HospitalInspections.org

Based on policy review, document review, record review, and interview the hospital failed to conduct a comprehensive detailed discharge planning process for each patient prior to discharge. The discharge plan should include a full investigation of each patient's medical, social, physical, financial, and psychological needs, review of resources available to meet those needs, and coordination with the patient and caregiver to ensure the patient's needs are fully met prior to discharge. The hospital failed to provide resources to meet those requirements.

Comprehensive discharge planning including meeting post hospitalization needs is a shared responsibility of facilities and health care professionals. The cumulative effect of the hospital's failure to ensure the provision of post hospitalization resources are placed all patients at risk of hospital readmission and a lack of continuum of care.


Findings Include:


1. The hospital failed to verify all patients can meet financial responsibilities for outpatient services and medications in one of 18 medical records reviewed (Patient 1) and failed to provide timely notification of pending dismissal to family members in one of 18 medical records reviewed (Patient 11). Refer to A-0806 for further details.

2. The hospital failed to ensure the patient and patient's representative were actively engaged in the development of the discharge plan/evaluation for one of 18 records reviewed (Patient 11). Refer to A-0811 for further details.

3. The hospital failed to fully investigate patient and family resources prior to dismissal in one of 18 medical records reviewed (Patient 1) and failed to provide discharge planning including both to the patient and the caregiver, in one of 18 medical records reviewed (Patient 11). Refer to A-0820 for further details.

4. The hospital failed to ensure reassessment of the discharge planning process on an ongoing basis to determine if they were responsive to the patient's post discharge needs for each patient at the hospital. Refer to A-0843 for further details.

Based on policy review, record review, document review, and interview the hospital failed to verify all patients can meet financial responsibilities for outpatient services and medications in one of 18 medical records reviewed (Patient 1) and failed to provide timely notification of pending dismissal to family members in one of 18 medical records reviewed (Patient 11). Failure by the hospital to fully investigate each patient's medical, social, physical, financial, and psychological needs and the caregiver's ability to meet those needs post hospitalization and failure to timely inform and prepare patients and caregivers for discharge placed all patients at risk of inappropriate, insufficient discharge planning leading to unsuccessful post hospital care and increased rehospitalization rates.

Findings Include:

Document review of the hospital's undated document titled, "Discharge Continuing Care Plan," showed a written review of post hospital arrangements including acknowledgement by the patient or the caregiver that medications can be afforded and obtained and transportation to and from appointments can be managed. This document requires a signature by either the patient or the family.

Document review of the hospital's undated policy titled, "Organizational Case Management Plan," showed discharge planning services include but are not limited to financial assistance and/or planning.

Document review of the hospital's document titled, "Job Description for the Intake Representative," revised 10/01/17, showed the Intake Representative is to include insurance eligibility verifications during the admission process.

Document review of the hospital's document titled, "Job Description for Case Manager," revised 10/01/17, showed the Case Manager is the primary payer source contact and communicates with patients, families, and referral sources to ensure positive treatment outcomes.

Review of Patient 1's discharged medical record on 07/30/18 showed Family Member (F)1, husband, stated during the team meeting on 06/13/18, he would like to have Patient 1 dismissed to his care and not placed in long term care. The County Court was notified on 06/13/18 of the request with approval of the plan. Staff D, Licensed Practical Nurse (LPN), Case Manager/Discharge Planner scheduled outpatient follow-up appointments. F2, son and F3, daughter were informed of the pending discharge plan. Staff D, LPN contacted F1 on 06/14/18 at 10:10 AM to discuss the discharge scheduled for 06/15/18 including prescriptions and outpatient mental health support. The discharge care plan for Patient 1 dated 06/15/18 at 8:00 AM and signed by Patient 1 showed she was aware of appointments and confirmed transportation for appointments could be managed and medications could be afforded and obtained. She was discharged using transportation provided by the hospital. Prescriptions were sent to the pharmacy on 06/15/18. Staff F, Registered Nurse (RN) received notification on 06/15/18 at 1:00 PM following Patient 1's dismissal at 10:00 AM that her insurance was not active and F1 could not pay for the prescriptions. Hospital staff notified the outpatient Counseling Service Agency at 1:10 PM requesting emergency assistance for the medications. Final documentation in the medical record showed the outpatient service agency would contact F1 and the pharmacy. The Hospital provided no further follow-up.

