The Centers for Medicare and Medicaid Services (CMS) found Dover Behavioral Health System to be out of compliance with the conditions of Medicare participation due to a deficiency with patient discharge planning. CMS “determined that the hospital failed to reassess the discharge plan throughout the continuum of care” for one patient, thus, placing the patient “at risk for adverse health consequences based on documented medical conditions and physical assistance needs.” CMS determined that a patient “who had multiple medical issues and was primarily wheelchair bound,” was discharged to an unsafe home environment. The patient, who lived alone, reported being scared of being discharged home due to the safety of the neighborhood and the shootings that took place nearby. Despite the patient’s concerns, and his/her desire for a nursing home placement, the patient was discharged home. Several days following the discharge, a social worker found the patient at home without a working telephone, no medication or means to acquire food, and no referral for Home Health/post discharge care. Additionally, the patient’s oxygen tubing—required for continuous oxygen intake—was found in pieces, tangled on the floor. There was no documented evidence in the patient’s medical record to determine why or when the discharge plan for the nursing home placement changed.