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Based on the complaint allegation ACTS Intake PR00000500 survey, review of thirty clinical record, policies/procedures interviews with staff, patients, and patients relatives with the Discharge planning Supervisor (employee #2), on 02/07/2013 from 8:00 am till 6:25 pm, it was determined that the Governing Body failed to carry out its responsibility for the operation and management of the hospital. It did not provide the necessary oversight and leadership as evidenced by the lack of compliance with: 42 CFR 482.43 Discharge Planning. (cross refer tags A799, A800, A806, A810,A821, A823 and A843).

Based on the review of thirty clinical records and policies/procedures with the Discharge planning Supervisor (employee #2), it was determined that the facility failed to have in effect a discharge planning process that applies to all patients and this Condition of Participation is Not Met (Please cross reference tags A800, A806, A810, A821, A823 and A843).

Based on the review of thirty clinical records, policies/procedures and interview with the Discharge planning Supervisor (employee #2), it was found that the facility failed to establish the criteria to identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge and failed to ensure to have criteria for identifying risks within an early stage of hospitalization for the patient for discharge planning for twenty-two out of thirty records reviewed (R.R #1, #2, #3, #4, #6, #7, #8, #9, #10, #11, #12, #14, #16, #17, #18, #19, #20, #21, #22, #25, #27 and #30).

Findings include:

1. During interview with the Discharge Planning Supervisor (employee #2) on 2/7/13 at 9:10 am related to the discharge planning process, she stated that she performs discharge planning evaluations on all patients over 65 years old and according with the medical insurance, if it is an advantage medical insurance, they have an agreement with some agency that provides the service to the patient, an example is the medical insurance company CMS Classic Care, they have an agreement with specific companies that provide the service to the patient with this insurance company and they are the ones that assign the agency that is going to provide the services after the patient is discharged, for the medical equipment for supplementary alimentation they have agreements with the Clinical Medical Services and that is the only company that they use to provide the services to the patient. If the patient requests a specific agency the medical insurance company changes and chooses the agency that is going to provide the services. If patient has Medicare insurance we ask them if they have a certain agency to choose and if not we provide a list of many agencies of Home Care, Hospice and medical Equipment that the patient can choose from.

2. The facility's policies and procedures establishes that Discharge Planning initial assessment is performed during 24 hour of admitting and the reassessment is performed 3-5 days as reviewed on 2/7/13 at 10:00 am. The facility failed to establish the patients' ability to perform activities of daily living, family support, person's ability to provide self-care, failed to determine that the patient or family is unable to meet patient needs, and as result, failed to provide adequate discharge planning.

3. The facility's Discharge planning services failed to perform surveillance of issues which need to be assessed to ensure the quality of care offered to patients. The data was not presented as indicators or information obtained in order to present the facility's approach of quality improvement and patient health outcomes as the result of the care provided by the service as evidenced on 2/7/13 at 10:30 am.

4. Twenty-two out of thirty records reviewed (R.R #1, #2, #3, #4, #6, #7, #8, #9, #10, #11, #12, #14, #16, #17, #18, #19, #20, #21, #22, #25, #27 and #30), provided evidence that the facility failed to perform an assessment and identified it at an early stage during the hospitalization for a patient who was likely to suffer adverse health consequences upon discharge:

a. R.R #1 is a 67 years old female admitted to the facility on 12/14/12 with a diagnosis of Brain Mass. During the record review performed on 2/7/13 at 1:00 pm, it was found that the patient was evaluated by discharge planning on 12/17/12 at 9:30 am three days after admission. During the discharge home a medical referral was performed for hospice service. According to the record review the patient's relative requested the hospice agency. The discharge planning coordinated ambulance services and the health insurance approved the services. However, no evidence was found related to the authorization and approval of the health insurance for the hospice services. The facility failed to perform the discharge planning initial assessment in an early stage of hospitalization, according to facility policies and procedures.

