HospitalInspections.org

Based on clinical record review, select document review and interview, it was determined the facility's staff failed to inform patients of their Rights in written form or verbally,
- failed to inform patients of the hospital's grievance process,
- failed to notify all complainants of the proposed resolution to their complaint, and
- failed to ensure a patient's right to confidentiality.

The findings were:

Cross reference to; 42 CFR 482.13 Patient Rights
42 CFR 482.13 Patient Rights, Notice of Rights Tag A 116,
42 CFR 482.13 Patient Rights, Notice of Rights Tag A 117,
42 CFR 482.13 Patient Rights, Grievances Tag A 118,
42 CFR 482.13 Patient Rights, Review of Grievances Tag A 119
42 CFR 482.13 Patient Rights, Grievance Procedure Tag A 121,
42 CFR 482.13 Patient Rights, Notice of Grievance Decision Tag A 123 and
42 CFR 482.13 Patient Rights, Personal Privacy Tag A 143

Based on clinical record review, select document review and interview it was determined the facility failed to provide and inform patients of their Notice of Rights (Patient Rights). Specifically, patients were not provided a written copy or a verbal explanation of their Rights during the admission process and or before care was furnished.

The findings were:

During an interview with the Director of QA (Quality Assurance) in the facility's conference room on June 25, 2012 beginning at or about 1 P.M. the director was asked how patients are informed of their Rights. The director stated that Patient Rights are posted in the ER and inpatients are informed of their Rights during the admission process. A copy of all information that is provided to a patient during the admission process was requested at that time including any policies regarding Patient Rights. On 6/26/12, at approximately 10 A.M., the director provided this writer with 3 forms and stated that this is what the patient is given and asked to sign when they are admitted to the hospital. The forms were entitled, "Virginia Advance Medical Directive, An Important Message From Medicare About Your Rights and, How Can I Quit Smoking."

During the daily summary report on 6/26/12 the director was asked again to provide this writer with all information that a patient is given or asked to sign when they are admitted to the hospital. On 6/27/12 at approximately 10 A.M. this writer was given a blue folder which contained admission information. The director explained that she placed information on the left side of the folder that is given to ER (Emergency Room) patients and the information on the right side of the folder was information given to all inpatients. The left side pocket contained, "Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment, Notice of Privacy Practices and Ask Me 3, (Good Questions for Your Good Health)." The right pocket of the folder contained the following forms/items;
"Release of Information to Clergy,"
a pamphlet entitled, "Plan ahead with Advance Directives,
How Can I Quit Smoking,
An Important Message From Medicare About Your Rights,
Virginia Advance Medical Directive and
Welcome To Southern Virginia Regional Medical Center."

The QA Director removed the Welcome To Southern Virginia Regional Medical Center booklet from the folder and stated that she had to get them to print her a copy because they had run out and they were waiting on the printer to send them more. Notice of (Patient) Rights was contained in this booklet.

On 6/28/12 at approximately 9 AM, this writer and the QA Director went to the patient registration area. Only one employee (#7) was working the patient registration area. Employee #7 was asked to demonstrate what happens when a patient is being admitted to the hospital. The clerk demonstrated the admission process which included which forms are given to the patient to read and or sign. At no time was the booklet, "Welcome to Southern Virginia Regional Medical Center," mentioned. The clerk was asked several times if any other information is discussed or given to the patient and she replied "No." At no time during the demonstration was Notice of Patient Rights discussed or a copy provided. Upon leaving the patient registration area the QA Director acknowledged Notice of Patient Rights is not being provided or explained to patients being admitted to the hospital.

A copy of the facility's policy titled, "Patient Rights and Responsibilities," was provided to this writer on 6/25/12 at or about 2:45 P.M.. A section under, "Facility Responsibilities," read in part, "It is the responsibility of Registration Clerks to notify all admitted patients registered of their rights and responsibilities by issuing and reviewing a copy of Rights and Responsibilities with the patient, parent or guardian."

