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Based on record review and interview, the hospital failed to ensure the QAPI (Quality Assessment and Performance Improvement) Program included QI (Quality Indicators) and QA (Quality Assurance) activities to review the hospital's Discharge Planning process in an on-going manner.
Findings:

A review of the Discharge Planning QA indicators, provided by S2VP/QA, revealed no documented evidence of QI (Quality Indicators) developed/implemented by the hospital to review their discharge planning process in an on-going manner through any QAPI activities.

In an interview 10/20/16 at 1:00 p.m. with S2VP/QA she indicated that she was responsible for the hospital's QAPI program. She was asked for the QAPI - QIs for the discharge planning process review to assure the hospital's discharge processes/policies were identifying issues in discharge planning. She indicated that she had only been in the QA position for 5 months and she was not sure if this was being collected in QAPI. She indicated that she would have to look into this and check with other QAPI members who have been here longer than her. After checking with other QAPI members and after reviewing the QAPI binder and the QAPI meeting minutes, she indicated that there was no documented evidence of QI's in QAPI for the review of the hospital's discharge planning process to identify concerns or problems. S2VP/QA further indicated that QAPI was not collecting data on the discharge planning process and QAPI was not tracking, trending or analyzing discharge planning processes and therefore, she had no data to present to demonstrate whether the hospital's discharge planning process had identified any problems in the discharge planning process for needed review/revisions. S2VP/QA indicated that the hospital was not reviewing the discharge planning process in QAPI, at present.

Based on record reviews and interview, the hospital failed to ensure that staff members responsible for discharge planning activities followed the hospital's policy for discharge planning evaluation for 1(#5) of 5 (#1-#5) sampled patients reviewed for discharge planning screening evaluations.
Findings:

A review of the hospital policy titled, "Interdisciplinary Discharge Planning", as provided by S3DirCM as the most current policy for discharge planning, revealed in part: Discharge planning is an interdisciplinary process which begins on admission and involves the patient and all members of the health care team as appropriate. This process must identify all patients who are likely to suffer adverse outcomes when there is inadequate discharge planning. Discharge planning will be on-going during the hospital stay. Each patient is screened within 24-48 hours of admission. Patients/family must be involved with anticipated discharge needs. Patient discharge is coordinated in advance by the Case Manager/Social Worker in collaboration with the treatment team, patient, and family.

Patient #5
A review of the medical record for Patient #5 revealed the patient was admitted to the hospital on 10/05/16 with an admitting diagnoses of seizure disorder. A review of the medical record revealed the patient was previously admitted to the hospital on 08/23/16 also for seizure disorder. A further review of the patient's medical record revealed no documented evidence of any discharge screening/assessment or planning for 3 days. A review of the medical record revealed no documented evidence of a discharge screening assessment or any Social Worker/Case Management progress notes for 3 days.

In an interview on 10/20/16 at 11:30 a.m. with S3DirCM, she reviewed the medical record of Patient #5 and indicated that there was no documentation of a discharge screening assessment/planning in the medical record for Patient #5 and she indicated that she was unable to find any documentation of discharge planning progress notes for this patient for 3 days following admit. S3DirCM indicated that the discharge screening assessment tool should have been used for risks identified with re-admissions. She further indicated that there was no documented evidence of a review of additional medical equipment, home health needs or family involvement during those 3 days. She indicated that without the screening risk assessment being completed for re-admission there was no way to know if further needs were identified or if the patient's family was involved. She indicated that Patient #5 had been in the hospital for 3 days and the case manager or social worker should have addressed discharge planning needs; such as, home health, medical equipment needed and whether the patient had a support system available. She indicated that staff members responsible for discharge planning activities did not follow hospital policy regarding discharge screening assessment to be completed within 24-48 hours upon patient admission.

Based on record review and interview, the hospital failed to have a process in place for on-going reassessment and review of its discharge planning process that tracked and trended readmissions for potential problems in discharge planning or in implementations of discharge plans in order to identify preventable readmissions and make needed changes to its discharge process/policy that addressed any identified discharge planning problems.
Findings:

A review of the Discharge Planning QA indicators, provided by S3DirCM, revealed no documented evidence of Quality Indicators developed/implemented by the hospital to review their discharge planning process in an on-going manner through any QAPI activities.

In an interview on 10/20/16 at 11:00 a.m. with S3DirCM she indicated that she was the Director of Case Management that included discharge planning. She was asked for the hospital's QA indicators/activities used to review their discharge planning process that included tracking and trending of readmissions in order to identify potential factors to prevent readmissions. S3DirCM indicated that her department was not reviewing the discharge planning process and that she was not collecting any data on the discharge planning process for QAPI, nor was she tracking readmissions as part of discharge planning review and therefore, had no data to present to demonstrate whether readmissions were due to implementation of the prior discharge plan to identify problems in the discharge planning process. She indicated that she used to track and trend about 5 key indicators (such as, lack of family support, transportation, medicine non-compliance or inability to pay for medicines) that she would collect data on, relating to patient's readmissions and she would put this data on a spread sheet and track and trend to determine what went wrong and then this would be discussed in the IDT (Interdisciplinary Team) conferences for patients so that all team members were aware of the prior barriers. S3DirCM indicated that she stopped doing this around 2013 due to lack of sufficient staff and the increased workload in her department. S3DirCM indicated that the hospital had no process in place, at present, for an ongoing reassessment of its discharge planning process that identified preventable readmission factors. S3DirCM further indicated that the hospital was not conducting any in-depth review of its discharge planning process in order to revise/modify their discharge planning and/or related processes.