b. R.R #2 is a 65 years old female admitted to the facility on 12/19/12 with a diagnosis of Coronary Arterial Disease (CAD). During the record review performed on 2/7/13 at 1:15 pm, it was found that the patient was evaluated by discharge planning on 12/21/12 at 2:05 pm two days after admission. During the discharge home a medical referral was performed for physical therapy service. According to the record review the health insurance was the one who choose the agency that provided the services to the patient. However, no evidence was found related to the authorization and approval of the health insurance for the physical therapy services. The facility failed to perform the discharge planning initial assessment in a early stage of hospitalization, according to facility policies and procedures.

c. R.R #3 is a 77 years old male admitted to the facility on 12/12/12 with a diagnosis of Acute Renal Insufficiency. During the record review performed on 2/7/13 at 1:30 pm, it was found that the patient was evaluated by discharge planning on 12/21/12 at 2:50 pm, nine days after admission. During the discharge home a medical referral was performed for medical equipment and Home Care service. According with the record review the health insurance was the one who chose the agency that provided the services to the patient. However, no evidence was found related to the authorization and approval of the health insurance for the services. The facility failed to perform the discharge planning initial assessment in an early stage of hospitalization, according to facility policies and procedures.

d. R.R #4 is a 71 years old male admitted to the facility on 12/8/12 with a diagnosis of Bronchopneumonia (BKP). During the record review performed on 2/7/13 at 1:45 pm, it was found that the patient was evaluated by discharge planning on 12/13/12 five days after admission by a medical referral for equipment and Home Care service. According with the record review the health insurance was the one who chose the agency that provided the services to the patient. The discharge planning reassessment was on 12/14/12, 12/17/12, 12/18/12 and evaluated on 12/18/12. However, no evidence was found related to the authorization and approval of the health insurance for the services. The facility failed to perform the discharge planning initial assessment in an early stage of hospitalization, according to facility policies and procedures.

e. R.R #6 is an 86 years old female admitted to the facility on 12/7/12 with a diagnosis of Syncope. During the record review performed on 2/7/13 at 2:15 pm, it was found that the patient was evaluated by discharge planning on 12/11/12 four days after admission by a medical referral for home care service. According with the record review, the health insurance was the one who chose the agency that provided the services to the patient. The discharge planning reassessment was on 12/11/12, 12/12/12, 12/13/12 and evaluated the discharge planning on 12/17/12. However, no evidence was found related to the authorization and approval of the health insurance for the services. The facility failed to perform the discharge planning initial assessment in an early stage of hospitalization, according to facility policies and procedures.

f. R.R #7 is a 78 years old female admitted to the facility on 12/6/12 with a diagnosis of Left Leg Cellulites. During the record review performed on 2/7/13 at 2:30 pm, it was found that the patient was evaluated by discharge planning on 12/10/12 at 3:05 pm four days after admission by a medical referral for home care service. According with the record review the patient chose the home care that provided the services. The facility failed to perform the discharge planning initial assessment in an early stage of hospitalization, according to facility policies and procedures.

g. R.R #8 is a 60 years old female admitted to the facility on 12/7/12 with a diagnosis of Lumbar Disc. During the record review performed on 2/7/13 at 2:45 pm, it was found that the patient was evaluated by discharge planning on 12/11/12 at 11:30 am four days after admission by a medical referral for medical equipment and home care service. According with the record review the health insurance was the one who chose the agency that provided the services to the patient. The discharge planning reassessment was on 12/11/12 and 12/17/12. However, no evidence was found related to the authorization and approval of the health insurance for the home care services. The facility failed to perform the discharge planning initial assessment in an early stage of hospitalization, according to facility policies and procedures.

h. R.R #9 is a 78 years old male admitted to the facility on 12/4/12 with a diagnosis of Gastrointestinal Bleeding, Ankle Fracture. During the record review performed on 2/7/13 at 3:00 pm, it was found that the patient was evaluated by discharge planning on 12/12/12 at 4:45 pm eight days after admission by a medical referral for medical equipment and home care service. According with the record review the health insurance was who chose the agency that provided the services to the patient. The discharge planning reassessment was on 12/13/12, 12/27/12, 12/28/12, 1/2/13, 1/4/13 and 1/8/13. The facility failed to performed the discharge planning initial assessment in a early stage of hospitalization, according to facility policies and procedures.

