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Based on record review, document review and interviews it was revealed the facility failed to ensure all patients who were intellectually disabled and needed a representative were informed of patient's rights in one (1) of ten (10) patients (patient #1). This failure to ensure all patient's representatives of intellectually disabled patients were informed of patient's rights has the potential to negatively impact all care at the facility if patients or patient's representatives do not understand their rights for medical care.

Findings include:

1. A review of the medical record for patient #1 on the identifier list revealed a start of care at the facility of 7/16/19 as an involuntary commitment due to violent outbursts. A copy of the court-ordered commitment papers documented an assessment by a masters prepared social worker that detailed the patient's problem and brief history. The patient's diagnoses listed included intellectual disability and intermittent explosive disorder. His sister was listed on this court document as his medical power of attorney which established the patient had a designated representative. A review of patient rights information received by the patient at admission revealed he signed his own acknowledgement of understanding of patient rights. The facility failed to contact the patient's representative to inform them of the patient's rights and let a patient who did not understand his rights sign that he did understand them.

2. A review of the facility policy titled Patient Rights and Responsibilities, last revision/review date of 5/01/13, revealed the only mention of patient representatives was under the signature section and stated "To validate that patients have been apprised of their rights and responsibilities, an attempt shall be made to obtain a signature from the patient, legal guardian, or next-of-kin and one witness. If all signatures are not obtained, documentation will explain why it couldn't be obtained." The policy fails to address any time frame for contact of patient representatives, examples of types of patients that may need a representative, who will identify the need or any follow up needed to ensure patients or their representatives are informed of their rights.

3. The Director of Admissions was interviewed on 8/13/19 at approximately 1:33 p.m. It was revealed for admission to the facility the clerk reviews the document and if the patient will sign they are allowed to sign. The facility does not attempt to determine if the patient understood what he signed. She stated, "The clerk cannot make capacity decisions." She stated if there was questionable understanding the facility follows up two (2) times until the document is signed. She stated there was no feedback taken from the admitting nursing staff related to patient's ability to understand his rights or from outside documentation of intellectual disability. The clerk was interviewed on 8/14/19 at approximately 3:10 p.m. When asked whether the facility determines the patient has a representative, who it is and whether the patient rights were provided as required, she stated, "No".

Based on record review and interviews it was revealed the facility failed to ensure all patients with intellectual disability and their patient representatives participated in the development and implementation of patient's plan of care in one (1) of ten (10) records of intellectually disabled patient records reviewed who had need of a representative to understand their plan of care (patient #1). This failure by the facility to include a patient representative who could understand and guide a patient with intellectual disability with their plan of care has the potential to negatively impact all intellectually disabled patients who receive care at the facility.

Findings include:

1. A review of the medical record for patient #1 on the identifier list revealed a start of care at the facility of 7/16/19 as an involuntary commitment due to violent outbursts. A copy of the court-ordered commitment papers documented an assessment by a masters prepared licensed social worker that detailed the patient's problem and brief history. The patient's diagnoses listed included intellectual disability and intermittent explosive disorder. His sister was listed on the document as his medical power of attorney which established the patient had a designated representative. A review of the only master treatment plan, dated 7/18/19, was completed. It listed the patient as his own decision maker even though his diagnosis included intellectual disability. It stated the patient was unable to report his education history. He quit school. It also stated, "Individual and group interaction will be tailored to [patient #1's] intellectual capacity." The nursing assessment completed upon admission 7/16/19 stated the patient's diagnoses included intellectual disability. The patient did not know where he would go upon discharge or who would help him when he got there. He stated the most important person to him was his mother. In a social worker progress note dated 7/25/19 it was documented the social worker was informed the patient had a sister and included her name, phone number and email address and the patient's mother could also be contacted for any questions. It was documented the patient has someone with him twenty-four (24) hours a day through intellectual disability waiver services. There was no documentation of contact with the sister or mother to offer participation in the patient's plan of care.

2. In an interview with social worker #1, assigned to patient #1, on 8/13/19 at approximately 9:05 a.m., he was asked about planning care for the patient. He stated he talked to the staff at the out-patient services companies to see if the patient would still be able to return home with previous services. He stated he did not talk with patient #1's sister or mother. He stated he failed to offer the opportunity to the patient's representative during the patient's stay at the facility. He stated he failed to arrange a specific time for service staff to meet the patient in his home after discharge from the facility.

3. In an interview with the Director of Clinical Services and social worker #1 on 8/14/19 at approximately 3:34 p.m. the above findings were discussed. They both agreed the patient's representatives were not contacted about participation in his plan of care.

