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Based on document review and interview, it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.43, Discharge Planning.

Findings include:

1. The hospital failed to demonstrate periodic assessment of the discharge planning process, including review of patients admitted within 30 days of previous admission were conducted. See A-803.

2. The hospital failed to ensure that the psychosocial assessments were completed as part of the discharge planning evaluation, as required. See A-805.

3. The hospital failed to ensure that the discharge planning evaluation was discussed with the patient's state guardian. See A-808.

Based on document review and interview, it was determined that the hospital failed to demonstrate periodic assessment of the discharge planning process, including review of patients admitted within 30 days of previous admission were conducted. This potentially affect the discharge planning needs and outcomes for any patient in the hospital.

Findings include:

1. On 3/27/2024, the hospital's policy titled, "Discharge Planning" (revised on 1/2015) was reviewed and included, " ... IV. Procedures ... 10. Assessment of multiple admissions which includes an evaluation of whether readmissions were potentially due to problems in discharge planning or the implementation of discharge plans ..."

2. On 3/27/2024 at approximately 10:30 AM, any documentation, meeting minutes, or data collected to indicate that the hospital conducted periodic review of the discharge planning program was requested. No available information was provided.

3. On 3/27/2024 at approximately 11:30 AM, E #2 (Clinical Director, Behavioral Health Unit) and E #6 (System Vice President for Quality and Regulatory Compliance) could not provide any documentation, meeting minutes, or data collected to indicate that the hospital conducted periodic review of the hospital's discharge planning program. E #6 stated that there is no meeting minutes or documentation available.

Based on document review and interview, it was determined that for 4 of 8 patients' (Pt. #1, Pt.# 2, Pt. #4, and Pt. #6) clinical records reviewed for discharge planning on the behavioral health unit, the hospital failed to ensure that the psychosocial assessments were completed as part of the discharge planning evaluation, as required.

Findings include:

1. On 3/26/2024, the hospital's policy titled, "Psychosocial Completion Guidelines" (10/2018) was reviewed and included, "... Policy: 1. All patients who are hospitalized on the Behavioral Medicine Units will have a Psychosocial Assessment completed within 48 hours of admission..."

2. On 3/26/2024, the clinical record for Pt. #1 was reviewed. On 11/17/2023, Pt. #1 was admitted to the hospital's behavioral health unit for bizarre and paranoid behavior. The required psychosocial assessment was not completed for Pt. #1.

3. On 3/26/2024, the clinical record for Pt. #2 was reviewed. On 3/19/2024, Pt. #2 was admitted to the hospital's behavioral health unit with a diagnosis of schizoaffective disorder. As of 3/26/2024 (seven days after admission), the required psychosocial assessment was not completed.

4. On 3/26/2024, the clinical record for Pt. #4 was reviewed. On 3/22/2024, Pt. #4 was admitted to the hospital's behavioral health unit with a diagnosis of schizoaffective disorder. As of 3/26/2024 (four days after admission), the required psychosocial assessment was not completed.

5. On 3/26/2024, the clinical record for Pt. #6 was reviewed. On 3/21/2024, Pt. #6 was admitted to the behavioral health unit with a diagnosis of schizoaffective disorder. As of 3/26/2024 (five days after admission), the required psychosocial assessment was not completed.

6. On 3/26/2024 at approximately 11:30 AM, findings were discussed with E #2 (Clinical Director, Behavioral Health Unit). E #2 oversees the discharge planning for the hospital's behavioral health unit. E #2 stated that the required psychosocial assessments as part of the discharge planning evaluation were not completed for the above patients.

Based on document review and interview, it was determined that for 2 of 2 patients' (Pt. #1 and Pt. #5) clinical records reviewed for discharge planning with state guardians, the hospital failed to ensure that the discharge planning evaluation was discussed with the patient's state guardian.

Findings include:

1. On 3/26/2024, the hospital's policy titled, "Discharge Planning" (1/2015) was reviewed and included, " ...IV. Procedures: A. Department Staff identify patients for discharge planning intervention through Department high risk screening and assessment which are completed within 1 working day of the patient's admission ...B. Department Staff conducts a discharge planning assessment ...that includes ...a discussion or meeting with the family, surrogate decision maker, members of the Treatment Team and facilities/agencies that have previously provided care to the patient ...Department Staff gather the following information ...to determine a patient's need for discharge services: ...4. Decision Making Capacity, i.e., ...Power of Attorney ...Guardianship etc. ...".

2. On 3/26/2024, the hospital's policy titled, "Patient Rights" (12/2022) was reviewed and included, " ...Privacy and Confidentiality: ...Intake staff (nurses, physicians, Social Workers etc.) must notify any Power of Attorney (POA) or Guardian of admission, prior to transfer, or discharge ...".

3. On 3/26/2024, the clinical record of Pt. #1 for the following hospitalization dates were reviewed:

- On 11/11/2023, Pt. #1 was admitted due to bizarre, paranoid behavior. The clinical record indicated that Pt. #1 had a state guardian. On 11/16/2023, Pt. #1 was discharged to another facility for residential placement.

- On 11/17/2023, Pt. #1 was admitted due to bizarre, paranoid behavior. On 11/16/2023, Pt. #1 discharged home with (Pt. #1's) brother.

- On 12/24/2023, Pt. #1 was admitted due to schizoaffective disorder (mental disorder of abnormal thought processes and unstable mood). On 1/01/2024, Pt. #1 was discharged home with (Pt. #1's) brother.

- The clinical record for Pt. #1's hospital encounters included documentation that Pt. #1 had a state guardian. However, the clinical record did not include documentation that the state guardian participated, nor follow-ups were made to discuss the discharge planning evaluation.

4. On 3/26/2024, the clinical record for Pt. #5 was reviewed. On 3/18/2024, Pt. #5 was admitted due to bizarre and paranoid behavior. The clinical record indicated that Pt. #5 had a state guardian. On 3/25/2024, Pt. #5 was discharged to a nursing facility. The clinical record did not include notification and follow-up with state guardian regarding the plan and results of discharge planning evaluation.

5. On 3/26/2024 at approximately 1:18 PM, an interview with the Clinical Director of Behavioral Health (E #2) was conducted. E #2 stated that a patient's legal/state guardian, POA and or Emergency Contact person should be included in the patient's discharge plan and then notified of patient's discharge disposition.