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Based on review of facility documentation and staff interview (EMP), it was determined the facility failed to ensure the QAPI program reflected the complexity of the hospital's organization and services.

Findings include:

Review of facility documentation "Quality Improvement Plan CY 2019" revealed "PIOC(Performance Improvement Oversight Committee) ... The PIOC reviews data provided by AHN Quality Analytics, clinical and operational departments, and/or other services throughout the hospital. The Committee, in conjunction with administrative staff, reviews trends, identifies variances and facilitates the identification of quality and/or patient safety problems in the hospital and their timely investigation and resolution through a variety of mechanisms from simple procedural changes to chartering of quality improvement teams. identified problems are referred to the appropriate department and/or clinical chairperson for corrective action and , then the Committee reviews the effectiveness of corrective actions. the Committee reviews all possible serious (sentinel) events and may charter teams for root cause analyses in cases of serious events, review the analyses, recommended/approve proposed action plans and monitor to assure implementation."

1. Review of the facility's PIOC meeting minutes dated September 25, 2018, October 23, 2018, November 27, 2018, January 22, 2019, February 26, 2019, and March 26, 2019, revealed no documentation that the committee, in conjunction with administrative staff, included data from clinical and operational departments i.e. Nursing service, Dietary, Pharmacy, Medical Records, Emergency Service, Anesthesia, Radiology, Nuclear Med., and Surgical services.

Interview with EMP1 on May 15, 2019, at 12:28 PM confirmed the above findings and revealed "Your not going to find it in there [in the PIOC meeting minutes].

Based on review of facility documentation, medical records (MR) and staff interview (EMP), it was determined that the facility failed to provide the patient a list of home health agencies available to the patient for two of three medical records reviewed (MR2 and MR6).

Findings include:

Review of facility policy and procedure "Care Management Discharge/Transition Planning" last revised September 2018, revealed "vi. ... Patient Choice is considered a priority in the planning process (e.g. level of care agency selection). A Patient Choice Notification Form ... is signed by the patient/family/representative/legal guardian and the document is filed in the medical record."

Review of facility policy and procedure "Admission, Discharge, Reservation, and Transfer of Patients" last approved May 2019, revealed "16. The patient/representative will be presented with a list of post acute facilities/providers (i.e., skilled nursing facilities, acute rehabilitation providers, home health agencies, etc.) within the patient's geographic area of choice and notified of their right/freedom to select the post acute facility/service providers of their choosing."

Review of facility policy and procedure "Freedom of Choice" last approved August 2018, revealed "D. Each patient and/or family is presented, with a generated list either through electronic means or manually, of relevant providers in their area and the patient chooses a provide(s). It is essential that the patient be informed as to whcih entities are affiliated with AHN. Hospitals can not specify that patients will receive services from a specific provider. Staff should refer to the approved scripting on the Freedom of Choice Form ... when initiating post-hospital continuation of care services conversation. ... E. The receipt of the provider listing will be documented in the patient's medical record by the staff member who delivered the Freedom of Choice form."

1. Review of MR2 on May 14, 2019, revealed the patient was discharged on April 27, 2019, with home health services. Further review revealed no documentation the patient, or patient representative was presented with a list of home health agencies within the patient's geographic area.

2. Review of MR6 on May 14, 2019, revealed the patient was discharged on May 03, 2019, with home health services. Further review revealed no documentation the patient, or patient representative was presented with a list of home health agencies within the patient's geographic area.

Interview with EMP1 on May 15, 2019, at 9:26 AM confirmed the above findings and revealed "I can't find them [list of home health agencies].