§483.21(c)(1) Discharge Planning Process
The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and-
(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident.
(ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.
(iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan.
(iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.
(v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan.
(vi) Address the resident's goals of care and treatment preferences.
(vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community.
(A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose.
(B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities.
(C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why.
(viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences.
(ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer.
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Observations:
Based on interviews and clinical record reviews it was determined that the facility failed to update a resident's discharge plan in the clinical record for two of three clinical records reviewed (Residents 2, and 3).
Findings include:
Review of Resident 2's clinical record revealed diagnosis that included; hemiplegia (paralysis of one side of the body), difficulty walking, diabetes (the body's ability to produce or respond to insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), dementia (a chronic disorder of the mental processes marked by memory disorders, personality changes, and impaired reasoning), anxiety (a feeling of worry, nervousness or unease), congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), spinal stenosis (a narrowing of the spinal canal), and osteoporosis (bones become brittle and fragile from loss of tissue). Further review of Resident 2's clinical record revealed she was admitted to the facility on February 26, 2021, and transferred to the hospital on March 16, 2021.
During an interview with Licensed Practical Nurse 1 (LPN 1), and Social Service Director 1 (SS 1); on March 17, 2021, at approximately 12:46 PM it was revealed that resident specific notes pertaining to discharge planning are not documented in the chart, each Social Service employee keeps a working form that they use. During their initial interview with Resident 2 the discharge plan was for her to return to home. Both LPN 1 and SS 1 acknowledge that Resident 2 had not asked to go home at any point during her stay at the facility up to that point.
Review of Resident 2's care plan stated a focus area: shows potential for discharge and patient, relative or representative express wish for discharge, initiated date February 26, 2021; with a goal to discharge to home when clinical and rehabilitation goals are met, date initiated February 26, 2021; and interventions that included to assess future placement setting to determine if the patient's needs can be met, initiated date of February 26, 2021. Further review of Resident 2's clinical record failed to include an update to the discharge plan based on the assessment of the safety of the home and possible need for alternate placement. Further review of the clinical record revealed the following statement on the resident information ribbon in the electronic record: "DO NOT DISCHARGE RESIDENT. Any request for discharge: call administrator".
During an interview with LPN 1 and SS 1 on March 17, 2021, at approximately 2:00 PM it was revealed that the aforementioned statement was added to Resident 2's clinical record because Resident 2's daughter called the facility to inform them she would be picking her mother up from the facility on Friday, March 12th or over that weekend. LPN 1 also revealed that Resident 2's daughter called her on March 11th or 12th to say she wanted to take her mother home, LPN 1 informed her that the facility would not discharge her mother back into the home at that time.
Resident 2's discharge plan was not updated in the clinical record to reflect the aforementioned information.
Clinical record review revealed that on March 16, 2021, Resident 2 was transferred to the hospital. There was no documented evidence that the facility communicated to the hospital regarding the needs identified in discharge plan for Resident 2.
Review of Resident 3' clinical record revealed diagnoses that included; homeless, gout (defective metabolism of uric acid causes arthritis especially in the smaller bones of the feet), depression (constant feeling of sadness and loss of interest which stops you from doing your normal activities), insomnia (persistent problems falling and staying asleep), emphysema (disorder effecting the lungs making it harder to breath), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), osteoarthritis (degeneration of joint cartilage causing pain and stiffness), and difficulty walking.
Further review of Resident 3's clinical record revealed he was admitted to the facility on February 27, 2021, from the hospital. Review of Resident 3's care plan stated a focus area: shows potential for discharge and patient, relative or representative express wish for discharge, initiated date February 27, 2021; with a goal to discharge to home when clinical and rehabilitation goals are met, date initiated February 27, 2021 and revised March 13, 2021; and interventions that included to assess future placement setting to determine if the patient's needs can be met, initiated date of February 27, 2021 .
During an interview with Resident 3 on March 17, 2021, at approximately 12:30PM it was revealed that his therapy services stopped and SS 1 informed him verbally. He stated that he was admitted to the facility for rehabilitation, and then he was to transfer to a halfway house until permanent housing was available. As of that day, he was not sure if that was still his discharge plan.
During an interview with LPN 1 and SS 1 on March 17, 2021, at approximately 12:45 PM it was revealed that Resident 3 was recently cut from therapy services, and that the facility was in the process of helping him apply for Medicaid, and Social Security Disability. It was also revealed that his current insurance will cover his stay at the facility for thirty days from the time of admission.
During an interview with SS 1 on March 17, 2021 at approximately 2:00 PM it was revealed that once Resident 3 is approved to receive Medicaid, he has a choice of three different plans, once he decides on a plan, a case worker will be assigned to him, and provide assistance in finding appropriate housing. Surveyor asked if Resident 3's care plan should have been updated to reflect details of Resident 3's discharge plan, to which they responded that it should have been updated.
During an interview with Assistant Business Office Manager 1 (ABOM 1) on March 17,2021, at approximately 2:30 PM it was revealed that the needed information was gathered and submitted Resident 3's Medicaid application on March 10, 2021. It was also revealed that he was cut from therapy services on March 16th, due to meeting his therapy goals, and his current insurance plan will pay for his stay for thirty days from the time of admission, after that point he will be considered Medicaid pending.
The facility failed to re-evaluate and update discharge plans when needs change, and accurately document changes to resident discharge plans in the clinical record.
28 Pa. Code 211.11(d) Resident Care Plans
| | Plan of Correction - To be completed: 04/09/2021
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Laurel Lakes Rehabilitation & Wellness Center agrees with the allegations and citations listed on the statement of deficiencies. Laurel Lakes Rehabilitation & Wellness Center maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Laurel Lakes Rehabilitation & Wellness Center's written credible allegation of compliance.
By submitting this plan of correction, Laurel Lakes Rehabilitation & Wellness Center does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Laurel Lakes Rehabilitation & Wellness Center reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.
Identified discharge plan details for Residents 2 and 3 were incorporated into their care plan potential for discharge approaches.
Social Services Director will audit care plans of active residents with potential for discharge goals to validate care plans accurately reflect individualized approaches. Concerns will be corrected upon discovery.
Social services staff will be re-educated concerning clinical record discharge plan documentation by the Administrator or designee. Lead Registered Nurse Assessment Coordinator or designee will conduct a random audit of five discharge care plans weekly for three weeks and monthly for three months to validate care plans accurately reflect individualized approaches. Audit results will be reported to the Administrator. Concerns will be addressed upon discovery.
Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.
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