Throughout the survey process (6/25 - 28/12) no Notice of Rights or Patient Rights and Responsibility's booklets or printed information was found displayed in the hospital. Areas observed were, Emergency Department and its waiting room, Acute care, Intensive Care, Administration, Front lobby and Registration.

Based on clinical record review, select document review and interview it was determined facility staff failed to provide patients with their Notice of Rights in advance of providing care. Additionally the facility failed to provide patients with the correct telephone number to the Virginia Department of Health, Office of Licensure and Certification's Complaint unit or direct line.

The findings were:

Cross reference to 42 CFR 482.13(a) Patient Rights, Tag A 116

The Welcome to Southern Virginia Regional Medical Center booklet contains a section entitled, Our Commitment to Care. This section in the booklet provides patients with the name and address of the Virginia Department of Health's Office of Licensure and Certification and a fax number but does not provide the reader with the actual phone number to that office.

Six (6) inpatient records (#1, 8, 9, 13, 18 & 19), were reviewed between 6/27 and 6/28/12. All records failed to contain documented evidence that patients were given a written copy and or a verbal explanation of their Rights.

Based on select document review, Event Occurrence Log review for 2012 and interview, it was determined the facility's staff failed to comply with their grievance process. Specifically, the hospital failed to inform patients and or families of the hospital's grievance process, who to contact if a patient or family member has a grievance and lastly, respond to grievances within an acceptable timeframe. Also, the hospital has received 27 grievances during 2012, of those grievances, two (2) had no documented letter of resolution and two (2) written letters of follow-up (resolution) were dated greater than seven (7) days from the date of receipt of the grievance which violated the hospital's policy titled "Patient/Resident Complaint/Grievance."

The findings were:

During the entrance conference in the hospital's Administrative Conference room on 6/25/12 with the Administrator and the Director of QA at or about 12 noon, the hospital's Event Occurrence log was requested. The Log (complaint log) was initially reviewed on 6/25/12 at or about 3 P.M. and then multiple times after that between 6/26 and 6/28/12.

The log contained 27 grievances that had been reported to the hospital during 2012. Of those 27 grievances, two (2) grievances during the month of May had no documented letters of resolution that had been sent to the complainants. Two (2) grievances, one (1) in January and one (1) in February, had documented letters of resolution that were sent to the complainant greater than 10 days from the time the grievance was received.

A hospital policy entitled, "Patient/Resident Complaint/Grievance was reviewed on 6/25/12 in the hospital's conference room beginning at 2:45 P.M., a portion of that policy read in part, "The Hospital Quality Improvement Committee ensures that the patient is provided written notice of its receipt, investigation and outcomes regarding a complaint/grievance within 7 days of the Hospital's receipt of the grievance, even though the Hospital's resolution need not be complete within the seven-day limit... If the grievance is not yet resolved within the initial, written response of 7 days, the written response will indicate that the hospital is working towards a resolution of the grievance and that follow-up written response will be provided within a specified period but not to exceed 30 days until the grievance is resolved..."

On 6/28/12 at approximately 9 AM, this writer and the QA Director went to the patient registration area. Only one employee (#7) was working the patient registration area. Employee #7 was asked to demonstrate what happens when a patient is being admitted to the hospital. The clerk demonstrated the admission process which included which forms are given to the patient to read and or sign. At no time was the booklet, "Welcome to Southern Virginia Regional Medical Center," mentioned. The Welcome to Southern Virginia Medical Center booklet contains information about the hospital's grievance process. The clerk was asked several times if any other information is discussed or given to the patient and she replied no. At no time during the demonstration was the hospital's grievance process discussed or a copy provided. Upon leaving the patient registration area the QA Director acknowledged that the booklet that has the hospital's grievance process in it is not being provided or explained to patients being admitted to the hospital.

Based on select document review, interview and review of the hospital's Event Occurrence log, it was determined that the hospital's Quality Improvement Committee failed to ensure the effectiveness of their grievance process. Specifically four (4) of 27 grievances received in 2012 were not responded to or were not responded to within the timeframes specified in the hospital's policy and procedure titled "Patient/Resident Complaint/Grievance."