The prescribed discharge medications included:
- Bupropion, antidepressant
- Duloxetine, antidepressant and antianxiety
- Haloperidol, antipsychotic
- Hydroxyzine, antihistamine
- Acidophilus, probiotic
- Synthroid, thyroid replacement
- Latuda, antipsychotic
- Melatonin, hormone
- Mirtazapine, antidepressant
- Pantoprazole, used to treat gastroesophageal reflux
- Trazadone, antidepressant
- Hiprex, antibiotic
- Salbutamol, treats shortness of breath
- Ipratropium, treats shortness of breath
- Olanzapine, antipsychotic
- Vitamin C, vitamin replacement

During an interview on 07/31/18 at 9:00 AM, Staff C, Director of Nursing (DON), Registered Nurse (RN) stated Patient 1's admission was involuntary, so initial consents were not signed. She stated that Kansas Health Services (KHS) pays the hospital directly for involuntary admissions without insurance involvement and so the hospital does not verify the patient's insurance coverage. Staff C, reviewed the objectives of the policy "Organizational Case Management" and stated she interprets the hospital dismissal plan is to confirm medication prescriptions are received by the pharmacy, but not make sure the patient can pay for the medications or that the patient obtains the medications after discharge. She stated, "that it is the patient's responsibility". She further stated best practice would be for the hospital to review the patient's ability to pay for all medications and services prior to discharge to help them be compliant with the prescribed treatment plan. "It will be my recommendation that we look at the discharge planning going forward and confirm the patient's ability to pay." She further stated the hospital has one discharge planner who writes the plan that is followed by the nursing staff at the time of discharge. There is no back up discharge planner.

During an interview on 07/31/18 at 9:45 AM with Staff D, LPN, Case Manager/Discharge Planner, stated her training is on the job with guidance provided by the corporate hospital quality director. She stated the initial discharge plan for Patient 1 was to dismiss her to a long-term care facility until Family Member (F) 1, stated during the team meeting on 06/14/18 that he wanted to take her home. The court system was contacted with the request for a change of discharge location. "We honored what he said he could provide for her and the team agreed." Patient 1 was in the treatment team meeting and she agreed to go home with her husband. Staff D stated at no time did F1 tell anyone that there was no active medical insurance for Patient 1, until after she was dismissed when he was trying to pick her medications up at the pharmacy. She further stated the outpatient service agency was notified for emergency assistance to purchase the medications because "this was considered a crisis". During the phone call to outpatient services, Staff D was told that F1 refused services and only wanted her medications. "She was no longer our patient. I learned from this experience that insurance coverage is necessary, and this is a learning experience for me. I did not know to ask the questions."

During an interview 07/31/18 at 10:45 AM, Staff Y, Intake Coordinator, stated that when an admission request is made, she verifies insurance, the patient's demographic information and behaviors exhibited.

During a telephone interview on 08/06/18 at 11:13 AM Staff Z, Counseling Center Risk Manager (RM) (outside referral agency) stated the hospital requested emergency intervention for Patient 1 regarding lack of funds for prescribed medications and a need for follow-up psychiatric care as an outpatient. Staff Z explained patients not previously established with the Counseling Center require an intake to become an active patient. She further stated patient's requiring medications are referred to the medication clinic, after approval of the intake. She stated it is a common practice for dismissing facilities to make sure patients have three to four weeks of medications available to take until the patient is established as a client of the Counseling enter and are evaluated in the medication clinic. Staff Z stated the Family Member (F1) was contacted 06/15/18 at 4:00 PM to schedule the initial intake appointment. The attempt to schedule the appointment failed. F1 stated he was trying to obtain Patient 1's medication from the pharmacy and scheduling the appointment would have to wait. Staff Z re-stated patients receive medication assistance from the Clinic after they are established and evaluated by a physician and medications are reviewed through the medication clinic, otherwise the Clinic is unable to assist with obtaining medications. An appointment was scheduled on 06/19/18 for Patient 1, four days after discharge. She stated the hospital is responsible to ensure Patient had sufficient medication to cover her needs until the outpatient Clinic appointment. The Clinic does not provide emergency medication services. Initial contact with patients normally occurs within 24-48 hours of the intake request.

During a telephone interview on 08/06/18 at 11:20 AM with Staff AA, Counseling Clinic Emergency Service Clinician, Licensed Medical Social Worker (LMSW) (outside referral agency) stated Patient 1 had not been established as a Clinic patient through the intake process at the time of the request for medication assistance. She further stated Patient 1 would have qualified for other services and without insurance, provision of those services by the Clinic would be difficult until funding was obtained. Staff AA stated Patient 1 was requested to come to the Clinic on 06/15/18, the day of discharge, but (F)1 told the Clinic he wanted to wait at the pharmacy to pick up her prescriptions, instead. The Clinic provided the emergency number to F1 and he did return a call to the Clinic and stated he was trying to obtain the medications from the pharmacy and if Patient 1 needed additional care, he would take her to the local hospital.



