Other·June 15, 2021

0660 Discharge Planning Process(c)(1)(i)-(ix) §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. 0661 Discharge summary(c)(2)(i)-(iv) §483.21(c)(2) Discharge Summary When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative. (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services. 0055 1418 Health and Safety Code (d)(4) (d) If return to the community is part of the care plan, the facility shall provide to the resident or responsible party and document in the care plan the information concerning services and resources in the community. That information may include information concerning: (4) Other resources or services in the community available to support return to the community. The facility failed to ensure all available remedies for a safe and orderly discharge were in place and failed to address all discharge needs in a comprehensive post-discharge plan, for one Resident (Resident 1). This had the potential for Resident 1's failure to thrive in the community, resulting in possible re-admission to acute care. During an interview with the facility's Social Services Director (SSD) on 5/21/19 at 11:30 a.m., the SSD stated Resident 1 was still residing at the facility, and she was working with family to find somewhere local for him to live. The SSD stated more extensive investigation into discharge possibilities, other than the homeless shelter, had not been explored. Resident 1 was discharged to a homeless shelter prior but returned to the facility as he did not like it there. The ability for collection of an SSI payment (Social Security Income -- a State-provided monthly payment) and what services it could provide, had not been explored. The SSD stated she verbalized a plan for Resident 1 to return to the facility, if a homeless shelter placement was not available, but this had not been written on the plan of care. During review of Resident 1's clinical record, on 3/11/19, the written, 'discharge plan of care' (undated) did not show any plan for Resident 1, if a bed was not available, or subsequently lost, at the homeless shelter. The discharge plan did not include any other possible remedies for discharge placement. In addition, Resident 1's, 'written plan of care' failed to indicate any plan for a specific supply of medications, or a list of pharmacies, close to the place of discharge, where Resident 1's prescription medications could be re-filled. Review of the facility's policy and procedure titled, "Discharging A Resident," dated as revised on 6/2017, indicated, "It is the policy of this facility to provide a safe departure from the.....facility....that will assist in a comfortable adaptation to home or a new environment...." Under, "Procedure: Number 3. The licensed nurse will explain meds and treatments, to be followed at home or place of discharge, to the resident or resident's agent." The above violation had a direct or immediate relationship to the health, safety, or security of patients.