The findings were:

Cross reference to, 42 CFR 482.13(a)(2), Patient Rights, Tag A-0118

A hospital policy entitled, "Patient/Resident Complaint/Grievance was reviewed on 6/25/12 in the hospital's conference room beginning at 2:45 P.M., a portion of that policy read in part, "The Hospital Quality Improvement Committee ensures that the patient is provided written notice of its receipt, investigation and outcomes regarding a complaint/grievance within 7 days of the Hospital's receipt of the grievance, even though the Hospital's resolution need not be complete within the seven-day limit... If the grievance is not yet resolved within the initial, written response of 7 days, the written response will indicate that the hospital is working towards a resolution of the grievance and that follow-up written response will be provided within a specified period but not to exceed 30 days until the grievance is resolved..."

Based on clinical record review, observations made at the patient registration area and interview, it was determined that patients did not receive written or a verbal explanation of the hospital's grievance filing procedure.

The findings were:

During an interview with the Director of QA (Quality Assurance) in the facility's conference room on June 25, 2012 beginning at or about 1 P.M. the director was asked how patients are informed of their Rights. The director stated that Patient Rights are posted in the ER and inpatients are informed of their Rights during the admission process. A copy of all information that is provided to a patient during the admission process was requested at that time including any policies regarding Patient Rights and grievances. On 6/26/12, at approximately 10 A.M., the director provided this writer with three (3) forms and stated that this is what the patient is given and asked to sign when they are admitted to the hospital. The forms were entitled, "Virginia Advance Medical Directive, An Important Message From Medicare About Your Rights and, How Can I Quit Smoking."

During the daily summary report at about 4 P.M. on 6/26/12 the director was asked again to provide this writer with all information that a patient is given at the time they are admitted to the hospital. On 6/27/12 at approximately 10 A.M. this writer was given a blue folder which contained admission information. The director explained that she placed information in the right side of the folder that is given to all inpatients. The right side pocket contained the following forms/items;
"Release of Information to Clergy,"
a pamphlet entitled, "Plan ahead with Advance Directives,
How Can I Quit Smoking,
An Important Message From Medicare About Your Rights,
Virginia Advance Medical Directive and
Welcome To Southern Virginia Regional Medical Center."

The QA Director removed the Welcome To Southern Virginia Regional Medical Center booklet from the folder and stated that she had to get them to print her a copy because they had run out and they were waiting on the printer to send them some more. This writer was unable to determine how long the hospital had been out of the Welcome To Southern Virginia Regional Medical Center booklets. A page entitled, Our Commitment to Care, was in the booklet. This page in the booklet read in part, "Our goal is to provide exceptional care. If at any time you have questions or concerns about the quality of care that you or a family member are receiving or have received at our hospital, do not hesitate to speak with your nurse or the nursing supervisor. If you feel that your issue wasn't resolved or are extremely pleased with your care, please contact our Patient Advocate at (extension and telephone number) with your compliments, complaints or concerns. You may call at any time during or after your stay. In addition, you have the right to file a complaint or concern with either or both: Virginia Department of Health (address and fax number), Office of Quality Monitoring The Joint Commission (address, phone number and e-mail address)." The booklet also contained, "Patient Rights and Responsibilities," which read in part, "You also have the right to: Lodge a concern with the state, whether you have used the hospital's grievance process or not..." The booklet did not contain documentation that described how the complainant would be notified of the complaint resolution or a timeframe in which the complainant would receive information regarding the complaint investigation and resolution. It only explained who a complaint could be made to.