Document review of the hospital's undated document titled,"Preassessment form and Discharge Receiving Acknowledgement, showed every attempt is made to discharge patients back to the place or home they were admitted from with notice to the patient and family given a minimum of 24 hours in advance of dismissal.

Review of Patient 11's current medical record on 07/31/18 at 11:30 AM showed an admission date of 07/29/18 at 6:00 PM. Staff O, Physician, listed four tentative discharge criteria to be met by Patient 11 prior to dismissal:
- Free of any suicidal ideation and plans at the time of discharge
- Free of any symptoms of depression
- Free of any symptoms of anxiety
- Will sleep six to eight hours per night.
- The discharge prognosis at that time was guarded.

Medication changes included discontinuation of Amitriptyline (mood elevator) and a prescription for Trazadone (antidepressant) per patient request was started. Long term goals established were that Patient 11 would remain free from suicidal ideation and self-harm and she would be free from anxiety with increased sleep patterns.

Documentation during the team meeting conducted 08/01/8 showed Patient 11 continued to be depressed and irritable with a flat affect, flight of ideas, and in denial of need for treatment. She continued to have difficulty sleeping.

Documentation also showed Patient 11 attended group but is withdrawn and does not actively participate and has made no progress towards goals.

Documentation of the physician progress note by Staff O, Psychiatrist on 08/01/18 at 9:10 AM, showed Patient 11 was to be dismissed to her daughter's custody on 08/01/18 because she no longer had suicidal ideation. She was instructed to follow-up at her county mental health outpatient program. She was dismissed with written and verbal instructions regarding follow-up appointments and prescriptions. Her daughter was informed of the pending discharge during the team meeting and was requested to pick her up on 08/01/18. There was no documentation prior to the team meeting that discharge planning was initiated or completed.

During an interview with Staff T, Chief Executive Officer (CEO) on 08/06/18 at 5:02 PM stated the interdisciplinary team discusses who, when, and where of all needs for each patient discharge, the staff provide support documentation of patient progress toward meeting goals during hospitalization, but ultimately it is the physician/psychiatrists responsibility to determine each patient's discharge appropriateness. The assessment tool used by the hospital is the McKesson Interqual tool. Staff and Physicians reference the tool to assist in the identification of individual patient goals and assessment of goals attained. Staff have received in-services related to interdisciplinary team meetings and use of the Interqual tool. He further stated Physician's consider the information provided by staff. The discharge decision and team meetings are physician driven and the physician ultimately makes the discharge decision. Staff T clarified a short-term goal as the reason for the admission and those goals are to be met at an acceptable percentage before patients are discharged.

Based on interview, record review, document review and policy review the hospital failed to ensure the patient and patient's representative were actively engaged in the development of the discharge plan/evaluation for one of 18 records reviewed (Patient 11). The hospital's failure to actively engage the patient and patient's representative in the development of the discharge plan/evaluation has the potential to effect the continuity of care after the hospital discharge related to meeting the patient's needs for safety, recovery and health transitions to meet the needs of the patient.

Findings include:

Document review of an article from the Center for Medicare Advocacy titled, "Rights and Procedures for Medicare Beneficiaries in Various Health Care Setting," showed receiving oral and written notice of a proposed discharge from one care setting to another is essential. This is particularly important when the beneficiary (or client) feels that the discharge is inappropriate for any reason. Similarly, good discharge planning for patients, their families, and their healthcare providers, paves the way to successful transitions from one care setting to another. Good discharge notices and good discharge planning should go hand in hand.

Document review of the hospital's undated policy titled, "Case Management Discharge Planning Program," showed the patient and the patient's family/legally responsible person and the multidisciplinary team that are involved in the patient's care treatment services participate in the planning of the patient's discharge ...conducts a discharge conference with the patient and the patient's families/legally responsible person as appropriate within 48 hours of discharge.

Document review of the hospital's undated policy titled, "Case Management Organizational Case Management Plan," showed to assist the family in dealing with ...post-hospitalization plans.

Document review of the hospital's undated form titled, "Pre-assessment Form and Discharge Receiving Acknowledgement," showed it is our policy for...families that we will always discharge the patient back to the place they came from unless prior arrangements in writing are made by the patient or family in advance 72 hours before being discharged...per policy a minimum of 24 hours notice of discharge will be provided for arranging pickup or transfer.

