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RML HEALTH PROVIDERS LIMITED PARTNERSHIP
DISCHARGE PLANNING PROGRAM REVIEW
Tag No.: A0803
Based on document review and interview, it was determined that the Hospital (Campus A and B), failed failed to ensure that a periodic assessment of a representative sample of discharge plans are conducted, to ensure that the plans are responsive to the patient post-discharge needs.
Findings include:
1. On 06/23/2022 at 9:00 AM, the Hospital's policy titled, "Quality and Performance Improvement Plan" dated 08/2020, was reviewed and included, "...Quality and Performance Improvement Plan ...structure to provide multi-disciplinary oversight of quality and patient safety ...performance improvement activities are data driven ...follow-up measurements provide leadership with the information necessary to focus on the outcomes of care, treatment, and services ..."
2. On 06/23/2022 at 9:10 AM, the Hospital was unable to provide the following: data that indicated that representative sample of discharge plans for patients were reviewed, the care coordination committee meeting minutes, tracking of the 30-days re-admission to the hospital, and ongoing quality assessment indicators for the care coordination process.
3. On 06/23/2022 at 9:15 AM, the Manager of Quality and Patient Safety (E #6) was interviewed. E #6 stated that the Care Coordination Manager (E #1) does not submit any data to the monthly quality committee meetings. E #6 stated the data of the discharges and readmissions can be extracted from the computer; however is not aware why they are not doing any quality review of the discharged patients. E #6 stated that there is no reviews done based on the discharge needs of patients at both Hospital campuses.
4. On 06/23/2022 at 9:30 AM, the Executive Director of Operations (E #7) at Campus Location B was interviewed. E #7 stated that the total of the referrals denied and approved are reviewed on a quarterly basis. E #7 stated that he does not recall if sample of discharged patients for post-discharge needs are reviewed.
5. On 06/23/2022 at 9:45 AM, the Director of Risk and Compliance (E #8) was interviewed. E #8 stated that she thinks it is necessary to review a sample of the patients that are discharged for quality of care. E #8 stated that there is no formal review process at both the locations.