The facility failed to ensure all patient's discharge planning needs were met in the instance of an individual with an intellectual disability.

The facility discharge evaluation did not include an evaluation of the patient's capacity for self care, tag A 806. The facility did not ensure a timely discharge plan to avoid delays to patient care, tag A 810. The facility failed to discuss results of their discharge plan with the individual acting on the patient's behalf, tag A 811. The facility failed to ensure the patient's representative was engaged to participate in the discharge plan, tag A 818. The facility failed to arrange adequate implementation of the discharge plan, tag A 820. The facility failed to reassess the patient's discharge plan for factors that would effect his continuous care needs upon discharge, tag A 821.

Based on record review, document review and interviews it was revealed the facility failed to ensure a complete and detailed discharge plan assessment for all patient's with an intellectual disability in one (1) of ten (10) records reviewed of patients with an intellectual disability (patient #1). This failure by the facility to ensure patient's who are unable to plan for their safe discharge has the potential to negatively impact all patients at the facility who are intellectually disabled.

Findings include:

1. A review of the medical record for patient #1 on the identifier list revealed a start of care at the facility of 7/16/19 as an involuntary commitment due to violent outbursts. A copy of the court-ordered commitment papers documented an assessment by a masters prepared social worker that detailed the patient's problem and brief history. The patient's diagnoses listed included intellectual disability and intermittent explosive disorder. His sister was listed on the document as his medical power of attorney which established the patient had a designated representative. A review of the only master treatment plan, dated 7/18/19, was completed. It listed the patient as his own decision maker even though his diagnoses included intellectual disability and it stated the patient was unable to report his education history. He quit school. It also stated: "Individual and group interaction will be tailored to [patient #1's] intellectual capacity." The nursing assessment completed upon admission 7/16/19 stated the patient's diagnoses included intellectual disability. The patient told the nurse he did not know where he would go upon discharge or who would help him when he got there. He stated the most important person to him was his mother. In a social worker progress note dated 7/25/19 it was documented the social worker was informed the patient had a sister, included her name, phone number and email address. The patient's mother could also be contacted for any questions. It was documented the patient must have someone with him twenty-four (24) hours a day through intellectual disability waiver services. There was no documentation of contact with the sister or mother to offer participation in the patient's plan of care.

2. A review of patient #1's discharge planning evaluation by social worker #1 per the master treatment plan dated 7/18/19 revealed in part: "Social worker #1 had talked to the out-patient provider of intellectual disability waiver services. It was documented the social worker was aware of case management by an agency and patient #1's home was staffed with trained staff twenty-four (24) hours per day because the patient was unable to manage living by himself safely. He had to have continuous around the clock supervision. Upon discharge the staff, mother or a responsible individual would have to be at the apartment to receive the patient." The facility failed to arrange a specific time for the out-patient provider staff to receive patient #1 who needed continuous supervision.

3. A review of the facility policy titled Discharge Plan, last reviewed/revised 12/17/15, was completed. It revealed in part: "The Interdisciplinary Treatment Team shall determine the patient's community residential treatment and daily living needs and develop a written discharge plan to address those needs."

4. In an interview conducted with the Director of Clinical Services and social worker #1 on 8/14/19 at approximately 3:34 p.m., the above findings were discussed. They were asked if specific times for receiving staff were arranged to be at patient #1's apartment for continuous care to be provided. They both replied, "No." The discharge plan was not specific enough.

Based on record review, document review and interviews it was revealed the facility failed to ensure an updated discharge plan evaluation was completed for all patients with intellectual disability in one (1) of ten (10) records reviewed (patient #1). This failure by the facility to ensure discharge plans are evaluated for updates throughout the course of care, especially for patients with intellectual disabilities, has the potential to impact all patient's safe discharge from the facility.

Findings include:

1. A review of the medical record for patient #1 on the identifier list revealed a start of care at the facility of 7/16/19 as an involuntary commitment due to violent outbursts. A copy of the court-ordered commitment papers documented an assessment by a masters prepared licensed social worker that detailed the patient's problem and brief history. The patient's diagnoses listed included intellectual disability and intermittent explosive disorder. His sister was listed on the document as his medical power of attorney which established the patient had a designated representative. A review of the only master treatment plan, dated 7/18/19, was completed. It listed the patient as his own decision maker even though his diagnoses included intellectual disability. It stated the patient was unable to report his education history. He quit school. It also stated: "Individual and group interaction will be tailored to [patient #1's] intellectual capacity." The nursing assessment completed upon admission 7/16/19 stated the patient diagnoses included intellectual disability. The patient did not know where he would go upon discharge or who would help him when he got there. He stated the most important person to him was his mother. In a social worker progress note dated 7/25/19 it was documented the social worker was informed the patient had a sister, included her name, phone number and email address. The patient's mother could also be contacted for any questions. It was documented the patient has someone with him twenty-four (24) hours a day through intellectual disability waiver services. There was no documentation of contact with the sister or mother to offer participation in the patient's plan of care.