Observation on 08/01/18 at 9:02 AM, at the interdisciplinary team meeting, Staff D, Case Manager/Discharge Planner informed Patient 11's daughter the patient would be discharged today (the patient was admitted Sunday, 07/29/18 at 6:00 PM, 63 hours prior) and she would need to come to pick her up. The daughter was not asked if this was a workable plan for her or if things were in place for her mother's needs to be met. The daughter stated that she had to work and could not come until later this evening. The Patient asked if she could get off early and the daughter stated she has a new supervisor and that it would not be possible. The daughter stated that she would be able to come around 7:00 - 8:00 PM this evening.

During an interview on 08/01/18 at 11:59 AM, Staff D, Discharge Planner stated that documentation on the interdisciplinary team notes for Patient 11 do not support a discharge, but according to Staff O, Psychiatrist, he stated that the patient no longer meets inpatient criteria related to the fact she no longer has suicidal ideation as the determining factor. Staff D stated they defer to Staff O as a team for his decision concerning discharge. This surveyor asked if the team ever questioned the MD concerning an early discharge and Staff D stated that it would not be the discharge planner to bring it up. It is not my role. My job is just to be prepared for the discharge. Discharge criteria is based on McKesson, Interqual an app on the hospital phones that the hospital uses. It is based on acute behaviors the patient displays. The behavior criteria is recognized by most insurances although they do not always agree with what we say. Staff D stated that she would not be calling the daughter to further discuss the discharge, but that her role now is to make the follow-up and other appointments post discharge.

Observation on 08/02/18 at 11:42 AM, Staff D, Discharge Planner asked Staff U, Human Resources to help her get the password to sign on to use the McKesson, Interqual app so she could access it on her work phone.

During an interview on 08/01/18 at 11:02 AM, after the interdisciplinary team meeting, Staff C, Director of Nursing (DON), stated that review of Patient 11's plan of care for the interdisciplinary meeting held today (08/01/18) showed the client was admitted on 07/29/18 for suicidal ideation and was being discharged today 08/01/18 without 24 hour notice to the family. The social worker notes stated that the estimated date of discharge is 08/12/18 (in 11 days) and the next review will be on 08/08/18 (in 7 days). The discharge criteria is the patient will remain free from suicidal ideation and self-harm, free from anxiety and will increase sleep and remain free from falls. Nursing services documented the patient was depressed and irritable, flat affect, flight of ideas, in denial of need for treatment, is not sleeping well and she stated that she has no reason to go on living. Social Work/Therapy Services documented the patient is withdrawn and does not actively participate reflectively, and she is disassociated from the stressor. She stated that the client appears to have no association or recollection of self-harm or vandalism and the family is concerned for her safety and stability as she has been far out of her baseline behaviors. The interventions documented the patient has made no progress towards goals and is withdrawn. The patient had ten of ten goals that were not met at the time of discharge. Staff C stated that the 24 to 48-hour notice is a practice and not a policy for the hospital. She stated it was not a surprise to the team that Patient 11 was discharged. She stated that Staff O would have talked to the client last night and that she does not meet the criteria or qualifications to keep her as an inpatient at this time. The physician order by Staff O on 08/01/18 at 9:15 AM showed the patient was to be discharged today to her daughter as per team decision.

During an interview on 08/06/18 at 5:02 PM, Staff T, Chief Executive Officer (CEO), stated that it is the interdisciplinary team responsibility to provide progress for each patient with their long and short terms goals and after care needs. Staff T explained the staff is for support and ultimately it is the physician/psychiatrists responsibility for the discharge.

Based on policy review, record review and interview the hospital failed to fully investigate patient and family resources prior to dismissal in one of 18 medical records reviewed (Patient 1) and failed to provide discharge planning including both the patient and caregiver, in one of 18 medical records reviewed (Patient 11). Failure by the hospital to complete requirements of full disclosure to the patient and family members placed all patients at risk of discharge to an unsafe environment resulting in inability to complete the post hospital plan of care.

Findings Include:

Document review of the hospital's undated document titled, "Discharge Continuing Care Plan," showed a written review of post-hospital arrangements including acknowledgement by the patient or the caregiver that medications can be afforded and obtained and transportation to and from appointments can be managed. This document requires a signature by either the patient or the family.

Document review of the hospital's undated policy titled, "Organizational Case Management Plan," showed discharge planning services include but are not limited to financial assistance and/or planning.

