Centura St. Catherine-Dodge City

“DISCHARGE PLANNING-D/C PLANNING LIST CFR(s): [The hospital must] include the discharge planning a list of HHA’s, SNF’s, IRF’s, or LTCH’s that are available to the patient, that are participating in the Medicare program, and that serve the geographic area(as defined by the HHA) in which the patient resides, or in the case of a SNF, IRF, or LTCH, in the geographic area requested by the patient. HHAs must request to be listed by the hospital as available. (i) The list must only be presented to patients for whom home health care post hospital extended care services, SNF, IRF, or LTCH services are indicated and appropriate as determined by the discharge planning evaluation. (ii) For patients enrolled in managed care organizations, the hospital must make the patient aware of the need to verify with their managed care organization which practitioners, providers or certified suppliers are in the network of the patient’s managed care organization, it must share this with the patient or the patient’s representative. (iii) [The hospital must] document in the patient’s medical record that the list was presented to the patient or to the patient’s representative.…. This Standard is not met as evidenced by: 45841 Based on record reviews, policy review, and interviews, the facility failed to provide 3 (Patients 1, 2, and 3) of 6 sampled patients with a resource list of post-acute agencies prior to discharge. Failure to provide a list of post-acute agencies prior to discharge place patients at risk for not making inform decisions for post-acute care. Findings Include: Review of a facility policy titled, “Case Management & Discharge Planning,” with a publication date of 08/30/2022, revealed, “Stage Three: Development of a Discharge Plan 1. The CM/SW [case manager/social worker] presents all viable options to patient/family/designated caregiver, when applicable, to allow the patient/family/designated caregiver to make informed decisions and choices for care along the continuum. Patient/families/designated caregivers will be given a resource list of post-acute agencies. This choice is documented on the CM/SW Choice form and in the CM/SW notes in the electronic health record and indicates consent for an outside agency to evaluate patient, including medical record indicated.” Per the policy, “b. This list must only be presented to patients whom home health care post-hospital extended services, SNF [skilled nursing facility], IRF [inpatient rehabilitation facility], or LTCH [long-term care hospital] services are indicated and appropriate as determined by the discharge planning evaluation.” Patient 1 A review of Patient 1’s “Facesheet” revealed the facility admitted the patient on 12/15/23, with a diagnosis to include history of right total hip replacement. A review of Patient 1’s social worker encounter note dated 12/18/23 at 1:51 PM, revealed Patient 1 expected to be discharged to a SNF. There was no evidence to indicate the patient was presented a resource list of post-acute agencies or documentation of the CM/SW choice form. Patient 2 A review of Patient 2’s “Facesheet” revealed the facility admitted the patient on 11/09/23, with a chief complaint of fall and facial swelling. A review of Patient 2’s social worker encounter note dated 11/10/23 at 2:51 PM, revealed Patient 2 expected to be discharged to a SNF. There was no evidence to indicate the patient was presented a resource list of post-acute agencies or documentation of the CM/SW choice form. Patient 3 A review of Patient 3’s “Facesheet” revealed the facility admitted the patient on 12/23/23 with a chief complaint of fall. A review of Patient 3’s social worker encounter note dated 12/26/23 at 3:27 PM, revealed Patient 3 expected to be discharged to an acute rehabilitation unit. There was no evidence to indicate the patient was presented a resource list of post-acute agencies or documentation of the CM/SW choice form. During an interview on 01/31/24 at 10:40 AM, the SW stated that patients were verbally informed of post-acute options during the discharge process. The SW acknowledged the facility did not have a choice form as specified in the facility’s policy. During an interview on 01/31/24 at 10:51 AM, the Patient Safety Program Manager confirmed the choice forms were unable to be found for Patient 1 and Patient 3. During an interview on 01/31/24 at 11:44 AM, the CM stated that the choice form previously given to patients and/or their families was no longer applicable after the name of facility changed. The CM stated a new form had not been developed. Per the CM, the patients were verbally informed of post-acute options.”

