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.

CORAL SHORES BEHAVIORAL HEALTH 5995 SE COMMUNITY DRIVE STUART, FL 34997 Sept. 26, 2019
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical and administrative record review and staff interview, the facility failed to provide evidence they evaluated all the patient's discharge needs, including medical needs for 1 of 3 sampled patients reviewed for discharge planning ( Patient # 1).

The findings included:

Review of the clinical record for Patient # 1 revealed the patient was admitted to the facility on [DATE] under a Baker Act. While hospitalized , in addition to receiving mental health treatment, the patient received treatment for her insulin dependent diabetes. Throughout her 8 day hospitalization , the patient was prescribed and received twice daily doses of Levemir Insulin and received blood glucose monitoring four times a day with Regular insulin coverage. The physician also prescribed for an increase in the patient's sliding scale coverage and twice daily routine insulin dosage. Despite, the obvious unstableness of the patient's diabetes, there is no evidence the patient was evaluated for her needs post hospitalization regarding her diabetes management; need for and/or the availability of post- hospitalization services or equipment for the patient's diabetes management; evaluation of the patient's capacity for self care of her diabetes medication and monitoring.

The patient was discharged on [DATE] to an assisted living facility. The facility is not licensed to provide blood glucose monitoring or injections for the insulin administration.

Review of the Discharge summary, Nursing and Social Worker Progress Notes, did not provide any documentation regarding the facility staff assessing the patient's medical needs post hospitalization , especially addressing the patient's needs for diabetes management. Nor is there an evaluation whether the patient is capable of self-administration of her injectable medications and glucose monitoring. On the Discharge Summary, Hospital Course and Progress, there is a notation regarding the patient's Levemir dose being increased secondary to elevated blood sugars. However, there is no indication of evaluation of the patient's diabetic needs post hospitalization .

An interview was conducted with the Social Worker and the Director of Clinical Services on 09/26/19 beginning at 9:32 AM. Discharge planning begins at admission and within 24 hours of the projected discharge date . The SW stated that because the patient was in a group home previously, she assumed the patient was capable of managing her diabetic needs. She further stated she will document placement and referrals made and the patient's medical needs are addressed by the physician and nursing.
VIOLATION: LIST OF HOME HEALTH AGENCIES Tag No: A0823
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on administrative and clinical record review and staff interview, the facility failed to provide evidence, patients are provided the freedom of choice in selecting the Home Health Agency and/or Skilled Nursing Facility for 1 of 1 medicare discharge patients reviewed (Patient # 4). The facility also failed to provide evidence the patients are provided a list of providers to make an informed choice.

The findings included:

An interview was conducted on 09/26/19 beginning at 12:15 PM with the Director of Clinical Services and the Risk Manager. The facility does not have a choice letter to document the patient was provided a list of providers for Home Health or Skilled Nursing Facility. The facility also does not document the patient's preferences/choice for those providers. The Director stated, they look at what insurance the patient has and just call the provider. The provider that accepts the patient, is the provider they identify on the After Care part two form and have the patient to sign, acknowledging they agree with the plan.

Review of the clinical record for Patient # 4, who was discharged on [DATE]. The patient was discharged Home with Home Care. On the Aftercare Part II, the SW listed one Home care agency as the Home Health Agency and the patient signed the discharge plan.
The Discharge summary noted the discharge plan of Home Health Agency for psych and nursing. The 09/18/19 prescription also notes for medication management, Nursing, and Home Care.