Review of Patient 1's discharged medical record on 07/30/18 showed Family Member F1, husband, stated that during the team meeting on 06/13/18, he would like to have Patient 1 dismissed to his care and not placed in long term care. Notification of the request was made to the Court on 06/13/18 with approval. Staff D, LPN, Case Manager/Discharge Planner scheduled outpatient follow-up appointments and she informed F 2, son and F 3, daughter of the pending discharge plan. Staff D contacted F 1 on 06/14/18 at 10:10 AM to discuss the discharge plans scheduled for 06/15/18 including prescriptions and outpatient mental health support. The discharge care plan for Patient 1 dated 06/15/18 at 8:00 AM and signed by Patient 1 showed she was aware of appointments and confirmed transportation for appointments could be managed and medications could be afforded and obtained. The hospital provided transportation at discharge.

Prescriptions were sent to the (outside) pharmacy on 06/15/18. Staff F, Registered Nurse (RN) received notification at approximately 1:00 PM on 06/15/18 following Patient 1's dismissal at 10:00 AM that her insurance was not active and F 1 could not pay for the prescriptions. Hospital staff notified an outpatient service agency at 1:10 PM requesting emergency assistance for the medications and failed to confirm the outside agency could supply the medications. Final documentation in the medical record showed the outpatient service agency would contact F 1 and the pharmacy. The Hospital provided no further follow-up.

The prescribed discharge medications included:
- Bupropion, antidepressant
- Duloxetine, antidepressant and antianxiety
- Haloperidol, antipsychotic
- Hydroxyzine, antihistamine
- Acidophilus, probiotic
- Synthroid, thyroid replacement
- Latuda, antipsychotic
- Melatonin, hormone
- Mirtazapine, antidepressant
- Pantoprazole, used to treat gastroesophageal reflux
- Trazadone, antidepressant
- Hiprex, antibiotic
- Salbutamol, treats shortness of breath
- Ipratropium, treats shortness of breath
- Olanzapine, antipsychotic
- Vitamin C, vitamin replacement

During an interview on 07/31/18 at 9:45 AM with Staff D, LPN, Case Manager/Discharge Planner, stated the initial discharge plan for Patient 1 was to dismiss her to a long-term care facility until Family Member F1, her husband stated during the team meeting on 06/14/18 that he wanted to take her home. Notification to the court requested a change of discharge location. "We honored what he said he could provide for her and the team agreed." Patient 1 was in the treatment team meeting and she agreed to go home with F 1, her husband. F 1, requested transportation assistance for Patient 1 at dismissal and asked if the transportation could stop at the pharmacy to obtain her medications. Staff D stated that she explained to F 1 that transportation was not able to stop at the pharmacy and F1 stated he would pick the medications up. F1 was not in attendance at the hospital at the time of dismissal for Patient 1. The discharge care plan for Patient 1 signed and dated 06/15/18 at 8:00 AM showed she was aware of appointments and confirmed transportation for appointments could be managed and medications could be afforded and obtained.

Staff D, LPN, Case Manager/Discharge Planner stated at no time did F1 tell hospital staff that there was no active medical insurance for Patient 1, until after dismissal. He called from the pharmacy stating there was no insurance coverage and he was unable to afford the prescriptions. She further stated the outpatient service agency was notified by the hospital requesting emergency assistance to obtain the prescriptions because "this was considered a crisis." Staff D failed to ensure the outpatient services could supply the medications. During the phone call to outpatient services, Staff D was told that F1 refused services and only wanted Patient 1's medications. Staff D stated, "She was no longer our patient. I learned from this experience that insurance coverage is necessary, and this is a learning experience for me. I did not know to ask the questions."



Document review of the hospital's undated document titled, "Preassessment form and Discharge Receiving Acknowledgement," showed every attempt to discharge patients back to the place or home they were admitted from with a minimum 24-hour notification of pending dismissal given to the patient and family.

Review of Patient 11's current medical record on 07/31/18 at 11:30 AM showed an admission date of 07/29/18 at 6:00 PM. Staff O, Psychiatrist, listed four tentative discharge criteria to be met by Patient 11 prior to dismissal:
- Free of any suicidal ideation and plans at the time of discharge
- Free of any symptoms of depression
- Free of any symptoms of anxiety
- Will sleep six to eight hours per night.
- The discharge prognosis at that time was guarded.

Medication changes included discontinuation of Amitriptyline (mood elevator) and Staff O ordered Trazadone (antidepressant) per Patient 11's request. Long term goals established were that Patient 11 would remain free from suicidal ideation and self-harm and she would be free from anxiety with increased sleep patterns.