On 6/28/12 at approximately 9 AM, this writer and the QA Director went to the patient registration area. Only one employee (#7) was working the patient registration area. Employee #7 was asked to demonstrate what happens when a patient is being admitted to the hospital. The clerk demonstrated the admission process which included which forms are given to the patient to read and or sign. At no time was the booklet, "Welcome to Southern Virginia Regional Medical Center," mentioned. The clerk was asked several times if any other information is discussed or given to the patient and she replied no, At no time during the demonstration was Notice of Patient Rights or the hospital's grievance process discussed or a copy provided. Upon leaving the patient registration area the QA Director acknowledged that the Welcome to Southern Virginia Medical Center booklet with the grievance process in it is not being provided or explained to patients being admitted to the hospital.

Throughout the survey process (6/25 - 28/12) no Welcome To Southern Virginia Regional Medical Center booklets or written information was found displayed in the hospital. Areas observed were, Emergency Department and its waiting room, Acute care, Administration, Intensive Care, Front lobby and Registration.

Based on Event Occurrence Log for 2012 review, select document review and interview, it was determined that the facility failed to ensure that the complainants for two (2) of 27 grievances received in 2012 were informed in writing of the resolution to a grievance that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

The findings were:

During the entrance conference in the hospital's Administrative Conference room on 6/25/12 with the Administrator and the Director of QA at or about 12 noon the hospital's Event Occurrence log was requested. The Log (complaint log) was initially reviewed on 6/25/12 at or about 3 P.M. and then again multiple times between 6/26 and 6/28/12.

The log contained 27 grievances that had been reported to the hospital during 2012. Of those 27 grievances, two (2) grievances during the month of May had no documented letters of resolution that had been sent to the complainants. The Director of QA reviewed the log with this writer on 6/27/12 beginning at 3 P.M., the director acknowledged the log failed to contain evidence that letters of resolution had been sent to two (2) complainants for grievances received in May 2012.

A hospital policy entitled, "Patient/Resident Complaint/Grievance was reviewed on 6/25/12 in the hospital's conference room beginning at 2:45 P.M., a portion of that policy read in part, "The Hospital Quality Improvement Committee ensures that the patient is provided written notice of its receipt, investigation and outcomes regarding a complaint/grievance within 7 days of the Hospital's receipt of the grievance, even though the Hospital's resolution need not be complete within the seven-day limit... If the grievance is not yet resolved within the initial, written response of 7 days, the written response will indicate that the hospital is working towards a resolution of the grievance and that follow-up written response will be provided within a specified period but not to exceed 30 days until the grievance is resolved..."

On 6/28/12 at 1 P.M. in the Administrative conference room, the QA Director acknowledged the above findings.

Based on observations made during a tour of the hospital's Emergency Department (ED), and interview, it was determined the hospital failed to ensure a patient's right to privacy. Specifically, an electronic information board mounted on the wall in a public access area between two (2) patient rooms contained patient identifiable information. The board listed the room number, last name, age and sex of each patient who was receiving care in the Emergency Department.

The findings were:

A tour of the hospital's Emergency Department was conducted on 6/25/12 beginning at 1:45 P.M. with the Director of QA, an ED registered nurse (employee #10) and this writer.

Mounted on the wall across from the nurses station in a public hallway and between two (2) patient rooms was a lighted electronic board, the ED nurse assisting with the tour referred to the board as the "ProMed Board." When asked to explain what the board was the ED nurse replied, these are all of our patients being treated here in the ED. She then continued to explain that this, pointing to the board, is the room number, patient's name, age, sex and status of tests ordered. When asked by this writer if this (meaning the board) compromised a patient's privacy the nurse replied, I guess so but we can fix that.

On 6/27/12 beginning at 9:10 A.M. another tour of the ED was conducted. The "ProMed Board" on the wall across from the nurses station in the public hallway was observed again. The board listed four (4) patients that were in the ED being treated, No changes to the board appearance had occurred, the board listed all four (4) patients last name, their room number, age and sex.

Upon leaving the ED, the Director of the ED and the Director of QA acknowledged the board provided identifiable information about who was being treated in the ED and failed to ensure a patient's right to privacy.

Based on review of the hospital's QAPI (Quality Assessment Performance Improvement) Plan for 2011 and the quality indicators for 2012, it was determined the hospital failed to measure, analyze and track all grievances that the hospital has received. The hospital also failed to review through their QAPI program discharge planning processes.

