Midamerica Rehabilitation Hospital

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 47234 Based on record review, document review, policy review and interviews, the hospital failed to ensure the discharge planning process identified a patient likely to suffer adverse health consequences upon discharge and failed to provide discharge evaluation for 1 (Patient 1) of 3 discharged patient records reviewed. This deficient practices places patients at risk for inappropriate discharge, loss of continuity of care which could potentially cause harm to the patients and result in rehospitalization. Findings Include: Review of Hospital Policy titled “Discharge Planning” effective date 03/09/23 showed “Purposes and Objectives; Discharge planning is a patient-centered, interdisciplinary process that involves the patient, caregiver(s), support person(s), authorized representative(s), physicians, hospital clinical staff, and case managers. It is re-evaluated and adjusted as the patient’s condition, functional status, and clinical care needs change throughout the stay. The discharge plan is individualized and supports patient independence and self-management. The goal of the discharge planning process is to ensure an effective transition of care and reduce factors leading to preventable acute inpatient hospital readmissions. Policy; Discharge Planning Evaluation; ...Throughout the patient’s stay, the case manager works with the patient / patient representative to develop a discharge plan based on the patient’s clinical care requirements, goals of care and treatment preferences, available support network, insurance coverage and financial resources and documents the discussions in the medical record .... The physician, case manager, registered nurse, and therapists from each discipline with current knowledge of the patient meet and assess the appropriateness of the discharge plan based on the patient’s condition, functional status, clinical care needs, and readmission risk. The discharge plan is adjusted as needed. Discharge planning includes case management evaluation of the availability of appropriate post-discharge care and services and the patient’s access to those services. Considerations in the discharge planning process: ... Need for clinical care and chronic condition management after discharge ... ... Discharge Planning Process and Documentation ... The case manager researches and discusses applicable community resource options and services, assesses the patient’s access to those resources and initiates appropriate referrals ... The case manager, in collaboration with the physician and interdisciplinary care team, helps to determine the most appropriate post-discharge care setting, services and medical equipment to meet the patient’s care needs after discharge ... Review of Hospital Policy titled “Plan for the Provision of Patient Care” effective date 03/29/19 showed “ ...Case Management; All patients will be provided with the services of a Case Manager. Case Managers provide for assessment and intervention relative to psychosocial factors and the social context in which the physically disabled person lives and includes the following: 1. Assessment of the patient’s personal coping history and current psychosocial adaptation to/her disability, age, religious beliefs and other factors affecting the rehabilitative patient. 2. Assessment of immediate and extended family members and other patient support persons. 3. Assessment of housing, living arrangements, and stability and source of income relative to facilitating discharge plans. Intervention strategies, designed to increase the effectiveness of coping, strengthen informal support systems, and facilitate continuity of care, include: 1. Referrals to community resources. 2. Monitoring the achievement of goals relative to discharge planning, activities designed to meet the basic needs of patients and their families, consistent with the age and cultural background of the patient and his or her family. 3. 5. Coordination of patient care with external referral sources ...” Review of Hospital documents titled “Position Title: Certified Case Manager” undated showed “Position Purpose; Certified Case Manager (CCM) The CCM coordinates and advocates for the patient during their hospitalization and from pre-admission to post-discharge. . The CCM facilitates timely communication regarding the patient’s care and establishes and monitors the discharge plan implementation while identifying and addressing patient’s psychosocial and support systems issues...Responsibilities and Tasks ...Coordinates with interdisciplinary team to establish tentative discharge plan and contingency plans. Establishes contingency discharge plans for high-risk cases ...Facilitates team conferences weekly and coordinates all treatment plan modifications. Identifies potential complications relative to patient care and discharge plan after initial and ongoing team conferences. Completes case management addendums and all required documentation. Manages documentation such as, but not limited to, contact notes, Interdisciplinary Plan of Care (IPOC), team conference form, family conference, continues stay reviews and discharge instructions. Maintains knowledge of regulation/standards, company policies/procedures, and department operations ... Patient 1 Review of Patient 1’s discharged medical record showed a 58-year-old female was admitted on 12/01/23 for status post fall with left femur fracture (a break in the thigh bone after a fall), with recent status post hip arthroplasty (hip replacement surgery) on the same side. Patient 1 discharged on 12/13/23 at 12:05 PM transported by stretcher to home. Review of “CM Discharge Planning Ongoing - Text” dated 12/06/23 at 11:52 AM showed “Case Management Note: Spoke with [Patient 1] about team conference udpate (sic) and plan of care. Discussed dc [discharge] on 12/13/23. Discussed accessing her apartment due to stairs and being non weight bearing. CM [Case management] provided education on long term care benifit (sic) but [Patient 1] states she will not go to LTC (Long Term Care) because she does not want to give up her money. She states she will go home. [Patient 1] states that she has 3 hours of caregiving services a day so CM asked [Patient 1] to please