i. R.R #10 is a 90 years old female admitted to the facility on 12/15/12 with a diagnosis of Bronchopneumonia (BKP), Congestive Heart Failure (CHF) and Alzheimer. During the record review performed on 2/7/13 at 3:15 pm, it was found that the patient was evaluated by discharge planning on 12/20/12 at 11:40 am five days after admission by a medical referral for home care service. According with the record review the health insurance was who chose the agency that provided the services to the patient. The discharge planning reassessment was on 12/29/12 and 12/31/12. The facility failed to perform the discharge planning initial assessment in an early stage of hospitalization, according to facility policies and procedures.

j. R.R #11 is a 53 years old male admitted to the facility on 1/8/13 with a diagnosis of Acute Stroke and End Stage Renal Disease (ESRD). During the record review performed on 2/7/13 at 3:30 pm, it was found that the patient was evaluated by discharge planning on 1/15/13 at 2:40 pm seven days after admission by a medical referral for medical equipment and home care service the same day of discharge home. According with the record review the patient chose the home care that provided the services. The facility failed to perform the discharge planning initial assessment in an early stage of hospitalization, according to facility policies and procedures.

k. R.R #12 is an 86 years old male admitted to the facility on 12/27/12 with a diagnosis of Cerebro Vascular Accident (CVA). During the record review performed on 2/7/13 at 3:45 pm, it was found that the patient was evaluated by discharge planning on 1/9/13 at 1:25 pm thirteen days after admission by a medical referral for medical equipment and home care service. According with the record review the patient was the one who chose the home care that provided the services to him. The discharge planning reassessment was on 1/10/13, 1/11/13 and 1/14/13. The facility failed to perform the discharge planning initial assessment in an early stage of hospitalization, according to facility policies and procedures.

l. R.R #14 is an 81 years old male admitted to the facility on 12/10/12 with a diagnosis of Cellulites and Alzheimer. During the record review performed on 2/7/13 at 4:15 pm, it was found that the patient was evaluated by discharge planning on 12/19/12 at 11:05 am nine days after admission by a medical referral for Skill Nursing Facilities Services, then referred for Hospice services. According with the record review the patient's relative was the one who chose the hospice services. The discharge planning reassessment was on 12/18/12, 12/19/12 and 12/20/12. The facility failed to perform the discharge planning initial assessment in an early stage of hospitalization, according to facility policies and procedures.

m. R.R #16 is an 84 years old female admitted to the facility on 1/18/13 with a diagnosis of Colon Neoplasia. During the record review performed on 2/7/13 at 4:30 pm, it was found that the patient was evaluated by discharge planning on 1/21/13 three days after admission. The discharge planning reassessment was on 1/24/13, 1/25/13 and 2/1/13. The facility failed to perform the discharge planning initial assessment in a early stage of hospitalization, according to facility policies and procedures.

n. R.R #17 is an 87 years old female admitted to the facility on 1/9/13 with a diagnosis of Dysphagia and Sepsis. During the record review performed on 2/7/13 at 4:45 pm, it was found that the patient was evaluated by discharge planning on 1/11/13 at 2:40 pm two days after admission. On 1/24/13 the patient was referred by the physician for hospice service. According with the record review the patient's relative chose the hospice services. The discharge planning reassessment was on 1/24/13 and 1/25/13. However, no evidence was found related to the authorization and approval of the health insurance for the hospice services. The facility failed to perform the discharge planning initial assessment in an early stage of hospitalization, according to facility policies and procedures.

o. R.R #18 is an 81 years old female admitted to the facility on 1/8/13 with a diagnosis of Severe Dehydration and Metastatic Colon Cancer. During the record review performed on 2/7/13 at 5:00 pm, it was found that the patient was evaluated by discharge planning on 1/11/13 at 8:25 am three days after admission by a medical referral for hospice services. According with the record review the patient's relative was the one who chose the hospice services. The facility failed to perform the discharge planning initial assessment in an early stage of hospitalization, according to facility policies and procedures.