Documentation during the team meeting conducted 08/01/8 showed Patient 11 continued to be depressed and irritable with a flat affect, flight of ideas, and in denial of need for treatment. She continued to have difficulty sleeping. Documentation also showed Patient 11 attended group but is withdrawn and does not actively participate and has made no progress towards goals.

Documentation of the physician progress note by Staff O, Psychiatrist on 08/01/18 at 9:10 AM, showed dismissal of Patient 11 would be to her daughter's custody on 08/01/18 because she no longer had suicidal ideation. Written and verbal instructions regarding appointments and prescriptions were provided. Patient 11's daughter was informed of the pending discharge during the team meeting. No evidence of documentation prior to the team meeting regarding pending discharge was noted.

During an interview on 08/01/18 at 11:12 AM, Staff C, Director of Nursing (DON) stated she was not surprised Staff O, Psychiatrist ordered Patient 11's immediate dismissal because Patient 11 was no longer having suicidal ideation and no longer met criteria for continued hospitalization. Staff C also stated, "the 24 to 48 hr. notification prior to dismissal is our process but is not policy".

During an interview on 08/01/18 at 11:30 AM, Staff D, LPN, Case Manager/Discharge Planner stated she was not totally surprised that Staff O, Psychiatrist decided to dismiss Patient 11. She further stated that arrangements had not been completed for discharge and appointments for post hospital care and prescriptions would be arranged prior the Patient 11's daughter picking her up in the evening. She further stated the hospital attempts to give at least 24 hours' notice prior to discharge so arrangements can be completed. Staff D also stated that she would visit with Staff O if she had questions regarding the timeliness of dismissal.

During an interview on 08/06/18 at 5:02 PM, Staff T, Chief Executive Officer (CEO), stated that the interdisciplinary team discusses who, when, and where of all needs for each patient discharge, the staff provide support documentation of patient progress toward meeting goals during hospitalization, but ultimately it is the physician/psychiatrists responsibility to determine each patient's discharge appropriateness. The assessment tool used by the hospital is the McKesson Interqual tool. Staff and Physicians reference the tool to assist in the identification of individual patient goals and assessment of goals attained. Staff have received in-services related to interdisciplinary team meetings and use of the Interqual tool. He further stated Physician's consider the information provided by staff but ultimately make the final discharge decision and team meetings are physician driven. Staff T, CEO clarified a short-term goal as the reason for the admission and those goals are to be met at an acceptable percentage before patients are discharged.

Based on interview, document review and policy review the hospital failed to ensure reassessment of the discharge planning process on an ongoing basis to determine if they were responsive to the patient's post discharge needs for each patient at the hospital. The hospital's failure to ensure reassessment of the discharge planning process on an ongoing basis has the potential for all patients to be discharged without appropriate medications, continuum of care, treatments and follow up appointments.

Findings include:

Document review of the Hospital's document titled, "Quality Assessment Performance Improvement Plan," dated 06/01/18, showed 2018 master list of internal reporting measures...discharge planning documentation...active status...case management...clinical social service director...attachment of the form discharge planning documentation - continuing care plan monitoring tool.

Document review of the hospital's Discharge Planning policies showed the facility failed to provide policies requested for reassessment of the discharge planning process.

Document review of the hospital's form, "Discharge Planning Documentation - Continuing Care Plan Monitoring Tool," April 2018 showed 11 discharge records were reviewed for the following criteria:
- Summary of Patients response to treatment
- Patient Teaching
- Unresolved/Deferred Problems
- Discharge level of care
- Follow-up Appointments (Psych/Medical)
- Special needs referrals/freedom of choice form
- Indication of Medication/Appointment affordability
- Patient Signature
- Discharge planner signature
- Discharge medication form completed with side effects/indications

The 11 discharge records reviewed showed 100% completion in each area.
May 2018 showed two discharge records were reviewed at 100% completion in each area.

During an interview on 08/07/18 at 11:33 AM, Staff T, Chief Executive Officer (CEO) stated that the Quality Assessment and Performance Improvement Committee (QAPI) met in March and addressed the discharge planning reassessment process. The Discharge Planning Documentation - Continuing Care Plan Monitoring tool was created and completed for all discharges in April 2018. The QAPI committee decided that since the results were found to be 100% for the 11 discharge records reviewed in April 2018 and for two discharge records reviewed in May 2018 the process would no longer be needed and was discontinued.