The findings were:

The hospital's QAPI (Quality Assessment Performance Improvement) activities were reviewed with the QA Director on 6/28/12 beginning at 1 P.M. QAPI is a mandatory requirement by Medicare. The Director reviewed with this writer the hospital's, "ORGANIZATIONAL PERFORMANCE IMPROVEMENT DASHBOARD FOR 2011" and January through May for 2012. The dashboard is a list of all performance improvement projects the hospital is looking at each month, quarter and year. The dashboard looks at important functions that most affect patient care processes, patient outcomes, patient safety and patient satisfaction.

The review of 2011 and 2012 dashboard did not reflect the hospital's use of the QAPI program to determine whether the discharge planning process effectively identifies patients in need of plans, and whether the plans were adequate and appropriately executed. The plan also failed to review complaint or grievances not related to physicians. The QA Director acknowledged that the omission of discharge planning and grievances in their QAPI program was an oversight.

Based on review of the hospital's QAPI (Quality Assessment Performance Improvement) Plan for 2011 and the quality indicators for 2012, it was determined the hospital failed to set priorities for its performance improvement activities that focused on high risk, high-volume or problem prone areas. Specifically, the hospital failed to include discharge planning processes and review of grievances as part of their QAPI program.

The findings were:

The hospital's QAPI (Quality Assessment Performance Improvement) activities were reviewed with the QA Director on 6/28/12 beginning at 1 P.M. QAPI is a mandatory requirement by Medicare. The Director reviewed with this writer the hospital's, "ORGANIZATIONAL PERFORMANCE IMPROVEMENT DASHBOARD FOR 2011" and January through May for 2012. The dashboard is a list of all performance improvement projects the hospital is looking at each month, quarter and yearly. The dashboard looks at important functions that most affect patient care processes, patient outcomes, patient safety and patient satisfaction.

The review of 2011 and 2012 dashboard did not reflect the hospital's use of the QAPI program to determine whether the discharge planning process effectively identifies patients in need of plans, and whether the plans were adequate and appropriately executed. The plan also failed to review complaint or grievances not related to physicians. The QA Director acknowledged that the omission of discharge planning and grievances in their QAPI program was an oversight.

Based on clinical record review, select document review and interview, it was determined the hospital failed to ensure an effective discharge planning process for all patients. Specifically, the hospital's Case Management Department failed to clearly document the process of events from the time a patient is admitted through the actual discharge or transfer of the patient when discharge planning has been initiated or a referral was made to Case Management.

The findings were:

Cross reference to;

42 CFR 482.43(b)(1) Discharge Planning Needs Assessment , Tag A 806
42 CFR 482.43(b)(6) Documentation of Evaluations, Tag A 811
42 CFR 482.43(c)(3) Implementation of A Discharge Plan, Tag A 820
42 CFR 482.43(c)(4) Reassessment of a Discharge Plan Tag A 821
42 CFR 482.43(e) Reassessment of Discharge Planning Process Tag A 843

Based on on clinical record review, select document review and interview, it was determined that Case Management staff failed to conduct and or document a Discharge Planning Assessment that would identify patients who were likely to require post hospitalization care. Specifically, at the time of the initial review, four (4) of five (5) clinical records for inpatients in the survey sample failed to contain a Discharge Planning Assessment conducted by the Case Management Department, (Patients #1, 9, 13 & 19).

The findings were:

1. Clinical records were reviewed at various times on 6/27 and 6/28/12 in the hospital's Administrative conference room.

a. The clinical record for patient #9 was initially reviewed on 6/27/12 beginning at 1:30 P.M. and contained a hospital admission date of 3/13/12. At the time of admission, known diagnosis included; COPD (Chronic Obstructive Pulmonary Disease), Bronchitis (an infection in the lungs), Hypertension (High Blood Preassure) and ASCVD (Arterial Sclerotic Cardiovascular Disease). The nursing assessment (Admission Assessment Database) conducted the day of admission listed the patient's chief complaint as, "Cough and shortness of breath." The nursing assessment identified a need for a case management referral which was made on 3/13/12 at 1610 (Military time). The assessment also identified that the patient had a "Rt AKA" (Right above the knee amputation), shortness of breath on exertion and required assistance with activities of daily living. Prior to this hospitalization the patient was receiving Personal Care Services and nursing documented the name of the agency providing personal care.

