2) and had a history of alcoholic dementia, stroke, and high blood pressure. P#1 had become more aggressive with staff and residents at Facility #2 and had auditory and visual hallucinations. P#1 was agitated, labile and yelling on admit to Facility #1.

A review of the Interdisciplinary Treatment Plan dated 11/3/21 at 2:00 p.m. revealed that P#1's goals for treatment was to 'go somewhere else'. A review of a Psychosocial Assessment on 11/5/21 by DCP AA revealed that P#1 would return to Facility#2. Continued review of the Psychosocial Assessment revealed that P#1 expressed his wish to 'go somewhere else' on discharge. A review of the Interdisciplinary Treatment Plan revealed that the discharge plan was for P#1 to return to a nursing home with outpatient behavioral health therapy and medication. Treatment team signatures included DCP AA, P#1, and RN CC on 11/10/21 at 2:00 p.m. A progress note written on 11/11/21 by physician (MD) BB revealed that P#1 appeared to be approaching psychiatric baseline and discharge was anticipated on Friday (11/12/21). Continued review of the medical record revealed that faxed copies of P#1 ' s medical notes and discharge medications were sent from Facility#1 to Facility#2 on 11/12/21 at 7:08 a.m.

A discharge order was received on 11/12/21 at 9:00 a.m. (verbal order) to discharge patient home with Medicaid transportation. Continued review of the record revealed that P#1 signed a copy of discharge instructions on 11/12/21, no time noted. A review of Patient Progress Notes written by Discharge Planner (DCP) AA on 11/12/21 at 4:00 p.m. revealed that Facility#2 had been notified of P#1's discharge on 11/10/21. Facility#2 has now informed Facility#1 that P#1's bed hold was up, and he cannot return to Facility#2. P#1 denied knowledge of Facility#2's bed hold policy. A family member of P#1 was contacted and stated that Facility#2 had contacted him (family) earlier on 11/12/21 and requested that the bed hold fee be paid. Continued review of the note revealed MD BB "made aware of facility's attempt to not accept pt back". MD BB instructed staff to continue transportation to "get the pt back to" Facility#2. "Medicaid transportation is expected to arrive around 1630". A review of Patient Progress Notes written 11/12/21 at 5:45 p.m. by Registered Nurse (RN) CC revealed that P#1 was cleared for discharge, denied any suicidal or homicidal thoughts and left Facility#1 at 5:45 p.m. with a Medicaid transportation company driver. Discharge medications had been called into Facility#2 at 1:00 p.m.

A Patient Progress Note written by DCP AA on 11/12/21 at 6:38 p.m. revealed that P#1 had completed the safety plan prior to discharge and was discharged to Facility#2 with Medicaid transportation. Continuing care information had been faxed to Facility#2 and P#1 voiced understanding of discharge instructions. Continued review of the medical record revealed that faxed copies of P#1's discharge continuing care plan were sent from Facility#1 to Facility#2 on 11/12/21 at 7:06 p.m. A Patient Progress note written by DCP AA on 11/15/21 at 11:20 a.m. revealed that the Ombudsman had been made aware that Facility#2 reported that they could not accept P#1. Ombudsman informed DCP AA that Facility#2 had a history of trying to illegally dump residents. Ombudsman was aware that Facility#2 had beds available as she (ombudsman) had recently been to Facility#2. Ombudsman made aware that a staff member at Facility#2 had spoken with DCP AA and per Ombudsman, the staff member had a history of unprofessional behavior.

A review of email correspondence from DCP AA to a staff member at Facility#2 on 11/10/21 at 11:37 a.m. revealed that clinical notes on P#1 were attached and discharge was anticipated for 11/12/21.

A review of email correspondence from Facility#2 to DCP AA at 11/11/21 at 3:49 p.m. revealed that P#1 exhausted his bed hold days with Facility#2 on 11/9/21 and based on review of psychological notes, Facility#2 cannot provide for his needs at this time.

A review of email correspondence from DCP AA to Facility#2 on 11/11/21 at 4:17 p.m. revealed that DCP AA explained that there were no psychological concerns noted in P#1's progress notes and P#1 had demonstrated stability for days. "We will still set up transportation to get him to" Facility#2 "on tomorrow". "Once he is there, I am sure that you all can work out a plan from there".

