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Based on interviews, clinical record reviews and facility documents the facility's staff failed to provide discharge planning evaluations for two (2) of six (6) patient records reviewed (Patients #3 and #5).

The findings include:

1. On 10/04/17 at 11:58 AM, a review of Patient #3's medical record was conducted, with the assistance of Staff Member (SM) #8 as the EMR (electronic medical record) navigator. The clinical record failed to include documentation of a discharge evaluation. On 08/17/17 at 5:11 PM the Hospitalist, SM #9 documented in the clinical record, and it reads in part as follows:

"Discharge Disposition
Discharge to home with home health."

An interview was conducted with the Director of Case Management, SM #13 on 10/04/17 at 12:00 PM. The Director of Case Management was unable to provide the surveyor with any documentation regarding discharge planning for Patient #3.

An interview was conducted with the Chief Nursing Officer (CNO), SM #1 on 10/04/17 at 12:10 PM. The CNO stated it would be his/her expectation that there would be documentation of discharge planning in the clinical record.

2. On 10/04/17 at 11:14 AM, a review of Patient #5's clinical record was conducted, with the assistance of SM #8 as the navigator. The clinical record failed to have documentation of a discharge evaluation being done.

An interview was conducted with Director of Case Management, SM #13 on 10/04/17 at 12:00 PM. The Director of Case Management was unable to provide the surveyor with any documentation in the medical record regarding discharge evaluation or planning. SM #13 stated, "I might be able to find something in my office," regarding information sent to a Home Health Agency. He/she did provide the surveyor with a copy of a fax sent to a Home Health Agency. None of the information given to the surveyor was documented in the clinical record.

On 10/04/17 at 1:50 PM, the Chief Quality Officer (CQO), SM # 4 gave the surveyors the following policy titled, "Case Management Plan for Discharge Planning Policy" (with an effective date 10/01/2013 and a revision date 03/31/2014). The policy read in part as follows:

"I. IDENTIFICATION OF PATIENTS IN NEED OF DISCHARGE PLANNING

B. The Case Manager will screen all patients, within one working day of admission, for potential discharge planning needs, utilizing a High-Risk Screening tool. This screen will take place during the initial clinical review for medical necessity and will be in conjunction with the initial screening completed by Nursing in the Admission Assessment process.

C. Screening criteria will include but not be limited to the following:
a. Age
b. Prior hospitalization
c. ED visit history
d. Medications
e. Principal diagnosis
f. Comorbidities
g. Functional impairment

II. DISCHARGE PLANNING ASSESSMENT

A. A comprehensive assessment will be completed by the Case Manager if the screening determines the patient has discharge planning needs.

E. The discharge planning evaluation will include, at a minimum:

* A review of the physiological, psychosocial, environmental, financial, functional needs

* Assessment of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital

* The likelihood of the patient needing post-hospital services and the availability of the services

F. Discharge planning evaluation will be completed in a timeframe no greater than one business day after identification of need by the Case Manager or referral from other sources.

G. Discharge planning evaluation will be documented in the patient's medical record for use in establishing an appropriate discharge plan and the results of the evaluation will be discussed with the patient or individual acting on his or her behalf.

Based on interviews, clinical record review and document review it was determined hospital staff failed to provide evidence, in the medical record, that a list of home health organizations and/or skilled nursing facilities was presented to three (3) of four (4) hospital inpatients who were discharged requiring home health or post-hospital extended care services. (Patients #3, #5 and #6).

The findings include:

1. The clinical record of Patient #3 was reviewed on 10/04/17 with the assistance of Staff Member #8. Review of the clinical record revealed Patient #3 was to be discharged home with home health services. The clinical record failed to provide evidence Patient #3 was provided a list of home health organizations serving the geographic area where the patient lived.

2. The clinical record of Patient #5 was reviewed on 10/04/17 with the assistance of Staff Member #8. Review of the clinical record revealed Patient #5 was to be discharged home with home health services. The clinical record failed to provide evidence Patient #5 was provided a list of home health organizations serving the geographic area where the patient lived.

3. The clinical record of Patient #6 was reviewed on 10/04/17 with the assistance of Staff Member #8. Review of the clinical record revealed Patient #6 was to be discharged to a health and rehabilitation facility. The clinical record failed to provide evidence Patient #6 was provided a list of nursing facilities serving the geographic area where the patient lived.

Interviews were conducted with Staff Member #13, the Director of Case Management on 10/04/17 at 12:00 PM and 4:10 PM. Staff Member #13 stated the clinical record should have contained "choice letters". SM #13 was unable to provide the survey team with evidence Patient's #3, #5 and #6 were given a list of organizations or facilities serving the geographic area where the patients lived.

On 10/04/17 at 1:50 PM, the Chief Quality Officer (CQO), SM # 4 gave the surveyors a policy titled, "Case Management Plan for Discharge Planning Policy" (with an effective date 10/01/2013 and a revision date 03/31/2014). The policy read in part as follows:

"III. DISCHARGE PLAN

D. Should the patient require post hospital services, they will be offered a choice of services available in the area that can provide the services recommended by the physician in accordance with the policy and procedure specific to offering Patient Choice.

F. The discharge plan will be documented in the patient's medical record to provide guidance to the healthcare team in preparing the patient for discharge."

The above findings were discussed for a final time with the management team on 10/05/17 at 5:30 PM. No further information was provided to the survey team.

Based on interviews and document review it was determined the hospital staff failed to appoint a doctor of medicine or osteopathy as the director of respiratory services.

The findings include:

On 10/03/17 at 3:30 PM the survey team conducted an interview with Staff Member (SM) #6. During the course of the interview it was determined that SM #6 was the Director of Respiratory Services for the hospital. SM #6 stated that he/she had worked for the hospital for multiple years and was a respiratory therapist. When asked if there was a physician in charge of overseeing the respiratory program, the RT stated there was not.

Review of the job description for the "Administrative Director: Laboratory, Cardiovascular, Respiratory, and Sleep Services" included the following under the heading "Licenses and Certificates": "Licensed to practice as a Respiratory Care Practitioner by the Commonwealth of Virginia, Board of Medicine. Registered Respiratory Therapist (RRT) by the National Board for Respiratory Care (NBRC)."

In an end of day meeting with the hospital management team on 10/03/17 at 4:55 PM, the survey team discussed the regulatory requirement that the directory of respiratory services be a physician. SM #4 stated that he/she had not been aware of the requirement.

The above findings were discussed with the Management team for a final time on 10/05/17 at 5:30 PM. No further information was provided to the survey team.



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