The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ASPIRE HEALTH PARTNERS 1800 MERCY DR ORLANDO, FL April 26, 2013
VIOLATION: COMPLIANCE WITH LAWS Tag No: A0021
Based on interview and record review, the facility failed to report to the Agency for Health Care Administration, an unlicensed assisted living facility (ALF) provider in Orlando, Florida, who accepted 4 of 13 sampled clients (#2, 3, 6 & 7).

Findings:

1. Record review of client #3's record revealed an in-patient hospital stay from 8/24/12 to 9/05/12. Review of the Therapist/Discharge planning notes revealed the therapist had made a referral to an unlicensed ALF on Willie Mays Parkway. No documentation was observed in the record that the client participated in the decision for the ALF referral or was offered choices of any licensed facilities.

2. Record review of client #2, #6, and #7 records revealed documentation that the clients had previously lived at an unlicensed ALF on Willie Mays Parkway. Upon hospital discharge, Therapist/Discharge planning notes revealed the clients were returned to the facility without being offered choices or referrals of other licensed ALFs.

Interview with the manager of the Risk Management/Quality Assurance Department on 4/26/13 at approximately 11:45 AM revealed the facility was not aware that unlicensed facilities should be reported to the Agency for Health Care Administration (AHCA) and that the unlicensed facility had not been reported.

Interviews with 5 facility Therapist/Discharge Planners on 4/26/13 throughout the survey at approximately 1 PM, 2:30 PM and 3:30 PM revealed the facility has protocols not to refer clients to an unlicensed facility. However, if a client previously lived in an unlicensed facility they would return them to the facility as it was their home. The Therapist/Discharge planners further related they were not aware an unlicensed facility should be reported to the AHCA and none had reported the unlicensed facility on Willie Mays Parkway.
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, the facility failed to provide appropriate discharges to State licensed Assisted Living Facilities (ALFs) for 4 of 13 sampled clients which included 1 initial assisted living facility (ALF) client referral (#3), and 3 ALF referrals (#2, 6 & 7) that returned the clients back to the unlicensed ALF post hospitalization .

FINDINGS:

1. Review of client #2's medical record revealed discharge planning documentation which read on 2/07/13 "RESIDENTIAL REFERRAL AGREEMENT...After diligent discharge planning, the client does NOT require referral placement as s/he has access to personal support system and residential placement in the community with family member, friend or other private residence." There was no client name documented on the form.

The form documented- Relationship to Client: Group Home Owner
Address: 737 Willie Mays Pkwy. 407-218-1082
Point of Contact: (owner's name)
The form was dated 2/07/13 and signed by the client and a staff member.

The facility "DISCHARGE PLANNING NOTES/CONTACT SHEET" of 1/23/13 at 12:08 PM documented a telephone call to the client's sister who stated "...he lives with ...at a group home....he wanders from the group home, had done well when first released from Macclenny....my main concern is someone's going to hurt him...wants him back at Macclenny."

A follow up discharge planning note of 1/23/13 at 12:16 PM documented a conversation with member #A of the FACT team which read, " ...he was screaming a lot at the group home....does take his meds but needs someone to supervise him doing it, hx of wandering, hx of alcohol abuse prior to State hospital, needs stabilization on meds, no discharge on Fridays."

A follow up discharge planning note dated 1/23/13 at 2 p.m. read, "came to visit (client #2), evaluate mental status....was in bed, easily aroused, mumbling speech, difficult to understand. Cooperative. Unable to remember events leading to admission. Difficult to evaluate for psychosis." No further discharge planning notes were observed in the record prior to the discharge documentation of 2/7/13. The client was discharged to Willie Mays Pkwy as documented.

The facility's "PHYSICIAN DISCHARGE ORDERS" dated 2/07/13 documented the client's discharge to an "ALF/Group Home". The facility's "INPATIENT DISCHARGE INSTRUCTIONS" form was completed and signed by the nurse, the discharge staff member and signed by the patient on 2/07/13.

No documentation was seen concerning additional referrals to licensed ALFs, other options, or client wishes.