An Interdisciplinary Plan of Care was developed by nursing on 3/13/12 and identified Discharge Planning on the patient's Problem List. A Problem List is a list of symptoms, special needs, or deficits that need to be addressed while the patient is in the hospital and before discharge.

The record failed to contain a Discharge Planning Assessment that was conducted and documented by Case Management. The record failed to contain any documented discharge planning or communication (regarding discharge needs) between the hospital staff, the patient and or family and the Personal Care agency that had provided care to the patient prior to admission. There was no documented evidence that the agency providing personal care was informed of the patient's discharge. A Discharge Planning Summary form written by a Case Manager on 3/19/12, documented that the patient was discharged to home on 3/19/12.

b. The clinical record for patient #1 was reviewed initially on 6/27/12 beginning at 3 P.M. and contained an admission date of 5/24/12. The patient's diagnoses included ESRD (End Stage Renal Disease) and Auto Immune Kidney Disease. An Admission Assessment Database was conducted for the patient by nursing at the time of admission and identified a need for Case Management. A referral to Case Management was made on 5/25/12 at 0100 hours (military time) and a Interdisciplinary Plan of Care was developed by nursing on 5/25/12 that identified a need for Discharge Planning on the patient's Problem List. The intervention for discharge planning was, "Involve Pt/Family at admission concerning discharge plans, goals, options. Assess discharge needs at admission and ongoing."
On 5/31/13, the patient signed a consent authorizing a transfer to a rehab center and was then transferred on 6/1/12.

At the time of the initial review of the record, the record failed to contain a Discharge Planning Assessment conducted by Case Management or any additional ongoing communication/documentation regarding the patient's status or discharge plan. The above information was presented to the QA Director during the daily summary report on 6/27/12 beginning at 4 P.M. The Director also reviewed the chart and acknowledged she did not find a Discharge Planning Assessment or other documented communication by the Case Management Department. On 6/28/12 the QA Director informed this writer that Case Management had reviewed the record and flagged their entries. The record for patient #1 was reviewed again on 6/28/12 beginning at 9:15 A.M. The record contained a Discharge Planning Assessment that was documented as being conducted on 5/25/12. The assessment contained a hand written note by a Case Manager that read in part, "(The patient's name) lives w/ family, and has been mostly independent; There are no anticipated d/c (discharge) needs. Will follow." A Case Management note was also flagged in the progress notes dated 5/31/12 that read as follows; "Case Mgt Note: Spoke to the pt (patient) regarding inpatient rehab and he is agreeable; Choice letter signed for (Name of facility to transfer to), referral made; Awaiting assessment decision. Case Manager's name" The record failed to contain any documented communication with the family concerning discharge planning, goals or options until the Choice Letter was signed

c. The clinical record for patient #13 was reviewed on 6/27/12 beginning at 2:25 P.M. and contained an admission date to the hospital as 4/27/12. The record listed multiple diagnosis which included; CHF (Congestive Heart Failure), Diabetes, Seizure Disorder, Morbid Obesity COPD, and Venous Stasis Ulcer (Open wounds from poor circulation). The record also contained an Admission Assessment Database conducted by nursing on 4/27/12. The assessment identified a need for a Case Management referral and a referral was made on 4/27/12 at 0313 hours. At the time the record was initially reviewed no Discharge Planning Assessment conducted by the Case Management department was identified. The above information was presented to the QA Director during the daily summary report on 6/27/12 beginning at 4 P.M. The Director also reviewed the chart and acknowledged she did not find a Discharge Planning Assessment or other documented communication by the Case Management Department. On 6/28/12 the QA Director informed this writer that Case Management had reviewed the record and flagged their entries. The record for patient #13 was reviewed again on 6/28/12 beginning at 9:30 A.M. The record contained a Discharge Planning Assessment that was documented as being conducted on 4/28/12. The assessment contained a hand written note by a Case Manager that read in part, "Pt lives at home with family. Has walker, cane & nebulizer. D/C plan is home upon discharge." A Discharge Planning Summary documented on 5/2/12 by Case Management was also flagged and read, "Patient transferred to (name of facility) for cardiac cath."

