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Based on record review and interview, the rehabilitation hospital failed to meet the requirements of the Condition of Participation for Discharge Planning as evidenced by:
1) failure to complete an ongoing, periodic review of a representative sample of discharge plans to ensure that the plans are responsive to the patient post-discharge needs (See findings in A0803).
2) failure to include appropriate post-hospital services on the discharge orders. (See findings in A0807).
3) failure to document in the patient's medical record that a list of HHA's, SNF's, IRF's, or LTCH's available to the patient participating in the Medicare program was presented to 3 (#1-#3) of 3 (#1-#3) patients sampled (See findings in A0815).
4) failure to inform 3 (#1-#3) of 3 (#1-#3) patients or their representatives of their freedom to choose among participating Medicare providers and suppliers of the post-discharge services (See findings in A0816).

Based on record review and interview, the Governing Body failed to ensure the members of the medical staff were accountable to the Governing Body for quality of care provided to patients. This deficient practice was evidenced by failure of medical staff members to ensure financial disclosure of the financial interest in a group home owned by S3SW of which Patient #1 was referred.
Findings:

Review of Patient #1's medical record revealed an admit date of 08/15/2025 with diagnosis other Neurologic Conditions. Primary insurance was Medicare. Patient was discharged on 08/25/2025 to a group home owned by S3SW.

During a interview on 09/02/2025 at 2:37 PM, S2DON reported that she was not familiar with the hospital process for disclosing financial interest.

During an interview on 09/02/2025 at 3:20 PM, S3SW confirmed Patient #1 lived at S3SW's group home. S3SW verified Patient #1's chart would not have evidence of financial disclosure of financial interest in the group home owned by S3SW in which Patient #1 was referred because Patient #1 did not sign documents that she was notified of S3SW's financial interest in the group home.

Based on Record review and interview the rehabilitation hospital failed to ensure the patients' right to privacy as evidenced by failure to protect patient personal information in 14 (#1, #2, and #R1-#R12) of 14 (#1, #2, and #R1-#R12) patient files located on a counter in an unlocked room accessible to any individual present at the hospital.
Findings:

Review of rehabilitation hospital policy #01-01-01 titled "Patient Rights & Privacy", adopted 01/2020, revealed in part: "Procedure: F. Patients' Basic Rights-The patient has the right to the following: 15. To have medical records kept confidential."

During a tour on 08/28/2025 at 8:46 AM, observations of the 1st floor revealed an unlocked room located to the left of the lobby. Noted were 14 patient folders with patient identification including medical record numbers and names attached to the folders, laying on counter accessible to anyone who walked into the unlocked room.

During an interview on 08/28/2025 at 8:47 AM, S17PT confirmed the door was unlocked and the patient files were laying on the counter accessible to anyone who walked into the unlocked room.

During an interview on 08/28/2025 at 9:15 AM, S2DON stated the files should have been located in a locked cabinet inside of a locked room in order to preserve patient privacy.

Based on record review and interview, the rehabilitation hospital failed to ensure care in a safe setting as evidenced by failure to ensure 1 (S6CNA) of 1 (S6CNA) unlicensed staff personnel files reviewed underwent a criminal back ground check.
Findings:

Pursuant to La. R.S. 40:1203.1-5, licensed health care providers shall request that a criminal history and security check be conducted on the non-licensed person, prior to any employer making an offer to employ or to contract with a non-licensed person or any licensed ambulance personnel to provide nursing care, health-related services, medic services, or supportive assistance to any individual.

Pursuant to La. R.S. 40:2179 and 2179.1, in part: "Non-licensed person" means any person who provides for compensation nursing care or other health-related services directly related to patient care to patients of a hospital.

The Louisiana Office of State Police, Bureau of Criminal Identification and Information (Bureau), is the State's designated repository for criminal history information pursuant to the laws cited in La. R.S. 15:575 et seq. Any criminal event that is documented by the submission of fingerprints to the State is stored in the Louisiana Computerized Criminal History (LACCH) database. The Bureau is authorized to release criminal history information stored in LACCH to those employers and Authorized Agencies defined in La. R.S. 40:1203.1 as required by La. R.S. 40:1203.2 Employers may request criminal history information stored in LACCH in one of three ways: (1) use of the Bureau's Internet Background Check (IBC) website (https://ibc.dps.louisiana.gov/), (2) via Authorized Agents, and (3) submission of applicants fingerprints.

