Health inspection·August 21, 2024

Code of Federal Regulations, Title 42, Section §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. (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. Code of Federal Regulations, Title 42, Section 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. California Code of Regulations, Title 22, Section 72521. Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. (b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents and to employees and the public. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or licensee. (c) Each facility shall establish at least the following: (2) Policies and procedures for patient admission, leave of absence, transfer, pass and discharge, categories of patients accepted and retained, rate of charge for services included in the basic rate, type of services offered, charges for extra services, limitations of services, cause for termination of services and refund policies applying to termination of services. California Code of Regulations, Title 22, Section 72547. Content of Health Records. (a) A facility shall maintain for each patient a health record which shall include: (10) Discharge planning notes when applicable. (14) Condition and diagnoses of the patient at time of discharge or final disposition. On 7/17/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a complaint regarding admission, transfer, and discharge. As a result of the investigation, the CDPH determined the facility failed to implement timely discharge planning and develop an accurate discharge summary for Resident 2 by failing to: 1. Accurately assess and document Resident 2’s discharge care needs and post-discharge plan to ensure Resident 2’s safe and effective transition to Resident 2’s home. 2. Consider Resident 2's caregiver (Resident 2's Representative [R2R]) capacity and capability to perform the required discharge care for Resident 2 and provide R2R with caregiver training before Resident 2 was discharged from the facility. 3. Assess Resident 2 for the need of assistive device/s at home to safely perform activities of daily living (ADLs) and for mobility. 4. Arrange and confirm home health services (medical services provided at a person's home to treat a chronic health condition or help with recovery from illness, injury, or surgery) as ordered by Resident 2's physician before Resident 2 was discharged from the facility. These violations resulted in the lack of continuity of care and delay in the provision of necessary care and services for Resident 2 post-discharge. These deficient practices violated Resident 2’s rights and placed Resident 2 at risk for injury, harm, and rehospitalization. A review of Resident 2's Admission Record indicated the facility initially admitted Resident 2, a 64-year-old male, on 5/20/2024, with diagnoses including cerebral infarction (ischemic stroke- disrupted blood supply to the brain, causing tissue death) with hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) affecting right dominant side, aphasia (language disorder affecting person's ability to understand and speak language), gait and mobility abnormalities, muscle wasting (thinning of muscle mass) and atrophy (loss of muscle mass and strength), and need for assistance with personal care. A review of Resident 2's History and Physical Examination (H&P), dated 5/20/2024, indicated Resident 2 was able to make needs known but could not make medical decisions. A review of Resident 2's Minimum Data Set (MDS- a standardized resident assessment and care-planning tool), dated 5/27/2024, indicated Resident 2 had no speech, usually able to understand others, and usually able to make himself understood. The MDS indicated Resident 2 had some difficulty making decisions regarding tasks of daily life in new situations only. The MDS indicated Resident 2 was dependent on staff for toileting hygiene, bathing, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 2 required substantial/maximal assistance with oral hygiene, upper body dressing, personal hygiene, and mobility. A review of Resident 2's Discharge Summary (DS), dated 7/9/2024, timed at 2:32 PM, indicated Resident 2 was admitted to the facility for skilled physical therapy (PT- rehabilitative services aimed to relieve pain, improve movement, and strengthen weakened muscles) and occupational therapy (OT- rehabilitative services aimed to promote health and well-being through the performance of activities of daily living). The DS indicated Resident 2 was non-ambulatory (propels with device) and required assistance with ADLs, hygiene, and grooming. The DS under "Medical Equipment Ordered," indicated Resident 2 did not have equipment needs. The DS under "Community Resources," indicated the facility arranged home health services with Home Health Agency (HHA- a public agency or private organization engaged in providing medical services provided at home) 1 including nursing, PT, and OT. The DS indicated the facility did not arrange outpatient therapy services. A review of Resident 2's Notice of Proposed Transfer/Discharge (NPTD), dated 7/9/2024, timed at 2:47 PM, indicated on 7/9/2024, the facility notified R2R of Resident 2's discharge to home on the same day, 7/9/2024. The NPTD indicated Resident 2's transfer/discharge was appropriate because Resident 2's health had improved sufficiently, and the services of the facility were no longer required. The NPTD indicated, R2R signed the NPTD and wrote, "Acknowledgment of receipt - disagree with insurance reason." A review of Resident 2's Physician Order (MDO 1), dated 7/9/2024, timed at 6:29 PM, indicated an order to discharge Resident 2 to home with Home Health (unspecified) on 7/9/2024. The MDO 1 indicated Resident 2 may have home health PT/OT & registered nurse (RN) for safety evaluation to follow. The MDO 1 indicated, "Resident discharged home with family at 5:40 PM (on 