HospitalInspections.org

Based on interview and document review, it was determined the facility failed to assess the discharge planning process on an ongoing basis by not performing the periodic review of sample discharge plans.

The findings included:

On 12/07/21 at 9:50 pm, the surveyor interviewed Staff Member #5 (Director of Case Management). In accordance with being compliant with the Discharge Planning Conditions of Participation, the surveyor requested evidence of the auditing practice of patient discharge plans. Staff Member #5 stated no such auditing or review of the facility's discharge planning process had been performed for "about two years". Staff Member #5 stated they had documentation of reviewing discharge plans during this time but that no such review has occurred since.

On 12/07/21 at 1:14 pm, Staff Member #5 provided discharge planning audit documentation from January 2020 through June 2020. When asked why the ongoing review of representative samples of discharge plans were not performed following this date, Staff Member #5 stated that the facility had essentially rebranded the Case Management department around this time which resulted in the task being discontinued.

During interview, the surveyor requested Staff Member #5 to provide the policy, procedure, or other facility guidelines pertaining to the periodic assessment of its discharge planning process.

On 12/07/21 at 1:50 pm, the surveyor met for interview with Staff Member #3 (Licensing and Accreditation Specialist) and Staff Member #6 (Regulatory and Risk Management). Both Staff Member #3 and Staff Member #6 confirmed that no such policy or procedure exists related to discharge planning assessment and auditing. Staff Member #3 added that Staff Member #5 did perform discharge planning reviews during 2019 and throughout the first two (2) quarters of 2020 but that none has occurred since.