p. R.R #19 is a 91 years old female admitted to the facility on 12/28/12 with a diagnosis of Breast Cancer. During the record review performed on 2/7/13 at 5:15 pm, it was found that the patient was evaluated by discharge planning on 1/2/13 at 11:42 am five days after admission. On 1/9/13 the physician referred to coordinate hospice services. According with the record review the patient's sister chose the hospice service for the patient. The discharge planning reassessment was on 1/18/13 and 1/9/13. However, no evidence was found related to the authorization and approval of the health insurance for the hospice services. The facility failed to perform the discharge planning initial assessment in an early stage of hospitalization, according to facility policies and procedures.

q. R.R #20 is an 80 years old female admitted to the facility on 11/24/12 with a diagnosis of Intestinal Obstruction. During the record review performed on 2/7/13 at 5:30 pm, it was found that the patient was evaluated by discharge planning on 12/11/12 at 2:45 pm seventeen days after admission, the physician referred for hospice services. According with the record review the health insurance was the one who chose the agency that provided the services to the patient. The discharge planning reassessment was on 12/12/12, 12/13/12, 12/19/12, 12/21/12, 12/22/12, 12/26/12, 12/27/12 and 12/28/12. The facility failed to perform the discharge planning initial assessment in a early stage of hospitalization, according to facility policies and procedures.

r. R.R #21 is a 79 years old female admitted to the facility on 1/17/13 with a diagnosis of General Weakness. During the record review performed on 2/7/13 at 1:10 pm, it was found that the patient was evaluated by discharge planning on 1/17/13 at 4:20 pm six days after admission. The facility failed to performed the discharge planning initial assessment in a early stage of hospitalization, according to facility policies and procedures.

s. R.R #22 is a 74 years old male admitted to the facility on 1/29/13 with a diagnosis of Right Femur Fracture. During the record review performed on 2/7/13 at 1:25 pm, it was found that the patient was evaluated by discharge planning on 2/1/13 at 11:45 am, three days after admission, the physician referred for Skilled Nursing Facility services. The discharge planning reassessment was on 12/4/13, 2/5/13 and 2/6/13. The facility failed to perform the discharge planning initial assessment in an early stage of hospitalization, according to facility policies and procedures.

t. R.R #25 is a 69 years old female admitted to the facility on 1/16/13 with a diagnosis of Cerebro Vascular Accident (CVA). During the record review performed on 2/7/13 at 2:05 pm, it was found that the patient was evaluated by discharge planning on 2/1/13 at 10:05 am, sixteen days after admission, the physician referred for nursing home services. The facility failed to performed the discharge planning initial assessment in a early stage of hospitalization, according to facility policies and procedures.

u. R.R #27 is a 56 years old male admitted to the facility on 11/16/12 with a diagnosis of Acute Respiratory Failure. During the record review performed on 2/7/13 at 3:05 pm, it was found that the patient was evaluated by discharge planning on 12/13/12, twenty eight days after admission, on 2/6/13 the physician referred for medical equipment, alimentation, portable mechanical ventilator and home care services. The facility failed to performed the discharge planning initial assessment in a early stage of hospitalization, according to facility policies and procedures.

v. R.R #30 is a 63 years old male admitted to the facility on 2/1/13 with a diagnosis of Infected abdominal wound. During the record review performed on 2/7/13 at 3:35 pm, it was found that the patient was not evaluated by discharge planning because the patient's health insurance was private. The facility failed to perform the discharge planning initial assessment in a early stage of hospitalization, according to facility policies and procedures.

Based on thirty records reviewed and the review of policies and procedures related to the Discharge Planning Program and interview with the Discharge Planning Supervisor (employee #2), it was determined that the facility failed to ensure that discharge planning has policies/procedures related to a defined time frame to assess patients after the screening for three out of thirty records reviewed (R.R #5, #10 and #17).