7/9/2024)." During a telephone interview on 7/17/2024 at 2 PM, R2R stated Resident 2's discharge came as a "total surprise." R2R stated R2R did not think Resident 2 was ready for discharge from the facility. R2R stated Resident 2's health insurance company called the facility on 7/9/2024 (date of discharge) at 2:20 PM to inform Resident 2 and R2R that health services and skilled nursing facility (SNF) stay would no longer be covered by Resident 2's health insurance. R2R stated R2R then picked up Resident 2 from the facility to avoid paying $350 per day out-of-pocket. R2R stated R2R did not appeal, because the facility informed R2R that per Resident 2's health insurance, the appeal could take up to 30 days. R2R stated she had no help at home. R2R stated R2R did not know how to lift or transfer Resident 2 from the bed. R2R stated there were no bed rails or any assistive device at home, and Resident 2's wheelchair was "so heavy." R2R stated she could not shower Resident 2 and could only change Resident 2's diaper while Resident 2 was in bed. R2R stated the facility did not arrange home health RN, OT, and PT visits for Resident 2. R2R stated R2R had her own medical issues and could not assist with Resident 2's mobility. During a concurrent interview and record review on 7/17/2024 at 2:50 PM, the Director of Nursing (DON) reviewed Resident 2’s MDO 1. The DON stated the facility did not arrange home health services prior to Resident 2's discharge from the facility. The DON stated the facility needed to follow the discharge order and maintain continuity of care to ensure Resident 2's safe discharge. During an interview and on 7/18/2024 at 8:42 AM, the Social Services Director (SSD) stated the facility must ensure a safe discharge for Resident 2 by ensuring Resident 2 had the necessary equipment at home, the facility made the follow-up appointments or instructed the family to make the follow-up appointments, and the facility arranged and confirmed (HHA have accepted the resident) the home health services to be provided. The SSD stated the SSD informed R2R that Resident 2's last covered date at the facility by the health insurance company (HIC) was 7/7/2024. The SSD stated on 7/8/2024, the SSD submitted Resident 2's nursing notes, rehabilitation notes, and physician's notes to Resident 2's HIC for review to request for an extension of covered stay at the SNF. The SSD stated on 7/9/2024, Resident 2's HIC notified the facility that Resident 2's last covered date at the SNF was 7/8/2024, so Resident 2 had to be discharged by 7/9/2024 to avoid any out-of-pocket costs. The SSD stated because of the short notice, the SSD documented on Resident 2's Discharge Summary that HHA 1 was arranged without any confirmation from HHA 1. The SSD stated the SSD called Resident 2's HIC's case manager (CM 1), who stated she (CM 1) would send the SSD outpatient rehabilitation resources for Resident 2. The SSD stated there was no home health arrangements made and no updates from CM 1 regarding outpatient rehabilitation resources for Resident 2. During an interview on 7/18/2024 at 9:41 AM, the Rehabilitation Director (Rehab D) stated the Rehab D was "very upset how it went down." The Rehab D stated the facility was not ready to discharge Resident 2 on 7/9/2024. The Rehab D stated on 7/14/2024 (5 days after Resident 2's discharge from the facility), the Rehab D personally came to Resident 2's home to "make things right" and check on Resident 2, since the facility did not arrange home health services before discharge. The Rehab D stated the Rehab D assessed the layout of Resident 2's home for ADLs and mobility and determined it was not possible for R2R to assist Resident 2 with transfers to and from chair and ambulation due to R2R's difficulty with bending. The Rehab D stated Resident 2's shower chair did not fit in Resident 2's shower area. The Rehab D stated Resident 2 needed a Hemi-walker (device that gives support to maintain balance while walking and allows the user to lean on just one side for support), which was steadier when walking and safer assistive device than a cane. The Rehab D stated when home health services were not arranged as ordered, Resident 2 had a potential to decline and was at an increased risk for deconditioning (decline in physical function of the body because of physical inactivity and disuse). During a telephone interview on 7/18/2024 at 11:52 AM, HHA 1’s DON stated HHA 1 did not receive a referral for home health services for Resident 2 from the facility. During an interview on 7/18/2024 at 12:30 PM, RN 1 stated RN 1 discharged Resident 2 on 7/9/2024. RN 1 stated RN 1 did not assess Resident 2's caregiver/support availability at home, equipment needed at home, or verified home health arrangements before and during discharge, because RN 1 assumed the SSD or case manager spoke to Resident 2 or R2R about these concerns. During an interview on 7/18/2024 at 2:42 PM, the DON stated discharge planning must begin on the first day of a resident's admission to the facility. The DON stated on 7/9/2024 (discharge date), R2R came to the facility and verbalized that Resident 2 was not ready for discharge to home. The DON stated the facility needed to question the rushed discharge date from Resident 2's health insurance company due to the need for more caregiver training and assistive device at home. The DON stated the facility needed to send out referrals to home health agencies timely and confirm home health services with visits from an RN, OT, and PT prior to discharging Resident 2 from the facility. The DON stated improper discharge planning could lead to an unsafe discharge, Resident 2's injury at home, and Resident 2's possible decline physically and mentally. A review of the facility's policy and procedure (P&P) titled, "Social Services," dated 10/2010, indicated the facility provided medically related social servi