HospitalInspections.org

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/Policies in an on-going manner.

Findings:
A review of the Discharge Planning QA indicators, discussed with S4QA, revealed she had 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 06/21/17 at 1:15 p.m. with S4QA 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 the QIs for the Discharge Planning Department included: medication reconciliation documentation on the medical record prior to patient discharge, the number of patients re-admitted within 30 days, the number of patient unfunded insurance days, patient length of stay data, and documentation that discharge summarys were being completed within 30 days. S4QA indicated that each department measured different criteria. She further indicated that there was no on-going QA process or specific QIs developed to detect problems in the Discharge Planning Process itself. She indicated that she had no data to present on this and that no data was presented or reported to her from the Discharge Planning Department or any other department. S4QA indicated that there were no specific QIs for Discharge Planning Processes/Policies in QA. She indicated that she reviewed all patient discharge plans in their medical records for completeness and if all the information listed in each patient's discharge plan were identified and present, but she did not collect any data on these reviews. She indicated that QAPI program did not have a system in place to evaluate whether the hospital's Discharge Planning Process/Policies had any identifiable problems that needed to be corrected or that required any Discharge Process changes. S4QA further indicated that the QAPI program did not have a system in place to collect on-going data with tracking, trending, and analysis activities when a patient's re-admission was potentially due to problems in the discharge plan or in the implementation of their discharge plan in order to identify problem areas and to implement corrective actions or changes within the Discharge Planning Processes or Policies. S4QA further indicated that since the QAPI program was not collecting data on the discharge planning processes and QAPI was not tracking, trending or analyzing Discharge Planning Processes, she had no data to present to demonstrate whether the hospital's Discharge Planning Process had identified any problems.

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 re-admissions for potential problems in discharge planning or in the implementations of discharge plans in order to identify preventable re-admissions and make any needed changes to its Discharge Planning Processes/Policies that addressed and identified discharge planning problems.

Findings:
A review of the Discharge Planning QA indicators, discussed with S3DirSS, revealed no documented evidence of Quality Indicators developed/implemented by the hospital to review their Discharge Planning Process in an on-going manner through QAPI activities.

In an interview on 06/21/17 at 10:15 a.m. with S3DirSS she indicated that she was the Director of Social Services that included discharge planning activities and policies. She was asked for the hospital's QA indicators/activities used to review their Discharge Planning Process/Policies that included tracking and trending of re-admissions in order to identify potential factors to prevent re-admissions. S3DirSS indicated that her department was not reviewing re-admissions in the Discharge Planning Process and that she was not collecting any data on the Discharge Planning Processes for QAPI, nor was she tracking re-admissions as part of discharge planning review and therefore, had no data to present to demonstrate whether re-admissions were due to implementation of the prior discharge plan to identify problems in the Discharge Planning Process. S3DirSS indicated that the hospital had no process in place, at present, for an ongoing reassessment of its Discharge Planning Process that identified preventable re-admission factors. S3DirSS 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/policies. She indicated that there were no specific Quality Indicators (QI) on the hospital's corporate dashboard at this time that allowed her to do specific data collection on the components of the Discharge Planning Process. S3DirSS indicated that she has patient lists with the raw data on it, but she is not tracking, trending or analyzing this raw data to present to QA for any improvement activities specific to Discharge Planning Processes. She further indicated that there was no correlation on the corporate dashboard that related to specific components in the Discharge Planning Process/Policies.