§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 clinical record review, facility documentation, and staff and resident interview, it was determined that the facility failed to develop and implement an effective discharge planning process, which begins on admission, including resident's assessments and goals for care for one of 24 residents reviewed (Resident 90).
Findings include:
Clinical record review for Resident 90 revealed that the resident was 57 years old and was admitted to the facility on October 20, 2023, following a fracture of the right proximal humerus (upper arm).
The surveyor requested an admission history and physical for Resident 90 and was provided with a history and physical competed by the referring hospital dated October 17, 2023. The history and physical revealed the resident lived at home prior to the hospitalization. The resident reported current drug use of marijuana and prescription drugs. Resident 90 lived with two roommates.
Review of a care plan for Resident 90 dated October 23, 2023, revealed the resident concealed medications when staff administered medications. The staff were to ensure that the resident swallowed medications during the medication pass and to observe for mental status or behavioral changes when new medication is started or when there is a change in dosage.
Review of a social service discharge plan completed for Resident 90 on October 24, 2023, revealed the resident wished to be discharged to live independently in an apartment.
Review of an admission MDS (Minimum Data Set, a comprehensive assessment to determine resident needs) for Resident 90 dated October 26, 2023, revealed the resident had a BIMS (Brief Interview for Mental Status, a score of 13 to 15 indicates the person is cognitively intact) of 15.
Review of physician progress notes for Resident 90 dated December 13, 2023, referred to the resident being opioid (narcotic) dependent and on January 3, 2024, referred to the resident as drinking a lot and was taking narcotics.
Interview with Resident 90 on February 6, 2024, at 11:35 AM revealed that the resident was being discharged the following day to a hotel. The resident indicated that the facility tried to get representative payee (a payee manages benefit payments for residents incapable of managing their Social Security Income payments) but the resident cancelled it by contacting the Social Security office. Resident 90 reported being homeless. The resident lived with roommates, but they did criminal activities, so the resident went to a hotel. Resident 30 indicated wanting to be discharged and the facility wanting the resident discharged.
Clinical record review for Resident 90 on February 6, 2024, at 12:30 PM revealed there were no care plans related to discharge planning and no social service notes regarding the impending discharge. In addition, clinical record review for Resident 90 revealed there were no referrals to agencies regarding drug abuse or offers of treatment for drug abuse upon discharge.
The surveyor requested discharge planning information for Resident 90 and subsequently met with the Nursing Home Administrator and Employee 5, business office manager, on February 6, 2024, at 12:30 PM. During this time, Employee 4 provided documentation entries, which included the resident's financial status, apartment application status, money the resident owed the facility, and conversations with the Social Security department and the facility social worker. The Nursing Home Administrator confirmed these records were not part of the resident's clinical record but documents in the financial record.
Following the surveyor's questioning Resident 90's discharge plans, social service documentation on February 6, 2024, at 12:49 PM revealed that the social worker and business office manager met with the resident to confirm that the resident received an application for a specific apartment, and that the resident had a reservation at a local hotel from February 7 to 14, 2024, paid by the facility and a $50.00 dollar gift care for necessities or food until Resident 90's Social Security funds become available on February 8, 2024. A social service note dated February 7, 2024, at 11:08 AM revealed the resident will be seen by a physician in the community for follow up on February 8, 2024.
Review of a physician discharge summary for Resident 90 dated February 7, 2024, revealed the resident got into trouble at a hotel in the area, was kicked out, was homeless, and had to be admitted to the facility. The reasons for admission were poor social support, homelessness, drug seeking, and associated abnormal behaviors. The resident wanted to be discharged and the facility provided her with some funds to rent a local hotel room.
The facility failed to develop and implement an effective discharge planning process, which begins on admission, including resident assessments and goals, and the reduction of factors leading to preventable readmissions, and referrals to local contact agencies for treatment of drug dependence.
28 Pa. Code 201.18 (3)(e)(1) Management
28 Pa. Code 211.10(a) Resident care plan
| | Plan of Correction - To be completed: 03/19/2024
Resident 90's care plan and social services notes cannot be retroactively revised. Referrals to outside agencies cannot be retroactively made.
A whole house audit was conducted to ensure any residents showing active discharge planning have discharge planning care plan(s) and interdisciplinary team approach documentation.
Education was provided to social services, IDT and licensed staff regarding documentation regarding active discharge planning.
The social service director or designee will complete audits of residents being discharged to ensure they have discharge planning care plans and referrals to outside agencies, when applicable x6 weeks. Audit results will be presented monthly during QAPI.
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