“ORGANIZATION OF REHABILITATION SERVICES CFR(s): 482.56(a) The organization of the service must be appropriate to the scope of the services offered. This Standard is not met as evidenced by: 45841 Based on record reviews, policy review, and interviews, the facility failed to ensure there was a physical therapist to provide physical therapy services to 2 (Patients 3 and Patient 4) of 6 sampled patients as ordered by the physician and directed by the patient’s physical therapy plan. Failure to ensure there was a physical therapist to provide physical therapy place patients at risk for delayed progress in healing. Findings Include: A review of the facility physical therapy policy titled, “Standard Operating Procedure,” dated 10/01/19, revealed, “Physical therapy services provided to all patients will be in accordance with all state and federal regulations and the standards of practice as established by the American Physical Therapy Association.” A review of Patient 3’s “Facesheet” revealed the facility admitted the patient on 12/23/23 with a chief complaint of fall. A review of Patient 3’s physician orders, revealed an order dated 12/24/23 for physical therapy to evaluate and treat the patient. A review of Patient 3’s “Physical Therapy Evaluation,” dated 12/26/23, revealed the plan to treat Patient 3 was twice a day. A review of Patient 3’s physical therapy documentation, revealed the patient was not seen on 12/24/23 or 12/25/23. Per the Facesheet, the facility discharged Patient 3 on 12/27/23. A review of Patient 4’s “Facesheet” revealed the facility admitted the patient on 11/07/23, with a diagnosis to include displaced intertrochanteric fracture of the right femur (hip fracture). A review of Patient 4’s physician orders, revealed an order dated 11/07/23 for physical therapy to evaluate and treat the patient. A review of Patient 4’s “Physical Therapy Evaluation,” dated 11/08/23, revealed the plan to treat Patient 4 was twice a day. A review of Patient 4’s physical therapy documentation, revealed the patient was seen only once by PT staff on 11/09/23 and 11/10/23 and the patient was not seen by PT staff on 11/11/23 or 11/12/23. Per the Facesheet, the facility discharged Patient 4 on 11/13/23. During an interview on 01/30/24 at 3:57 PM, the Director of Quality stated that there was one person who staffed the physical therapy department during the week and that staff person was a physical therapy assistant. During an interview on 01/31/24 at 9:47 AM, the Director of Physical Therapy stated that the physical therapy department was staffed with a physical therapy assistant Mondays through Thursday for inpatient coverage. Per the Director of Physical Therapy, an outpatient physical therapy assistant provided therapy coverage on Fridays. During an interview on 01/31/24 at 2:15 PM, the Physical Therapist stated that the physical therapy department was not staffed with a physical therapist every day of the week and there was no weekend coverage.”

“DELIVERY OF SERVICES CFR(s): 482.56(b)(2) The provision of care and the personnel qualifications must be in accordance with national acceptable standards of practice and must also meet the requirements of §409.17 of this chapter. This Standard is not met as evidenced by: 45841 Based on record reviews, policy review, and interview, the facility failed to ensure 2 (Patient 3 and Patient 4) of 6 sampled patients received physical therapy as ordered by the physician and specified in the patient’s physical therapy plan. Failure to implement and provide physical therapy as ordered places the patients at risk for delayed progress in healing. Findings Include: A review of the facility physical therapy policy titled, “Standard Operating Procedure,” dated 10/01/2019, revealed, “As prescribed by the physician or non-physician practitioner, the physical therapist will complete an evaluation. Based on the evaluation findings, a treatment plan will be established consisting of the type, amount, frequency, and duration of physical therapy. The plan will also indicate the patient’s diagnosis and anticipated goals. Therapists will operate at the level of their competency.” Patient 3 A review of Patient 3’s “Facesheet” revealed the facility admitted the patient on 12/23/23 with a chief complaint of fall. A review of Patient 3’s physician orders, revealed an order dated 12/24/23 for physical therapy to evaluate and treat the patient. A review of Patient 3’s “Physical Therapy Evaluation,” dated 12/26/23, revealed the plan to treat Patient 3 was twice a day. A review of Patient 3’s physical therapy documentation, revealed the patient was not seen on 12/24/23 or 12/25/23. Per the Facesheet, the facility discharged Patient 3 on 12/27/23. Patient 4 A review of Patient 4’s “Facesheet” revealed the facility admitted the patient on 11/07/23, with a diagnosis to include displaced intertrochanteric fracture of the right femur (hip fracture). A review of Patient 4’s physician orders, revealed an order dated 11/07/23 for physical therapy to evaluate and treat the patient. A review of Patient 4’s “Physical Therapy Evaluation,” dated 11/08/23, revealed the plan to treat Patient 4 was twice a day. A review of Patient 4’s physical therapy documentation, revealed the patient was seen only once by PT staff on 11/09/23 and 11/10/23 and the patient was not seen by PT staff on 11/11/23 or 11/12/23. Per the Facesheet, the facility discharged Patient 4 on 11/13/23. On 01/31/24 at 2:05 PM, the Director of Quality performed a chart review with the survey team and confirmed Patient 3 and Patient 4 were not provided physical therapy as ordered by the physician and directed by the patient’s physical therapy plan.”