Findings include:

1. During the review of policies and procedures on 2/7/13 at 10:00 am with the Discharge Planning Supervisor (employee #2) who performs discharge planning, the following was identified:

a. During interview with the discharge planning supervisor (employee #2) on 2/7/13 at 9:10 am related to the discharge planning process she stated that Discharge planning evaluations are performed during the 24 hours after admission for patients with Medicare and Medicare Advantage and those patient over 65 years old based on needs identified by screening during admission to the facility, the patient is re-assessed daily according to patient needs after the initial assessment. Other patients have to be referred by the physician or nurse to be evaluated by the discharge planning program. However, the policies and procedures related to the discharge planning process indicates that "A daily assessment will be performed for all Medicare cases admitted to the institution and other health insurance plan who present any social problems or high risk on discharge". Employee #2 stated that an assessment will be perform of the cases on the third to fifth days on those prolonged cases that need any services. They will assess all Medicare cases admitted to the hospital and other health plans that present some social problem or high risk. There will be a reassessment during the third to fifth day for those cases that require any services for prolonged cases.

b. R.R #5 is an 88 years old male admitted to the facility on 12/7/12 with a diagnosis of Intestinal Obstruction. During the record review performed on 2/7/13 at 2:00 pm, it was found that the patient's discharge evaluation was performed on 12/7/12. No evidence was found related to the discharge planning follow up or reassessment to identify other patient needs during the admission until 12/18/12 when the physician ordered discharge planning for medical equipment and home care services to be discharged on 12/19/12.

c. R.R #10 is a 90 years old female admitted to the facility on 12/15/12 with a diagnosis of Bronchopneumonia (BKP), Congestive Heart Failure (CHF) and Alzheimer's. During the record review performed on 2/7/13 at 3:15 pm, it was found that the patient was evaluated by discharge planning on 12/20/12 at 11:40 am five days after admission. The discharge planning reassessment was on 12/29/13, by a medical referral for home care service. No evidence was found related to the discharge planning follow up to identify other patient needs during the admission until 12/29/12 when the physician ordered discharge planning for medical equipment and Home care services to be discharged on 1/3/13.

d. R.R #17 is an 87 years old female admitted to the facility on 1/9/13 with a diagnosis of Dysphagia and Sepsis. During the record review performed on 2/7/13 at 4:45 pm, it was found that the patient was evaluated by discharge planning on 1/11/13 at 2:40 pm two days after admission. The discharge planning reassessment was on 1/24/13 and 1/25/13 by medical referral for hospice care. However, no evidence was found related to the authorization and approval of the health insurance for the hospice services. No evidence was found related to the discharge planning follow up to identify other patient needs during the admission until 1/24/12 when the physician ordered discharge planning for hospice services to be discharged on 1/25/13.

Based on thirty records reviewed and the review of policies and procedures related to the Discharge Planning Program with the Discharge Planning Supervisor (employee #2), it was determined that the facility failed to ensure that discharge planning personnel complete an evaluation and reassess the patients' needs on a timely basis for post-hospital care before discharge to avoid unnecessary delays with the discharge for one out of thirty records reviewed (R.R #10).

Findings include:

R.R #10 is a 90 years old female admitted to the facility on 12/15/12 with a diagnosis of Bronchopneumonia (BKP), Congestive Heart Failure (CHF) and Alzheimer's. During the record review performed on 2/7/13 at 3:15 pm, it was found that the patient was evaluated by discharge planning on 12/20/12 at 11:40 am five days after admission by a medical referral for home care service. The discharge planning reassessment was on 12/29/12 nine days after the initial assessment and 12/31/12. On 1/2/13 the physician omits the patient's discharge due to the discharge being performed during the evening and the patient's daughter refused the discharge due to the nursing home not accepting the patient at that time, the patient's discharge was delayed until 1/3/13 when the patient was discharged and the discharge planning process was delayed.

Based on the review of thirty medical records, policies/procedures and interview with the discharge planning supervisor (employee #2), it was determined that the facility failed to ensure that ongoing reassessments are performed for patient's needs for factors that may affect continuity of care for 1 out of 30 patients admitted to the facility (R.R #10).
Findings include:

1. During interview with the Discharge Planning Supervisor (employee #2) on 2/7/13 at 9:10 am related to the discharge planning process, she stated that she performs discharge planning evaluations on all patients over 65 years old and according with the medical insurance. If it is an advantage medical insurance they have an agreement with some agency that provides the service to the patient, an example is the medical insurance company CMS Classic Care, they have an agreement with specific companies that provide the service to the patient with this insurance company and they are the ones that assign the agency that is going to provide the services after the patient is discharged. For the medical equipment for supplementary alimentation they have agreements with the Clinical Medical Services and that is the only company that they use to provide the services to the patient. If the patient requests a specific agency, the medical insurance company changes and chooses the agency that is going to provide the services. If patient's have Medicare insurance we ask them if they have a certain agency to choose and if not we provide a list of many agencies of Home Care, Hospice and medical Equipment that the patient can choose from.

