HospitalInspections.org

Based on document review and interview in three (3) of 7 (seven) medical records reviewed, the hospital failed to ensure that a policy and procedure was in place that specify the role of non licensed individuals in discharge planning evaluations. (Patients # 2, 4, & 8).

Findings include:

Review of the hospital's policy and procedure titled: "Discharge Planning," last revised 01/2018, states: the team responsible for discharge planning includes the following: "Licensed Independent Practioner (LIPs), Residents/fellows, Physicians Assistants, Registered Nurses, Case Managers, Social Workers, Physical and Occupational Therapists, Dietician, Patient Access Staff and other health professionals..." Social Worker evaluates
the patient through initial screen and or psychosocial assessment pertaining to psychosocial, environmental and financial impact of the illness upon patient and significant others, including the extent to which the patient or his personal support system can provide for his needs in his own home."

Review of the medical record showed:
Patient #2 Social worker Initial Screen was conducted by a Social Work Intern on 3/20/19.

Patient #4 the Social worker Initial Screen was conducted by a Social Work Intern on 10/23/18.

Patient #8 the psychosocial Assessment was conducted by a Social Work Intern on 5/8/19.

The Policy and Procedure does not address the role of unlicensed individuals (Social Work Interns) to perform the discharge planning evaluation, nor does it address the limitations of these individuals.

During interview on 8/5/19 at 1:45 PM Staff A, Senior Social Work Supervisor acknowledged findings.