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Based on document review and interview, it was determined for 1 of 2 (Pt. #32) clinical records reviewed for patients discharged home with home care services, the Hospital failed to ensure discharge plan was discussed with the patient or her representative as required.

Findings include:

1. On 6/29/17 at approximately 11:00 AM, the clinical record of Pt. #32 was reviewed. Pt. #32 was a 64 year old female admitted on 3/28/17 with a diagnosis of acute cholecystitis. Pt. #32's discharge plan dated 4/2/17 indicated the case manager's discussion with Pt. #32's nurse regarding the discharge plan. The clinical record lacked documentation that the discharge plan was discussed with Pt. #32 or with her representative.

2. On 6/29/17 at approximately 1:30 PM, the Hospital's policy titled, "Discharge Planning" (revised 5/16) was reviewed and required, "... Results of the discharge planning... will be discussed with the patient/representative and results of this communication will be documented in the patient's medical record..."

3. On 6/29/17 at approximately 11:15 AM, the findings were discussed with E #19 (Discharge Planning Coordinator). E #19 stated that the discharge plan should have been discussed with the patient or her family.

Based on document review and interview, it was determined that for 1 of 2 (Pt. #32) patients discharged home with home care services, the Hospital failed to ensure the patient was provided a list of available home care agencies.

Findings include:

1. On 6/29/17 at approximately 11:00 AM, the clinical record of Pt. #32 was reviewed. Pt. #32 was a 64 year old female admitted on 3/28/17 with a diagnosis of acute cholecystitis. Pt. #32 was discharged on 4/2/17 with a physician's order for home care services. The clinical record lacked documentation of a list of home care agencies being provided to the patient.

2. On 6/29/17 at approximately 1:30 PM, the Hospital's policy titled, "Discharge Planning" (revised 5/16) was reviewed and required, "... Patient Choice of Post Acute Service Provider... Case Managers provide patient/family members with a list of facilities or agencies that: 1. Provide the specific services requested by the physician... Documentation attested to by Discharge Planner and Patient/Representative regarding patient/representative freedom of choice will be completed, signed by both parties and included in the medical record."

3. On 6/29/17 at approximately 11:15 AM, the findings were discussed with E #19 (Discharge Planning Coordinator). E #19 stated that there should have been documentation that a list of home health agencies was provided to the patient.