A review of email correspondence from Facility#2 to DCP AA on 11/12/21 at 8:47 a.m. revealed that P#1 was 'no longer on {our} census'. 'Per Administrator we cannot meet {P#1} needs. "His family has been contacted and are picking up his belongings today". An email response from DCP AA to Facility #2 on 11/12/21 at 9:15 a.m. revealed that DCP AA had been unable to contact P#1's family. DCP AA informed Facility#2 that she would contact an ombudsman to assist P#1 and questioned if P#1 had been made aware of the bed hold policy.

Facility #2 replied via email on 11/12/21 at 10:49 a.m. that P#1 had been notified of the bed hold policy. The family member had been contacted and was unable to provide financial support to hold P#1's bed. Facility#2 was unable to provide one on one care and therefore unable to meet P#1's psychological needs.

DCP AA replied to Facility#2 on 11/12/21 at 11:21 a.m. and explained that Facility#1 had a private transport set up for P#1 to return to Facility#2. "Your staff can get {P#1} back to your local ED if you feel as if you cannot accept him back. Your facility has failed to follow proper protocol for dismissing a resident".

Facility#2 replied to DCP AA on 11/12/21 at 11:42 a.m. "We are unable to accept him back. He will be sent back. The family has been made aware. We are not a psych facility. He is a danger to other residents and our employees. You are more than welcome to contact whomever."

A review P#4's medical record revealed that he was admitted to the Facility#1 2/16/21 at 5:55 p.m. with a diagnosis of schizophrenia. The Record of Admission form included a home address for P#4. Continued review of the record revealed that Family Member (FM) #1 was the primary caregiver but could not care for P#4 due to an illness. The Psychosocial Assessment dated 2/18/21 at 8:00 p.m. revealed that P#4 had resided with FM#2 for the past month. FM#2 was listed as P#4's emergency contact. A review of the Behavioral Unit Discharge Instruction dated 2/23/21 revealed that FM#2's address was included as the discharge address. A review of a Patient Progress Note revealed that FM#1 was informed of P#4's discharge from the facility. A Progress note revealed that a therapist attempted to reach FM#2 via telephone without success. P#4 was discharged on 2/23/21 to FM#2 residence via transport service. FM#2 was not at home when P#4 arrived, and the transport service left P#4 on the porch for an undetermined amount of time. FM#2 later informed Facility#1 that she had not expected P#4 to return to her residence.

A review of P#5's medical record revealed that Facility#1 had generated two Records of Admission during the hospitalization. Both Records of Admission contained the same home address and date of birth, but the medical record numbers and time of admission differed. A review of the Behavioral Unit Discharge Instructions dated 6/2/21 revealed that the discharge address did not match the home address on the Record of Admission. P#5 was discharged on 6/2/21 via transport service to the address listed on the Discharge Instructions. On arrival to the incorrect address, P#5 instructed the transport service to take her to the correct address. Facility#1 failed to provide P#5 with discharge medicines and a Facility#1 staff member delivered the medicines to P#5 on the day of discharge. On 6/3/21, a Facility#1 staff member phoned prescriptions in with the correct demographic information.

Review of the " Discharge -Transfer of Patients to Another Facility " policy #10.010, Effective 5/1/2017, last reviewed 6/1/21 revealed that patients must have been discharged from the behavioral health units, and all the customary practices and protocols for patient discharge would be performed. The discharge process provided for continuing care based upon the patient ' s assessed needs at the time of discharge. Acceptance of the patient by the physician at the receiving facility must precede the actual discharge of the patient. Clinical information would be exchanged with proper patient consent, and the transfer would be coordinated among the health care programs.

Review of the " Discharge Upon Completion of Treatment " policy #10.002, effective 5/1/2017, last reviewed 6/10/20 revealed that patients would be discharged from the program when deemed clinically suitable by the interdisciplinary team and the attending physician. The attending physician would sign and date the discharge order, complete the Discharge Form on Transfers from an appropriate facility, complete the psychiatric discharge note, and dictate the discharge summary. If a patient was transferred to another facility, the nurse would fill out the Patient Information and Transfer Form and give the forms to the accompanying family member or transportation driver. The social worker would review the continuing care/discharge plan and safety plan with the patient and family, write a discharge progress note addressing each problem, and forward the discharge plan to the outpatient provider or referral source.