2. The facility's policies and procedures establishes that Discharge Planning initial assessment is performed within 24 hour of admitting and the reassessment is performed within 3-5 days as reviewed on 2/7/13 at 10:00 am. The facility failed to establish the patients' ability to perform activities of daily living, family support, person's ability to provide self-care, failed to determine that the patient or family is unable to meet patient needs, for adequate discharge planning.

3. A mechanism to ensure that the discharge planning process is reassessed on an on-going basis was not performed nor followed as found on 2/7/13 from 9:30 am till 6:30 pm, for one out of eight clinical record reviews which did not reveal a re-assessment (R.R #10).

a. R.R #10 is a 90 years old female admitted to the facility on 12/15/12 with a diagnosis of Bronchopneumonia (BKP), Congestive Heart Failure (CHF) and Alzheimer's. During the record review performed on 2/7/13 at 3:15 pm, it was found that the patient was evaluated by discharge planning on 12/20/12 at 11:40 am, five days after admission by a medical referral for home care service. The discharge planning reassessment was on 12/29/12, nine days after the initial assessment and on 12/31/12. On 1/2/13 the physician omits the patient's discharge due to the discharge being performed during the evening and the patient's daughter refused the discharge due to the nursing home not accepting the patient at that time, the patients' discharge was delayed until 1/3/13 when the patient was discharged and the discharge planning process was delayed.

Based on the complaint allegation ACTS Intake PR00000500 survey, review of facility policies/procedures and interview with the Discharge planning Supervisor (employee #2), it was found that the facility failed to include a complete list of Home Care Agencies (HHA), Hospice and Skill Nursing Facilities (SNFs) that are available to the patient, in a geographic area in which the patient resides and failed to provide to patients with advantage medical insurance a list of available Home Care Agencies post-hospital extended care services that have a contract with the advantage medical insurance and failed to document in the patient's medical record that the list was presented to the patient or to the individual acting on the patient's behalf.

Findings include:

1. During interview with the Discharge Planning Supervisor (employee #2) on 2/7/13 at 9:10 am related to the discharge planning process, she stated that she performs the discharge planning evaluation on all patients over 65 years old and according with the medical insurance. If it is an advantage medical insurance they have an agreement with some agencies that they provide the service to the patient, an example is the medical insurance company CMS Classic Care which has an agreement with specific companies that provide the service to the patient with this insurance company and they are the ones that assign the agency that is going to provide the services after the discharge of the patient. For the medical equipment for supplementary alimentation they have an agreement with the Clinical Medical Services that is the only company that they use to provide the services to the patient. If the patient requests a specific agency the medical insurance company changes and chooses the agency that is going to provide the services. If patient has Medicare insurance we ask them if they have a certain agency and they choose, if not we provide a list of many agencies of Home Care, Hospice and medical Equipment that the patient choose from.

2. The facility provided evidence related to a list of twelve home cares, twelve Hospices and thirteen medical equipment companies that provide post-hospital care services to patient with traditional Medicare medical insurance. No evidence was provided on 2/7/13 at 1:10 pm related to a list of Home Care, Hospice and medical equipment company that have contract with the different advantage medical insurance companies.

Based on the review of documents and policies/procedures with the Social Worker Director (employee #2), it was determined that the facility failed to ensure that its discharge planning process is reassessed on an on-going basis.

Findings include:

1. Discharge planning services collects and reports to the Quality Assurance Program Statistical Reports instead of reports that include the patient's needs to continue with dialysis after discharge home and evaluations of ostomized patient. No evidence was found on 2/7/13 at 11:00 am related to indicators or information obtained in order to present facility approach of quality improvement and patient health outcomes as the result of the care provided by the service.

2. No evidence was found on 2/7/13 at 11:25 am of an ongoing mechanism to reassess its discharge planning process.