2. A review of patient #1's discharge planning evaluation by social worker #1 per the master treatment plan dated 7/18/19 revealed in part: "Social worker #1 had talked to the out-patient provider of intellectual disability waiver services. It was documented the social worker was aware of case management by an agency and patient #1's home was staffed with trained staff twenty-four (24) hours per day because the patient was unable to manage living by himself safely. He had to have continuous around the clock supervision. Upon discharge the staff, mother or a responsible individual would have to be at the apartment to receive the patient." The facility failed to arrange a specific time for the out-patient provider staff to receive patient #1 who needed continuous supervision.

3. A review of patient #1's medical record revealed after 7/25/19 when the facility received the information about the medical power of attorney and the out-patient services that were provided to the patient, no further updates to his discharge plan evaluation was completed. There was no communication with the receiving outpatient services about the date or the estimated time the patient would be arriving at his apartment for the continuous supervision required to be continued.

4. A review of the facility policy titled Discharge Plan, last reviewed/revised 12/17/15, was completed. It revealed in part: "The Interdisciplinary Treatment Team (ITT) shall make efforts to engage the patient, legal decision maker and/or the patient's family in discharge planning through discussions of the patient's community residential treatment and support service needs and review of the options available to the patient." It further states in part: "In the master treatment plan updates discharge plan documentation, the Treatment Plan Coordinator shall note: the patient's [and legal representative's] agreement/disagreement (when applicable) with the ITT's discharge plan recommendations."

5. In an interview conducted with the Director of Clinical Services and social worker #1 on 8/14/19 at approximately 3:34 p.m., the above findings were discussed. They were asked if specific times for receiving staff were arranged to be at patient #1's apartment for continuous care to be provided. They both replied, "No." The discharge plan was not specific enough.

Based on record review, document review and interviews it was revealed the facility failed to ensure the discharge plan evaluation was communicated to the patient representatives or service providers for all patients with intellectual disability in one (1) of ten (10) records reviewed (patient #1). This failure by the facility to ensure discharge plans are updated and communicated throughout the course of care, especially for patients with intellectual disabilities, has the potential to negatively impact all patient's safe discharge from the facility.

Findings include:

1. A review of the medical record for patient #1 on the identifier list revealed a start of care at the facility of 7/16/19 as an involuntary commitment due to violent outbursts. A copy of the court-ordered commitment papers documented an assessment by a masters prepared licensed social worker that detailed the patient's problem and brief history. The patient's diagnoses listed included intellectual disability and intermittent explosive disorder. His sister was listed on the document as his medical power of attorney which established the patient had a designated representative. A review of the only master treatment plan, dated 7/18/19, was completed. It listed the patient as his own decision maker even though his diagnoses included intellectual disability. It stated the patient was unable to report his education history. He quit school. It also stated: "Individual and group interaction will be tailored to [patient #1's] intellectual capacity." The nursing assessment completed upon admission 7/16/19 stated the patient diagnoses included intellectual disability. The patient did not know where he would go upon discharge or who would help him when he got there. He stated the most important person to him was his mother. In a social worker progress note dated 7/25/19 it was documented the social worker was informed the patient had a sister, included her name, phone number and email address. The patient's mother could also be contacted for any questions. It was documented the patient has someone with him twenty-four (24) hours a day through intellectual disability waiver services. There was no documentation of contact with the sister or mother to offer participation in the patient's plan of care.

2. A review of patient #1's discharge planning evaluation by social worker #1 per the master treatment plan dated 7/18/19 revealed in part: "Social worker #1 had talked to the out-patient provider of intellectual disability waiver services. It was documented the social worker was aware of case management by an agency and patient #1's home was staffed with trained staff twenty-four (24) hours per day because the patient was unable to manage living by himself safely. He had to have continuous around the clock supervision. Upon discharge the staff, mother or a responsible individual would have to be at the apartment to receive the patient." The facility failed to arrange a specific time for the out-patient provider staff to receive patient #1 who needed continuous supervision.

3. A review of patient #1's medical record revealed after 7/25/19 no further updates to his discharge plan evaluation was completed before he was discharged. There was no communication with the receiving outpatient services about the date or the estimated time the patient would be arriving at his apartment for the continuous supervision required to be continued.

