HospitalInspections.org

Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that discharge planning is developed under the supervision of a social worker in accordance with facility policy.

Findings include:

Facility policy titled, "Social Work Process" revised 12/23/19, stated, "Policy: The social worker is responsible for the coordination of continuing care services for patients who need or request assistance. He/she shall coordinate services as necessary in order to establish a plan for the appropriate, safe, and timely discharge of the patient from the hospital to home or other healthcare facility. ..."

On 5/13/25 at 10:00 AM, an entrance conference was conducted with Staff (S)1 (Chief Compliance Officer and Director of Quality). S1 stated the Long-Term Acute Care Hospital (LTACH) has two units with a total of 63-beds, that had a total census of 31 patients.

At 10:05 AM, during an interview, S1 indicated that the facility does not have a social worker for the LTACH and stated, "I am the director of quality and doing social work, do you think I know what I am doing?" S1 confirmed that he/she was responsible for planning the patients social work interventions, including discharge planning.

On 5/13/25, a review of medical records revealed the following:

A review of P1's medical record review was conducted with S8 (Director of Medical Records). P1 was admitted on 3/4/25 at 1:20 PM with a diagnosis of Cellulitis of right lower limb. The IDT (Interdisciplinary Team) Weekly Round note on 3/10/25 and 3/17/25, stated, " ...IDT-Social Work The patient requires the following: SW (social work) and CM (case management) to follow for discharge Interventions: SW and CM to follow safe and appropriate discharge plan. ... "

Upon interview, S8 stated that the IDT team consists of all disciplines including nursing, dietary, respiratory therapy, pharmacy, and wound nursing. The IDT Weekly Round notes on 3/31/25, 4/8/25, 4/16/25,4/21/25, 4/28/25, 5/4/25, 5/11/25 lacked documentation from a social worker. S8 further stated that S1 has been filling in as the social worker, and that S1 does not document in the social work section of the IDT notes, since he/she is not a social worker.

A review of P11's medical record indicated that P11 was admitted to the facility on 2/26/25 with the diagnosis of respiratory failure, dependence on respirator, heart failure, and diabetes. The IDT [interdisciplinary] Weekly Round report dated 4/21/25 was reviewed. The report was signed by Nutrition, Respiratory, Physical Therapy, and Wound Care. The Social Work section was blank. The Discharge Summary stated, " Condition at time of discharge ...Cleared by PMD [primary medical doctor] to be discharge [sic] home on trach as per family requested with home care services ..."

Upon interview, S1 stated it was blank because there was no social worker at the facility. P11 was discharged from the facility on 4/25/25. During the interview, S1 confirmed that there was no documentation in the medical record that services were set up for visiting nurse services and oxygen therapy prior to discharge.

On 5/13/25 at 4:05 PM, S1 confirmed the LTACH has been without a social worker since February 2025.