Review of S6CNA's personnel file revealed a date of hire of 09/26/2023. Continued review failed to reveal evidence of a Louisiana Office of State Police approved criminal background check.

During an interview on 09/02/2025 at 10:47 AM, S2DON confirmed S6CNA's personnel file did not reveal evidence of a Louisiana Office of State Police approved criminal background check.

Based on record review and interview, the rehabilitation hospital failed to ensure the Registered Nurse (RN) assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available as evidence by failure to complete patient care assignments.
Findings:

During a tour on 08/28/2025 at 8:54 AM observation of nursing station failed to reveal patient-care assignment documents.

During an interview on 08/28/2025 at 8:55 AM, S8RN stated the hospital had a census of 7 patients and that she was working with S9CNA, S10LPN and S11CNA. S8RN confirmed she did not complete patient care assignments.

During an interview on 08/28/2025 at 9:27 AM, S2DON confirmed the hospital's registered nurses did not complete patient care assignments.

Based on record review and interview the hospital failed to assess the discharge planning process on a regular basis as evidenced by failure to complete an ongoing, periodic review of a representative sample of discharge plans to ensure that the plans are responsive to the patient post-discharge needs.
Findings:

Review of Rehabilitation Hospital document titled "Performance Improvement Monitoring and Indicators 2025", undated, revealed in part: "Priority Focus Area: UR/Discharge Planning. Performance Standards Measures/Indicators/Outcomes. Threshold 100%. Data Collection All Patients. Frequency of Collection/reporting Monthly and Quarterly.

Review of Rehabiliation Hospital document titled "QI/PI Report QTR 2-2025" revealed in part: "Utilization Review Committee Function" (Includes social services/discharge planning). Quality indicators: Discharge planning is initiated by case manager and continues with social worker. Quality outcomes and results of monitoring activities: 2nd Quarter-April, May, June. April-Admissions 15, Discharges 12. May-Admissions 15, discharges 16, and June-Admissions 15, Discharges 19.

Further review of "QI/PI Report QTR 2-2025" failed to reveal the rehabilitation hospital assessed its discharge planning process on a regular basis by completing an ongoing, periodic review of a representative sample of discharge plans to ensure that the plans are responsive to the patient post-discharge needs.

During an interview on 09/02/2025 at 2:41 PM, S2DON stated the rehabilitation hospital did not assess the discharge planning process on a regular basis by completing an ongoing, periodic review of a representative sample of discharge plans to ensure that the plans are responsive to the patient post-discharge needs.

Based on record review and interview the rehabilitation hospital failed to ensure the evaluation of patient #3's need for appropriate post-hospital services as evidenced by failure to include appropriate post-hospital services on the discharge orders.
Findings:

Review of Patient #3's medical record revealed an admission date of 07/01/2025 with a diagnosis of Parkinsonism.

Review of Patient #3's History and Physical dated 07/01/2025 revealed Patient #3 had a complex medical history including schizoaffective disorder, tachycardia, bipolar, anxiety, cocaine use, COPD, GERD, PTSD, and diabetes. She had a progressive functional decline and recurrent acute hospitalizations necessitating 24-hour skilled nursing care and ongoing medical management. Patient with multiple comorbidities, hypertension, weakness, history of seizures, and functional decline.

Review of Patient #3's Treatment plan revealed patient was a high risk for falls with precautions not to leave patient alone in the bathroom. Further review patient with the following required treatments: Physical Therapy, 60 to 90 minutes per day, 5 to 7 days a week for 10-14 days.
Self-care admission status revealed patient needed grab bars, extended shower head and sitting bench. Patient lost her balance while showering and had to have assistance for safety.
Barriers to discharge revealed the following: Fall history, fall risk, requires caregiver assist, functional mobility training.

Review of Patient #3's anticipated post-discharge services included Home Health services, Nursing, occupational therapy, and physical therapy.

Review of Physician Discharge orders dated 07/10/2025 revealed the following:
Discharge Home 07/11/2025.
Order noted details: Discharge Home. Signed by S12MD.

Further review of Physician Discharge orders dated 07/10/2025 failed to reveal orders for the following:
Home Health
Nursing services
Occupational Therapy
Physical Therapy
Diet
Follow-up with medical provider / psychiatric provider
DME for shower

During an interview on 09/02/2025 at 2:35 PM, S2DON confirmed the above findings.

