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.

Based on document review and interview the hospital failed to ensure that the Discharge Planning Service was providing data on the performance of the service to the Quality Improvement Committee (QIC) prior to July 2011. This failure to include data on the performance of the Discharge Planning Service compromised the ability of the QIC to evaluate the effectiveness of the Discharge Planning Service. The findings are:

A. As part of the complaint investigation which authorized the survey of the Condition of Participation for Discharge Planning, the hospital was asked to provide the documentation of the involvement and participation of the Discharge Planning service in the hospital's Quality Assessment and Performance Improvement (QAPI) program. The Chief Quality Officer (CQO) provided two sets of documentation. One set of documentation was minutes and data from the Utilization Management Committee. This committee was the main management committee for the hospital. The other set of documentation was minutes and data of the QIC. This was the designated QAPI committee for the hospital. A review of both sets of documentation did not reveal any data collection for the Discharge Planning Service prior to July 2011.

B. On 10/12/11 at 2:15 pm, the CQO was asked why there was no data or indicators for the Discharge Planning Service. She asked the supervisor of the Case Management Department, the hospital's name for the Discharge Planning Service, to provide the surveyor with data from Case Management Department. The Case Management supervisor provided data for 2010 and 2011 for five different indicators. However this data was not included in any of the minutes of the QIC for 2010 and 2011 based on review of the documentation provided.

C. On 10/12/10 at 2:45 pm, an interview was conducted with the CQO and the Chief Financial Officer, who supervised the Discharge Planning Service, and the Case Management supervisor. All three were asked if it was a true statement to say that July 2011 was the first month that Discharge Planning Service indicators were submitted to the QIC. All three supervisors agreed that the statement was correct.