The record failed to contain documented ongoing reassessments for discharge planning or communication between the hospital staff, patient and or family or the facility to which the patient was transferred to.

d. The clinical record for patient #19 was reviewed on 6/28/12 beginning at 1 P.M. and contained a date of admission to the hospital as 4/6/12. The patient was initially seen in the Emergency Department with diagnosis of; Hypoglycemia (low blood sugar) seizure disorder and Pneumonia. A nursing Admission Assessment Database was documented for the patient on 4/6/12 and identified the patient as needing assistance with activities of daily living, anxious and confused. On 4/8/12, the physician wrote an order, "Pt reports must go home..." and the patient was discharged.

No Discharge Planning Assessment was conducted by Case Management.

2. On 6/28/12 beginning at 11 A.M. select documents were reviewed in the hospital's Administrative conference room. Those documents included;
a. "Position Description/Competency Based Evaluation for Case Manager, Case Management Services and read in part;
Position Purpose: The Case Manager will assist in the development, planning, coordination, and administration of the activities of Utilization Review and Discharge Planning. Including but not limited to daily review of medical records to determine appropriateness and medical necessity of admission, continued hospital stay, and use of ancillary services.
General Duties: ... Performs discharge planning screen on all patients on a timely basis to assess discharge planning needs.
Purposely coordinates the overall discharge planning and social services function ensuring compliance with federal and state laws and Joint Commission of Accreditation of Hospitals.
Communicatees effectively and actively with team members, physicians, PA and hospital staff concerning utilization and D/C planning.
Actively participates in Case Management/Discharge Planning meetings."

b. The policy entitled, "Discharge of a Patient" was reviewed and read in part, "Purpose: To arrange continuing care for a patient when acute care is no longer needed and patient can be managed at a lower level of care...
A. Discharge Planning
...It is the responsibility of the staff RN (registered nurse) to address the discharge planning needs of all newly admitted patients by completion of the Interdisciplinary admission database at time of admission and submitting needs to case management through the HMS (computer software) order system. ... Referrals are evaluated, documentation completed and physician consulted for individual plans of care..."

c. The hospital's policy entitled, "U R Plan," was reviewed and read in part as follows,
"IX. Discharge Planning / Social Service
1. Acute Medical-Surgical Units: The process of discharge planning begins prior to, at admission, or within twenty-four (24) hours of admission for all acute care Medical-surgical patients. The Case Management Coordinators screen all patients to assess their potential post-hospitalization needs... The Case Management Coordinator assesses discharge planning needs within one (1) working day of the patient's admission; initiates discharge planning... Discharge planning activities include provisions for, or referral to, services required to improve or maintain health status after discharge.
During the process of concurrent review, the Case Management Coordinator will reassess discharge planning needs as necessitated by changes in patient/family condition... All discharge planning activity will be clearly documented in the patient's medical record."

3. An interview was conducted on 6/26/12 with the hospital's two (2) Case Management Coordinators on the Acute Care Unit beginning at 11 A.M. Both Case Managers stated they they conduct a Discharge Planning Assessment on all admissions to the hospital within 24 hours of their admission. They also stated that ongoing assessments are conducted and patient's status are reviewed daily. When asked where do you document the ongoing assessment both replied, we don't usually document it in the record and acknowledged there was no paper trail that could demonstrate all that they do.

