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Based on record review and interview, the hospital failed to ensure its discharge planning evaluation included an evaluation of the availability of post-hospital services as evidenced by failure to determine whether a patient had an established primary care physician (PCP) when orders at discharge were given to contact the patient's PCP within 2 weeks after discharge if necessary for 1 (#2) of 5 (#1 - #5) patient records reviewed for evaluation of the availability of post-hospital services frrom a total sample of 5 patient records.
Findings:

Review of the hospital policy titled "Discharge Planning", presented as a current policy by S1ADM, revealed that the hospital would provide all patients with a discharge plan that identifies and addresses aftercare needs and ensures coordination of needed services.

Review of Patient #2's medical record revealed he was admitted on 04/20/17 and discharged to a group home on 05/02/17. Review of his nursing admission assessment revealed the section related to discharge planning had the column labeled "no" with a check mark for the criteria listed as "name address & (and) phone of primary care physician." There was no documented evidence in Patient #2's medical record whether he had a PCP or not.

Review of Patient #2's "Patient Instruction Sheet And Discharge Instructions", signed by Patient #2 on 05/02/17 and S5PLPC on 05/02/17, revealed the instructions included to follow-up with his PCP within 2 weeks if needed to address any physical health concerns and to follow-up with the intensive outpatient program for mental health services and his PCP if needed.

In an interview on 05/04/17 at 11:20 a.m., S5PLPC indicated unless the psychiatrist writes an order to consult for a PCP or a specialist for a patient who doesn't have Medicaid, the discharge planners don't have to set up an appointment with a PCP. She further indicated they just tell the patient to follow-up with their PCP if they need to. She indicated Patient #2 was on Medicare, and he was able to go to the intensive outpatient program for his medical needs. S5PLPC confirmed the intensive outpatient program has a psychiatrist on staff but not a medical doctor. She confirmed if a patient doesn't have a PCP, one of the responsibilities of the discharge planning staff is to assist the patient in establishing a PCP.

Based on record reviews and interview, the hospital failed to ensure the discharge planning staff were qualified to develop, or supervise the development of, the discharge planning evaluation as evidenced by failure to have documented evidence of an evaluation of competency in performing the discharge planning skills for 2 (S4LMSW, S5PLPC) of 2 discharge planning staff personnel files reviewed for competency from a total of 4 discharge planners.
Findings:

Review of the policy titled "Direct-Care Competencies", presented as a current policy by S1ADM, revealed that each employee is competent to perform his or her job responsibilities as evidenced by successful completion of orientation checklists for each classification of hospital employee.

Review of the personnel files of S4LMSW and S5PLPC revealed no documented evidence that they had documented evidence of an evaluation of competency in performing the skills required of the discharge planner.

In an interview on 05/04/17 at 10:45 a.m. with S1ADM and S6DHR present, both S1ADM and S6DHR confirmed the personnel files of S4LMSW and S5PLPC dod not have an evaluation of competency related to discharge planning.

Based on record reviews and interview, the hospital failed to ensure the patient and family members or interested persons were counseled to prepare them for post-hospital care as evidenced by failure to ensure the patient's list of medications to be taken after discharge clearly indicated the changes from the patient's pre-admission medications for 3 (#2, #3, #5) of 5 (#1 - #5) patient records reviewed for counseling related to discharge medications from a total sample of 5 patients.
Findings:

Review of the hospital policy titled "Discharge Planning", presented as a current policy by S1ADM, revealed the discharge plan should include special instructions, medication access/referral assistance, and patient acknowledgement of understanding and agreement. There was no documented evidence that the policy addressed that the patient and family members or interested persons were to be counseled regarding changes from the pre-admission medications and those being ordered upon discharge.

Review of the medical records of Patients #2, #3, and #5 revealed each discharge medication list revealed no documented evidence of the changes in the medications ordered at discharge from the medications taken prior to admission.

In an interview on 05/03/17 at 11:48 a.m. with S1ADM and S2DON present, S2DON confirmed the discharge process for nursing does not include a comparison of the patient's discharge medications from those taken prior to admission to the hospital.