Review of the " Discharge Planning and Continuing Care " policy #10.001, effective 5/1/2017, last reviewed 6/1/20 revealed that discharge planning would begin upon admission and would be the responsibility of the interdisciplinary team. The admission nursing assessment would note any barriers to discharge planning. Discharge Planning would be documented on the Master Treatment Plan. When specific therapeutic placement was ordered by the physician, the social worker would arrange placement involving the family as appropriate. The attending physician would write an order indicating the discharge date, medication, and condition of patient on discharge. The social worker would be responsible for the development and coordination of the discharge plan and safety plan. The social worker would coordinate with family and community resources to provide optimum implementation of the discharge plan. The discharge continuing care plan would be reviewed and education would be provided as needed with the patient and family. The policy further revealed that patients not returning home and being referred to other treatment facilities would be provided with ongoing treatment by that facility. The patient and family would participate in the decision-making process. Patient and family involvement would be coordinated by the social worker.

An interview with Discharge Planner (DCP) AA took place on 11/22/21 at 2:00 p.m. in the conference room. DCP AA explained that she was a licensed professional counselor and had been in this role since March 2018. She was responsible for discharge planning for the geriatric behavioral health patients. DCP AA explained that she did an assessment within the first three days of admission and contacted the facility, if any, where the patient resided. This could be a personal care home, skilled nursing facility, or group home. She recalled that she contacted Facility#2 and was informed that they would be accepting P#1 back at discharge. DCP AA was not sure of the exact date of initial contact. On 11/10/21, she emailed Facility#2 with P#1's medical notes and anticipated discharge date of 11/12/21. DCP AA recalled that she received communication from Facility#2 that they could not take P#1 back. DCP AA stated that she notified MD BB and was told to proceed with the discharge. DCP AA stated that she did not phone the facility just prior to P#1 leaving but that the facility had received the fax that contained his discharge information. DCP AA explained that she typically phoned Medicaid transportation companies in the morning between 8:00 a.m. and 8:30 a.m. and that the arrival time to pick patients up varied. She stated that the transportation company did not arrive until after 5:00 p.m. on 11/12/21 to pick up P#1 and did not drop him off at Facility#2 until after 2:00 a.m. She stated that it had been explained to her that the Medicaid transportation company does 'rideshare' meaning that they pick up multiple patients during a trip and the estimated time to the destination could not be predicted. DCP AA stated that Facility#2 initially agreed to take P#1 back but then provided several reasons why they couldn't take him back including lack of bed hold, staffing shortage, being psychiatrically unstable. She stated that P#1 had memory issues but was oriented to person, place and time at discharge and was ambulatory. DCP AA recalled that the morning after P#1 was discharged, a nurse from Facility#1 phoned her at home and she in turn spoke with a staff member at Facility#2. She stated that Facility#2 demanded that Facility#1 send transport to come back and 'get' P#1 and she explained that she could not arrange for that.
DCP AA stated that she attempts to touch base with facility's and/or patients' family at the time of discharge to ensure that someone will be prepared when the patient arrived. She stated that an incident in February 2021 involved a private transporter dropped a patient off at a family members home when no one was home. She stated that she spoke with the transporter and explained that she (transporter) must assure that patients are able to get into the home. She recalled that she had phone the residence and left a message prior to the patient leaving Facility#1.

An interview with psychiatrist (MD) BB took place on 11/21/21 at 3:45 p.m. in the conference room. MD BB stated that he recalled P#1 and he had improved and had been ready for discharge back to the nursing facility. He explained that the facility did discharge planning Monday, Wednesday, and Fridays and information had been sent to Facility#2 about a pending discharge on a Monday and questions were answered on Wednesday. P#1 was discharged and transported using Medicaid transportation. MD BB explained that he was not made aware of Facility#2's refusal to take P#1 back until after transport had left with the patient. He further explained that the facility did not discharge patients unless they had a place to go.

