The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ST ELIZABETH'S MEDICAL CENTER 736 CAMBRIDGE STREET BRIGHTON, MA 02135 Sept. 15, 2011
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
Based on review of documentation and interviews, the Hospital failed to ensure that psychosocial assessments were completed and/or completed in a timely manner for 6 of 8 patients (Patients #1, #3, #4, #5, #7 and #8).

Findings included:

The Hospital's Policy/Procedure titled Discharge Planning, effective June, 2009, indicated discharge planning for patients admitted to the psychiatric inpatient unit was initiated at the time of admission. Initial plans or potential obstacles related to discharge were documented in the initial treatment plan, psychosocial assessment and in the progress notes.

The Case Manager was interviewed several times on 9/15/11. The Case Manager said the Psychosocial Assessment was an electronic document completed at the time of admission and included a section addressing discharge planning.

A) Review of medical record documentation indicated Patient #1 was admitted to the Inpatient Psychiatric Unit (IPU) on 3/3/11.

Review of Patient #1's discharge record indicated the Psychosocial Assessment was not completed until 5/12/11.

B) Review of medical records for Patients #2, #3, #4, #5, #6, #7 and #8 indicated Psychosocial Assessments were not completed for Patients #3, #4, #5, #7 and #8.