4. A review of the facility policy titled Discharge Plan, last reviewed/revised 12/17/15, was completed. It revealed in part: "In the master treatment plan updates discharge plan documentation, the Treatment Plan Coordinator shall note: The patient's agreement/disagreement and the legal decision maker's agreement/disagreement (when applicable) with the Interdisciplinary Treatment Team (ITT) discharge plan recommendation." It also revealed in part: "The ITT shall ensure that patients discharged from [the facility] are referred to safe, therapeutic and supportive environments." It also revealed in part: "Prior to discharge...attempts to, or notification of the guardian or legal representative will be made and documented within 24 hours into the patient's electronic medical record." Lastly it revealed in part: "The receiving facility will be notified of [discharge] at least 4 hours prior to transfer."

5. In an interview conducted with the Director of Clinical Services and social worker #1 on 8/14/19 at about 3:34 p.m. the above findings were discussed. When asked if any staff communicated with the receiving staff or patient representative about updates to the discharge plan evaluation including specific times for receiving staff to be at patient #1's apartment for continuous care to be provided, they both replied, "No."

Based on record review and interviews it was revealed the facility failed to ensure the discharge plan assessment was re-evaluated to include specific factors needed for safe discharge for all patients with intellectual disability in one (1) of eight (8) records reviewed (patient #1). This failure by the facility to ensure discharge plans are re-evaluated throughout the course of care, especially for patients with intellectual disabilities, has the potential to impact all patient's safe discharge from the facility.

Findings include:

1. A review of the medical record for patient #1 on the identifier list revealed a start of care at the facility of 7/16/19 as an involuntary commitment due to violent outbursts. A copy of the court-ordered commitment papers documented an assessment by a masters prepared social worker that detailed the patient's problem and brief history. The patient's diagnoses listed included intellectual disability and intermittent explosive disorder. His sister was listed on the document as his medical power of attorney which established the patient had a designated representative. A review of the only master treatment plan dated 7/18/19, was completed. It listed the patient as his own decision maker even though his diagnoses included intellectual disability. It stated the patient was unable to report his education history. It also stated: "Individual and group interaction will be tailored to [patient #1's] intellectual capacity." The nursing assessment completed upon admission 7/16/19 stated the patient's diagnoses included intellectual disability. The patient told the nurse he did not know where he would go upon discharge or who would help him when he got there. He stated the most important person to him was his mother. In a social worker progress note dated 7/25/19 it was documented the social worker was informed the patient had a sister as medical power of attorney and documented her name, phone number and email address. The patient's mother could also be contacted for any questions. It was documented the patient has someone with him twenty-four (24) hours a day through intellectual disability waiver services to be safe. There was no documentation of communication with the sister or mother to offer participation in the patient's plan of care. There was no documentation of the discharge assessment being re-evaluated to include the new information about the medical power of attorney or the key factor the patient had to have supervision twenty-four (24) hours a day,or continuously, to be safe.

2. A review of patient #1's discharge planning evaluation by social worker #1 per the master treatment plan dated 7/18/19 revealed in part: "Social worker #1 had talked to the out-patient provider of intellectual disability waiver services. It was documented the social worker was aware of case management by an agency and patient #1's home was staffed with trained staff twenty-four (24) hours per day because the patient was unable to manage living by himself safely. He had to have continuous around the clock supervision. Upon discharge the staff, mother or a responsible individual would have to be at the apartment to receive the patient." The facility failed to arrange a specific time for the out-patient provider staff to receive patient #1 who needed continuous supervision

3. A review of patient #1's medical record revealed after 7/25/19 no re-evaluation to his discharge plan assessment was completed before he was discharged. There was no communication with the receiving outpatient services about the date or the estimated time the patient would be arriving at his apartment for the continuous supervision required to be continued. There was no communication with the patient representative or the acknowledgement these steps were needed to complete a safe discharge from the facility.

4. In an interview conducted with the Director of Clinical Services and social worker #1 on 8/14/19 at about 3:34 p.m. the above findings were discussed. When asked if any staff communicated with the receiving staff or patient representative about updates to the discharge plan evaluation including specific times for receiving staff to be at patient #1's apartment for continuous care to be provided, they both replied, "No."


4. In an interview conducted with the Director of Clinical Services and social worker #1 on 8/14/19 at approximately 3:34 p.m. the above finding was discussed. When asked if a re-evaluation of the discharge plan was done or if the facility communicated with anyone, updates to the discharge plan including specific times for receiving staff to be at patient #1's apartment for continuous care to be provided, they both replied, "No."