An interview with Registered Nurse (RN) CC took place on 11/23/21 at 9:30 a.m. in the conference room. RN CC had been employed at Facility#1 for two years on the behavioral health unit. RN CC explained that nurses were generally not involved in discharge planning, DCP AA was primarily responsible. RN CC recalled that she was working on the day that P#1 was discharged. She recalled that she faxed a list of medications to Facility#2 but did not have any other communication with the facility. She explained that she did not phone Facility#2 to alert them that P#1 was en route because she 'forgot'. RN CC stated that she had been under the impression that Facility#2 had agreed to take P#1 back. She recalled that P#1 voiced concerns about returning to Facility#2 because of the incidents that had taken place prior to his admission to Facility#1. RN CC stated that she did not call or speak with MD BB about P#1's discharge. RN CC stated that the social worker generally verified the residence that a patient was discharged to prior to discharge. RN CC stated that P#1 did not exhibit any aggressive behaviors while admitted to Facility #1.

An interview with Former Program Director of the Behavioral Health Unit (PD) EE took place in the conference room on 11/23/21 at 9:44 a.m. in the conference room. Interim Director (ID) of BHU FF and Interim Manager (IM) of BHU were present for interview. PD EE explained that she was the Program Director of Facility#1's behavioral health unit for four years prior to her departure in June, 2021. PD EE was still employed by the behavioral health management contractor. PD EE explained that she had developed several checklists and forms to assist with the discharge process. These forms had been in place for several years. She stated that these were operating procedures as the policy was broad. IM GG explained that she inquired about P#1's discharge status a couple of days prior to his actual discharge and was informed that he (P#1) was waiting on transport. She recalled that she received a call from a law enforcement detective a day or so after P#1's discharge inquiring about the conditions of P#1's discharge. ID FF stated that they (leadership) had started working on re-education for the staff on the discharge process. PD EE stated that MD BB would be contacted, and the discharge process would be discussed with him as well. PD EE stated that she had been aware of a couple of other incidents that had occurred previously around discharge transportation.

Based on review of medical records, review of policy and procedures, and staff interviews it was determined that the facility failed to ensure that one (P#1) of five (P#1, P#2, P#3, P#4, P#5) sampled was informed the of their freedom to choose among participating Medicare providers of post-discharge services and failed to respect the patients concerns and or preferences as it related to post acute placement. Findings included:

A review of Patient (P) #1's medical record revealed that Facility#1's behavioral health unit completed a pre-admission screening on 10/30/21 at 9:15 p.m. from a referral at Facility #3. A review of the Pre-Admission Screening revealed that P#1 resided at a skilled nursing facility (Facility#2) and had been sent to Facility#3's emergency department for increased psychosis and assaultive behavior toward staff and other residents. Facility #3 medically cleared P#1 for transfer on 11/1/21 at 5:52 p.m. P#1 was accepted for admission to Facility #1 and transported on 11/2/21. A review of the Psychiatric Evaluation dated 11/2/21 at 7:41 p.m. revealed that P#1 resided at a skilled nursing facility (Facility #2) and had a history of alcoholic dementia, stroke, and high blood pressure. P#1 had become more aggressive with staff and residents at Facility #2 and had auditory and visual hallucinations. P#1 was agitated, labile and yelling on admit to Facility #1.

A review of the Interdisciplinary Treatment Plan dated 11/3/21 at 2:00 p.m. revealed that P#1's goals for treatment was to 'go somewhere else'. A review of a Psychosocial Assessment on 11/5/21 by DCP AA revealed that P#1 would return to Facility#2. Continued review of the Psychosocial Assessment revealed that P#1 expressed his wish to 'go somewhere else' on discharge. A review of the Interdisciplinary Treatment Plan revealed that the discharge plan was for P#1 to return to a nursing home with outpatient behavioral health therapy and medication. Treatment team signatures included DCP AA, P#1, and RN CC on 11/10/21 at 2:00 p.m. A progress note written on 11/11/21 by physician (MD) BB revealed that P#1 appeared to be approaching psychiatric baseline and discharge was anticipated on Friday (11/12/21). Continued review of the medical record revealed that faxed copies of P#1 ' s medical notes and discharge medications were sent from Facility#1 to Facility#2 on 11/12/21 at 7:08 a.m.