Based on record review and interview the rehabilitation hospital, as part of the discharge planning process, failed to inform 3 (#1-#3) of 3 (#1-#3) patients or their representatives of their freedom to choose among participating Medicare providers and suppliers of the post-discharge services.
Findings:

Review of rehabilitation hospital policy #01-01-05 titled "Discharge Planning", 01/2020, revealed in part: "Post discharge plan that includes Home Health Agency (HHA) or long-term care: If the patient comes in without such services, a list of agencies in the geographical area that accept the insurance plan the patient has will be made available to them for review and selection. Patients are free to choose any agency available and the hospital does not specify or limit referral. Patients are free to choose any agency available and the hospital does not specify or limit patient choice. The hospital has no financial or related party interests in any local HHA or Skilled Nursing Facility programs."

Patient #1
Review of medical record revealed an admit date of 08/15/2025 with diagnosis other Neurologic Conditions. Primary insurance was Medicare. Patient was discharged on 08/25/2025 to a group home owned by S3SW.

Continued review failed to reveal evidence of her freedom to choose among participating Medicare providers and suppliers of the post-discharge services.

Patient #2
Review of medical record revealed an admit date of 08/18/2025 with diagnosis other Neuromuscular Conditions. Primary insurance was Medicare. Patient was discharged on 08/26/2025 to a friend's home.

Continued review failed to reveal evidence of his freedom to choose among participating Medicare providers and suppliers of the post-discharge services.

Patient #3
Review of medical record revealed an admit date of 07/01/2025 with diagnosis Parkinsonism. Primary insurance was Medicare. Patient was discharged on 07/11/2025 to a group home.

Continued review failed to reveal evidence of his freedom to choose among participating Medicare providers and suppliers of the post-discharge services.

Based on record review and interview the hospital failed to document in the patient's medical record that a list of HHA's, SNF's, IRF's, or LTCH's available to the patient participating in the Medicare program was presented to 3 (#1-#3) of 3 (#1-#3) patients sampled.
Findings:

Patient #1
Review of medical record revealed an admit date of 08/15/2025 with diagnosis other Neurologic Conditions. Primary insurance was Medicare. Patient was discharged on 08/25/2025 to a group home owned by S3SW.

Continued review failed to reveal Patient #1 was presented with a list of HHA's, SNF's, IRF's, or LTCH's available to this patient participating in the Medicare program.

During an interview on 08/28/2025 at 1:30 PM in the presence of S2DON, S3SW stated she and brother were the owners of the group home that Patient #1 was discharged to on 08/25/2025.

During an interview on 09/02/2025 at 3:20 PM, S3SW confirmed Patient #1 lived in the group home she owned. S3SW does not remember if she showed the list of HHA's, SNF's, IRF's, or LTCH's available to this patient participating in the Medicare program but she thought she did.

During an interview on 09/02/2025 at 2:45 PM, S2DON confirmed that Patient #1's medical record failed to reveal evidence that she was provided a list of HHA's, SNF's, IRF's, or LTCH's available to her who was a participant in the Medicare program.

Patient #2
Review of medical record revealed an admit date of 08/18/2025 with diagnosis other Neuromuscular Conditions. Primary insurance was Medicare. Patient was discharged on 08/26/2025 to a friend's home.

Continued review failed to reveal Patient #2 was presented with a list of HHA's, SNF's, IRF's, or LTCH's available to this patient participating in the Medicare program.

During an interview on 09/02/2025 at 1:20 PM, S2DON confirmed that Patient #2's medical record failed to reveal evidence that he was provided a list of HHA's, SNF's, IRF's, or LTCH's available to him who was a participant in the Medicare program.

Patient #3
Review of medical record revealed an admit date of 07/01/2025 with diagnosis Parkinsonism. Primary insurance was Medicare. Patient was discharged on 07/11/2025 to a group home.

Continued review failed to reveal Patient #3 was presented with a list of HHA's, SNF's, IRF's, or LTCH's available to this patient participating in the Medicare program.

During an interview on 09/02/2025 at 2:12 PM, S2DON confirmed that Patient #3's medical record failed to reveal evidence that she was provided a list of HHA's, SNF's, IRF's, or LTCH's available to her who was a participant in the Medicare program.

During an interview on 09/02/2025 at 2:50 PM, S2DON confirmed S3SW's group home was not on the list of HHA's, SNF's, IRF's, or LTCH's available to patients who participant in the Medicare program.