2. Review of client #3's record revealed discharge planning documentation as follows. On 9/05/12, a form entitled "RESIDENTIAL REFERRAL AGREEMENT" read, "After diligent placement planning, we found the following CONFIRMED LICENSED facility that is able to accept the individual for residential placement:
Name: "...ALF" Address: 737 Willie Mays Pkwy. Orlando FL Point of contact: (owner's name)

The facility's "DISCHARGE PLANNING NOTES/CONTACT SHEET" are as follows:
8/27 (no year) at 1:30 PM documented telephone conversation with member #B of the FACT team stating current med list and no contact info for family. Attempts to reach client's mother at old phone number 8/27 (no year) 2:15 PM.
8/29 (no year) at 12:30 PM - email from member #C from the FACT team - client will be visited today. 8/29/ (no year) at 12:30 PM stated, "FACT Team CM (case management) came to visit client-client had a colostomy 2 ? weeks ago due to weight lass/waiting on results, clt. will be moving to a new group home and everything will be moved for clt. Prior to discharge."
8/31 (no year) at 9 AM read, "Therapist met with ...(FACT Team psychiatrist) - clt. was evicted from group home and they are working on getting a new group home (FACT Team psychiatrist) wants clt. to be off Haldol..."
8/31/12 at 1:45 read, "Spoke to (client) to evaluate mental status. He said he was brain dead but was able to identify Dr. (name) as his psychiatrist. Stated he wants to go move and was informed that he would be going to a new placement after discharge.
9/05/ (no year) at 11:20 p. m, "Therapist notified CM of discharge today - (member #C of FACT team) will pick up and transport to a new group home."

The facility's "INPATIENT DISCHARGE INSTRUCTIONS" form was completed and signed by the nurse, the discharge staff member and signed by the patient on 9/05/12. The Discharge Plan documented (owner's name) ALF 407-294-2130, 737 Willie Mays Pkwy. Orlando, FL .

There was no documentation seen that the client was offered discharge options or that referrals were made to other licensed ALF/group home residencies.

3. Review of client #6's record revealed discharge documentation stating:
"RESIDENTIAL REFERRAL AGREEMENT" of 12/24/08 address of 737 Willie Mays Pkwy. Orlando, FL 407-294-2130 -Point of contact: (Owner's name) group home operator.

The facility's "DISCHARGE PLANNING NOTES/CONTACT SHEET" dated 12/09 (no year) read, "(Owner's name) group home operator; 12/19, "called (group home operator) to inform of upcoming discharge ..."

Physician's history and physical dated 12/05/08 documented "[AGE] year old male who lives in assisted living facility, was admitted to this facility on an ex parte. The client was discharged to the unlicensed ALF listed on Willie Mays Pkwy on 12/24/08.

4. Review of client #7's medical record revealed D/C Planning documentation which read, A form entitled "RESIDENTIAL REFERRAL AGREEMENT" read on 11/23/09 with a check mark on the box, "is capable of independent living and therefore does NOT need assistance with the multiple personal services and may select an independent living arrangement as desired by the individual and as afforded them under Florida Statute 394: Client Rights, and in keeping with the State of Florida Recovery & Resiliency Model. There was no address listed in the adjoining space.

An address listed on the form was: 737 Willie Mays Parkway, Orlando, Florida - 407-294-2130; Point of Contact: (owner's name) house owner. The form was dated 11/23/09 and signed by the client and a staff member as registered mental health intern.

The facility "DISCHARGE PLANNING NOTES/CONTACT SHEET" dated 11/12/09 read, "Therapist called to speak with (owner's name) ....She stated (client's name) is welcome to return after discharge."
11/19 (no year) at 2 PM read, "....called (owner's name) at client's request to let her know that he is OK...is still OK with client returning.

No further discharge planning notes were seen. The client was discharged on [DATE] to the ALF at 737 Willie Mays Parkway Orlando, Florida. No further referral options to licensed ALFs were documented.

Interview with the manager of the Risk Management/Quality Assurance Department on 4/26/13 at approximately 11:45 AM revealed the facility was not aware that unlicensed facilities should be reported to the Agency for Health Care Administration (AHCA) and that the unlicensed facility had not been reported.

Interviews with 5 facility Therapist/Discharge Planners on 4/26/13 throughout the survey at approximately 1 PM, 2:30 PM and 3:30 PM, revealed the facility has protocols not to refer clients to an unlicensed facility however if a client previously lived in an unlicensed facility they would return them to the facility as it was their home. The Therapist/Discharge planners further related they were not aware an unlicensed facility should be reported to the AHCA and none had reported the unlicensed facility on Willie Mays Parkway.