set those services up for dc on 12/13/23. CM discussed safety concerns with going home and not being able to do the stairs safely but [Patient 1] states she will go home she does not want to give up her money for long term care. CM discussed dc home with a home exercise program ...” Review of “Case Management” dated 12/08/23 at 10:15 AM showed “...Pt reports she lives alone, she prepares meals, and manages her own meds. Pt reports she has some help getting groceries and doing laundry ... pt reports she doesn’t have a shower chair, may need one. Pt does not want a w/c [wheelchair] as she has 23 stairs to climb to her apartment.” Review of “CM Discharge Planning Ongoing- Text” dated 12/11/23 at 10:10 AM showed “Anticipated Discharge Plan: Home/Community Independent (No services needed) ... Case Management Note : CM spoke with [Patient 1]about discharge on 12/13/23. [Patient 1] wants to go home. She does not want to go to a nursing home. CM provided education about long term care nursing home but [Patient 1] has declined. She wants to go home. She does not want to give up her money for nursing home. [Patient 1] states she has a caregiver from Missouri Medicaid. CM encouraged her to set up the caregiver services for discharge. CM encouraged her to call with questions or concerns ... Case Management Interventions: Educate patient/family/caregiver regarding community resources, Encourage family/caregiver participation in rehabilitation activities ...” Review of “Progress Note- Physician” dated 12/11/23 at 12:02 PM showed “... [Patient 1] is a 58-year-old female, discussed discharge planning, explained to her that we will write all the prescriptions and support services will be arranged ...” Review of “Progress Note-Physician” dated 12/13/23 at 8:49 PM showed “ ... [Patient 1] discharge is today. She has no physical complaints. ...She will be discharging at wheelchair level. I spoke to case manager. We teamed her today. They have made arrangements for a stretcher to bring her into her apartment ... I told her to be extra safe when she gets home ... She needs to keep off the right lower leg nonweightbearing (sic) toe-touch, home today.” Review of Hospital Document titled “Free or Discounted Local Transportation of Patients (CMP-201)” dated 12/13/23 showed “ ... Justification for Transportation: “[Patient 1] had stairs that we stretchered her into apartment ...” Review of “Instructions From Your Doctor” dated 12/13/23 at 7:19 AM showed “Additional Referrals Made: [Patient 1] states she has a caregiver through Medicaid ...Physical Therapy Discharge Instructions ...Safety and Wt [Weight] Bearing Special Inst: You are toe touch weight bearing only; try not to put too much weight through your leg; good luck at home ...Stairs Special Instructions: You must have someone take you up the stairs or assist all the way up so you don’t put weight on your leg ...Occupational Therapy Discharge Instructions ...Tub/Shower Special Instructions: Please use your roller walker to get to and from shower. Utilize grab bar and roller walker to get in and out of the shower char(sic).” During an interview on 02/27/24 at 8:50 AM, Staff H, Physical Therapist, (PT) stated that Patient 1 had moments that she would try to put weight on her non weight bearing leg. He stated that Patient 1 had a full flight of stairs to her apartment and that she would have not been able to hop up the step. Staff H stated that Patient 1 refused going to the nursing home for 3 months. During an interview on 02/27/24 at 9:14 AM with Staff G, Licensed Bachelor Social Worker, (LBSW), Case manager, stated that her job duties include setting up discharges, discharge planning with patients and their family which includes ongoing services for equipment, education on community resources and ongoing therapy if prescribe by the doctor. Staff G stated that they were very concerned about Patient 1 because of her non weight bearing status and they did not want her going home since her apartment had stairs. She stated that Patient 1 was not open to going to a nursing home and wanted to go home. Staff G stated that she documented Patient 1 should call and set up with state Medicaid for home services. There was no documentation in the medical record to show Staff G contacted Medicaid or any other agency for services in the home. During an interview on 02/27/24 at 11:33 AM, Staff F, Doctor of Medicine (MD), stated “I knew that she was going to have a barrier to going home since she had stairs at her apartment. She was to go home using Medicaid Nursing Services. I was not aware that Case Manager did not follow up with Missouri Medicaid to see if she received services and it doesn’t surprise me.” During an interview on 02/28/24 at 8:23 AM Staff C, Speech Language Pathologist (SLP), Director of Case Management stated that there was no documentation in chart showing that she was receiving State Medicaid Services from a home health agency (HHA) or if a HHA would be able to meet her needs. Staff C stated that staff thought Patient 1 would get a Certified Nurse Aide (CNA) to help with light housekeeping and shower assistance. During an interview on 02/28/24 at 9:01 AM with Staff A, Director of Quality and Risk, confirmed Patient 1’s case manager did not follow up per policy and stated that the case manager is to attempt to arrange post-hospital care to meet request for a specific HHA. During an interview on 02/28/24 at 8:35 AM, SW1, (Hospital B Social Worker) stated that she spoke to the case manager at the above named hospital and was told that Patient 1 was transported by stretcher and taken up the 26 stairs to her apartment on the stretcher. SW 1 stated that Patient 1 told SW 1 that she was discharged too soon, still needed physical therapy, wanted an alternate rehabilitation center and the only Social Worker coming to visit her was for food stamps. SW 1 stated that Patient 1 presented to Hospital B on 12/14/23 at 2:51 AM and was admitted as an inpatient on 12/15/23. She stated that she was discharged home and was provided a walker with wheels. Patient 1’s medical record failed to show the hospital researched and discussed applicable community resource options and services, assessed the patient’s access to those resources and initiated appropriate referral per hospital policy.”

