HospitalInspections.org

Based on document review, observation, and interview, it was determined that the Hospital failed to comply with the Condition for Coverage 42 CFR 482.43, Discharge Planning.

Findings include:

1. The Hospital failed to ensure that social workers were qualified to conduct discharge planning evaluations. (A-809)

Based on document review and interview, it was determined that for 2 of 4 social workers' (E#7 and E#13) personnel files reviewed for discharge planning qualifications, the Hospital failed to ensure that the social workers were qualified to conduct discharge planning evaluations.

Findings include:

1. The Facility's Social Worker Job Description, dated 5/13/2021, was reviewed and included minimum qualifications: "...Must be licensed in the State of Illinois as an Licensed Social Worker (LSW)..."

2. The List of Current Social Workers as of 11/29/2023 was reviewed and indicated that 2 of 15 (E#7 and E#13) social workers were from a staffing agency.

3. The personnel files for E#7 and E#13 were reviewed on 11/30/2023 indicated the following:
- E#7 was hired on 9/13/2022 as a social worker. The file included attestations signed on 9/27/2022 and 11/30/2023 from an agency representative that E#7 was licensed and met the minimum requirements for the job description of social worker. E#7's file lacked a valid license as a social worker.
- E#13 was hired on 3/15/2022 as a social worker. The file lacked a valid license as a social worker.

4. An interview was conducted with Human Resources Representative (E#14) on 11/30/2023, at approximately 12:45 PM. E#14 stated that the agency is responsible for ensuring that staff have valid licenses and meet the minimum requirements for the job based on the provided job description from the Hospital. E#14 stated that since the agency does the primary verifications of the licenses and degrees, the Hospital does not keep these on record. E#14 stated that the agency signs an attestation form annually to acknowledge that each staff meets the requirements of the job.

5. An interview was conducted with the Director of Inpatient Care Coordination (E#10) and Director of Regulatory (E#1) on 11/30/2023, at approximately 1:30 PM. E#10 stated that they had two social workers from agency and just found out that they were not licensed. E#10 stated that the Hospital requires the social workers to have a masters in social work and be licensed. E#10 stated that their employee badges have been revoked and they will no longer work at the Hospital as of now (11/30/2023). E#1 stated that both E#7 and E#13 came from the same agency.