On 6/28/12 an interview was conducted with Case Manager, employee #6. The manager was asked what is their high risk screening criteria and how does it identify patients who are in need of a discharge planning evaluation. The manager replied we don't have that here, I'm not sure what you are talking about. The manager was also asked about their involvement with the Interdisciplinary Plan of Care and the manager responded by saying we do not document on the Interdisciplinary Plan of Care.

Based on Clinical record review, select document review and interview it was determined that the facility's staff failed to conduct a discharge planning assessment/evaluation on all patients that were identified as possibly needing discharge planning. Specifically, at the time of the initial review, four (4) of five (5) clinical records for inpatients that were in the survey sample failed to contain a Discharge Planning Assessment conducted by the Case Management Department, (Patients #1, 9, 13 & 19).

The findings were

Cross reference to 42 CFR 482.43(a) Criteria For Discharge Evaluations. Tag A 0800

Based on clinical record review, select policy review and interview it was determined the facility failed to maintain a complete comprehensive medical record. Specifically, four (4) of five (5) hospitalized patients (#1, 9, 13, & 19) in the survey sample were either discharged or transferred. All four (4) records failed to contain all or part of the following; the decision that a discharge plan is needed,
- the actual discharge plan,
- what steps were taken initially to implement the plan, and or
- evidence of an ongoing evaluation of the discharge planning needs of the patient.

The findings were:

Cross reference to 42 CFR 482.43(a) Criteria For Discharge Evaluations. Tag A 0800

Based on clinical record review and interview it was determined that two (2) of two (2) patients who were discharged or transferred from the hospital and had Discharge Planning Assessments completed failed to have a discharge plan, (patients #1 & 13).

The findings were:

The clinical records for patients #1 & 13 were reviewed 6/27 and 6/28/12. Both records contained Discharge Planning Assessment's that stated, "Will need further evaluation." No discharge plan was documented in either record.

An interview was conducted on 6/26/12 with the hospital's two (2) Case Management Coordinators on the Acute Care Unit beginning at 11 A.M. Both Case Managers stated they they conduct a Discharge Planning Assessment on all admissions to the hospital within 24 hours of their admission. They also stated that ongoing assessments are conducted and patient's status are reviewed daily. When asked where do you document the ongoing assessment both replied, we don't usually document it in the record and acknowledged there was no paper trail that could demonstrate all that they do.

On 6/28/12 an interview was conducted with Case Manager, employee #6. The manager was asked what is their high risk screening criteria and how does it identify patients who are in need of a discharge planning evaluation. The manager replied we don't have that here, I'm not sure what you are talking about. The manager was also asked about their involvement with the Interdisciplinary Plan of Care and the manager responded by saying we do not document on the Interdisciplinary Plan of Care.

Based on clinical record review and interview it was determined that for two (2) of two (2) patients who had a Discharge Planning Assessment the facility failed to document any reassessments or communication notes, (records #! & 13).

The findings were:

Cross reference to 42 CFR 482.43(c)(4) Reassessment Of A Discharge Plan, Tag A 821

Based on review of the facility's QAPI (Quality Assessment Performance Improvement) Plan for 2011 and interview it was determined the facility failed to assess/reassess its discharge planning process on an ongoing basis.

The findings were:

The hospital's QAPI (Quality Assessment Performance Improvement) activities were reviewed with the QA Director on 6/28/12 beginning at 1 P.M. QAPI is a mandatory requirement by Medicare. The Director reviewed with this writer the hospital's, "ORGANIZATIONAL PERFORMANCE IMPROVEMENT DASHBOARD FOR 2011" and January through May for 2012. The dashboard is a list of all performance improvement projects the hospital is looking at each month, quarter and yearly. The dashboard looks at important functions that most affect patient care processes, patient outcomes, patient safety and patient satisfaction.

The review of 2011 and 2012 dashboard did not reflect the hospital's use of the QAPI program to determine whether the discharge planning process effectively identifies patients in need of plans, and whether the plans were adequate and appropriately executed. The QA Director acknowledged that the omission of discharge planning in their QAPI program was an oversight.