“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: 47234 Based on record review, document review, policy review and interviews, the hospital failed to ensure the discharge planning included a list of agencies or providers who provide post-hospital care for 1 (Patient 1) of 3 discharged patient records reviewed. This deficient practices places patients at risk for inappropriate discharge, loss of continuity of care which could potentially cause harm to the patients and result in rehospitalization. Findings Include: Review of Hospital Policy titled “Discharge Planning” effective date 03/09/23 showed “Informed Choice ... The case manager uses quality data and resource use measures to assist the patient in selecting a provider and may share the data with the patient / patient representative ... For patients who require home health services or home hospice services, the case manager provides a list of Medicare certified Home Healthcare or Hospice agencies that have requested to be on the hospital’s list, and which service the geographic area where the patient will be discharged ... If the patient requests a specific HHA [home health agency], SNF [skilled nursing facility] or LTCH [long term care hospital], the case manager attempts to arrange post-hospital care to meet that request. If the case manager is unable to secure the requested provider arrangement (i.e., there is no bed available or the HHA cannot provide the services needed) the reason the request could not be fulfilled is explained to the patient and a list of alternative facilities are provided ... Discharge Planning Process and Documentation ... The case manager researches and discusses applicable community resource options and services, assesses the patient’s access to those resources and initiates appropriate referrals ... The case manager, in collaboration with the physician and interdisciplinary care team, helps to determine the most appropriate post-discharge care setting, services and medical equipment to meet the patient’s care needs after discharge ... Patient 1 Review of Patient 1’s discharged medical record showed a 58-year-old female was admitted on 12/01/23 for status post fall with left femur fracture (a break in the thigh bone after a fall), with recent status post hip arthroplasty (hip replacement surgery) on the same side.Patient 1 discharged on 12/13/23 at 12:05 PM transported by stretcher to home. Review of “CM Discharge Planning Ongoing - Text” on 12/06/23 at 11:52 AM showed “Case Management Note: Spoke with [Patient 1] about team conference udpate (sic) and plan of care. Discussed dc [discharge] on 12/13/23. Discussed accessing her apartment due to stairs and being non weight bearing. CM (Case management) provided education on long term care benifit (sic) but [Patient 1] states she will not go to LTC (Long Term Care) because she does not want to give up her money. She states she will go home. [Patient 1] states that she has 3 hours of caregiving services a day so CM asked [Patient 1] to please set those services up for dc on 12/13/23. CM discussed safety concerns with going home and not being able to do the stairs safely but [Patient 1] states she will go home she does not want to give up her money for long term care. CM discussed dc home with a home exercise program ...” Review of “CM Discharge Planning Ongoing- Text” dated 12/11/23 at 10:10 AM showed “ ... Case Management Note: CM [Case Manager] spoke with [Patient 1] about discharge on 12/13/23. [Patient 1] wants to go home. She does not want to go to a nursing home. CM provided education about long term care nursing home but [Patient 1] has declined. She wants to go home. [Patient 1] states she has a caregiver from Missouri Medicaid. CM encouraged her to set up the caregiver services for discharge. CM encouraged her to call with questions or concerns ...” Review of “Progress Note- Physician” on 12/11/23 at 12:02 PM showed “... [Patient 1] is a 58-year-old female, discussed discharge planning, explained to her that we will write all the prescriptions and support services will be arranged ...” Review of “Instructions From Your Doctor” dated 12/13/23 at 7:19 AM showed “Additional Referrals Made: [Patient 1] states she has a caregiver through Medicaid ...” During an interview on 02/27/24 at 9:14 AM with Staff G, Licensed Bachelor Social Worker, (LBSW), Case manager, stated “I did document that she [Patient 1] should call and set up with state Medicaid for home services.” During an interview on 02/27/24 at 11:33 AM, Staff F, Doctor of Medicine (MD), stated “Patient 1 was to go home using Medicaid Nursing Services. I was not aware that the case manager did not follow up with state Medicaid to see if she received services and it doesn’t surprise me.” During an interview on 02/28/24 at 8:23 AM Staff C, Speech Language Pathologist (SLP), Director of Case Management stated that the case manager would document the list was given from medicare.gov of the Home Health Agencies (HHA) in their zip code. The case manager would be the one who puts in the referral for HHA and all the supporting documentation. During an interview on 02/28/24 at 9:01 AM with Staff A, Director of Quality and Risk, confirmed Patient 1’s case manager did not follow up per policy and stated that the case manager is to attempt to arrange post-hospital care to meet request for a specific HHA. Review of discharge planning failed to show Patient 1 was presented a list of post acute care agencies per hospital policy.”