A verbal order was received on 11/12/21 at 9:00 a.m. to discharge patient home with Medicaid transportation. Continued review of the record revealed that P#1 signed a copy of discharge instructions on 11/12/21, no time noted. A review of Patient Progress Notes written by Discharge Planner (DCP) AA on 11/12/21 at 4:00 p.m. revealed that Facility#2 had been notified of P#1's discharge on 11/10/21. Facility#2 has now informed Facility#1 that P#1's bed hold was up, and he cannot return to Facility#2. P#1 denied knowledge of Facility#2's bed hold policy. A family member of P#1 was contacted and stated that Facility#2 had contacted him (family) earlier on 11/12/21 and requested that the bed hold fee be paid. Continued review of the note revealed MD BB "made aware of facility's attempt to not accept pt back". MD BB instructed staff to continue transportation to "get the pt back to" Facility#2. "Medicaid transportation is expected to arrive around 1630". A review of Patient Progress Notes written 11/12/21 at 5:45 p.m. by Registered Nurse (RN) CC revealed that P#1 was cleared for discharge, denied any suicidal or homicidal thoughts and left Facility#1 at 5:45 p.m. with a Medicaid transportation company driver. Discharge medications had been called into Facility#2 at 1:00 p.m.

A Patient Progress Note written by DCP AA on 11/12/21 at 6:38 p.m. revealed that P#1 had completed the safety plan prior to discharge and was discharged to Facility#2 with Medicaid transportation. Continuing care information had been faxed to Facility#2 and P#1 voiced understanding of discharge instructions. Continued review of the medical record revealed that faxed copies of P#1's discharge continuing care plan were sent from Facility#1 to Facility#2 on 11/12/21 at 7:06 p.m.

Review of the " Discharge -Transfer of Patients to Another Facility " policy #10.010, Effective 5/1/2017, last reviewed 6/1/21 revealed that patients must have been discharged from the behavioral health units, and all the customary practices and protocols for patient discharge would be performed. The discharge process provided for continuing care based upon the patient ' s assessed needs at the time of discharge. Acceptance of the patient by the physician at the receiving facility must precede the actual discharge of the patient. Clinical information would be exchanged with proper patient consent, and the transfer would be coordinated among the health care programs.

Review of the " Discharge Upon Completion of Treatment " policy #10.002, effective 5/1/2017, last reviewed 6/10/20 revealed that patients would be discharged from the program when deemed clinically suitable by the interdisciplinary team and the attending physician. The attending physician would sign and date the discharge order, complete the Discharge Form on Transfers from an appropriate facility, complete the psychiatric discharge note, and dictate the discharge summary. If a patient was transferred to another facility, the nurse would fill out the Patient Information and Transfer Form and give the forms to the accompanying family member or transportation driver. The social worker would review the continuing care/discharge plan and safety plan with the patient and family, write a discharge progress note addressing each problem, and forward the discharge plan to the outpatient provider or referral source.

Review of the " Discharge Planning and Continuing Care " policy #10.001, effective 5/1/2017, last reviewed 6/1/20 revealed that discharge planning would begin upon admission and would be the responsibility of the interdisciplinary team. The admission nursing assessment would note any barriers to discharge planning. Discharge Planning would be documented on the Master Treatment Plan. When specific therapeutic placement was ordered by the physician, the social worker would arrange placement involving the family as appropriate. The attending physician would write an order indicating the discharge date, medication, and condition of patient on discharge. The social worker would be responsible for the development and coordination of the discharge plan and safety plan. The social worker would coordinate with family and community resources to provide optimum implementation of the discharge plan. The discharge continuing care plan would be reviewed and education would be provided as needed with the patient and family. The policy further revealed that patients not returning home and being referred to other treatment facilities would be provided with ongoing treatment by that facility. The patient and family would participate in the decision-making process. Patient and family involvement would be coordinated by the social worker.

An interview with Registered Nurse (RN) CC took place on 11/23/21 at 9:30 a.m. in the conference room. RN CC had been employed at Facility#1 for two years on the behavioral health unit. RN CC explained that nurses were generally not involved in discharge planning, DCP AA was primarily responsible. RN CC recalled that she was working on the day that P#1 was discharged. She recalled that she faxed a list of medications to Facility#2 but did not have any other communication with the facility. She explained that she did not phone Facility#2 to alert them that P#1 was en route because she 'forgot'. RN CC stated that she had been under the impression that Facility#2 had agreed to take P#1 back. She recalled that P#1 voiced concerns about returning to Facility#2 because of the incidents that had taken place prior to his admission to Facility#1. RN CC stated that she did not call or speak with MD BB about P#1's discharge. RN CC stated that the social worker generally verified the residence that a patient was discharged to prior to discharge. RN CC stated that P#1 did not exhibit any aggressive behaviors while admitted to Facility #1.