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.
| WILLIAMSPORT REGIONAL MEDICAL CENTER | 700 HIGH STREET WILLIAMSPORT, PA 17701 | Dec. 10, 2015 |
| VIOLATION: CRITERIA FOR DISCHARGE EVALUATIONS | Tag No: A0800 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined facility staff failed to complete the Transition of Care Assessment for one of 14 medical records reviewed (MR1). Findings include: Review on December 10, 2015, of the facility's "Transition of Care Process" policy, last reviewed August 2014, revealed "I. Patient Identification A. Purpose: To identify as early as possible, patients who may require or benefit from Transition of Care (TOC) planning assistance. ...VI. General Areas of Social Service Discharge Planning Activity ...B. Housing Resources (long term): 1. Population Served: Elderly, destitute, homemakers and/or handicapped patients whose previous living situations no longer meet their needs due generally to cost or accessibility problems. 2. Scope of Social Service Activity: Social worker may provide direct services and resources, or may assist patient and family in gaining access to services and resources by the following means: provide information, counsel, support and encouragement, gives direction, recommends specific resources, collaborates and helps to establish eligibility. ... E. Emergency Discharge Problems: 1. Population Services: Patients generally seen in the Emergency Department who have been victims of abuse, neglect, and/or violent crime, intoxicated/addiction problems, homeless, or in need of placement (Nursing Home etc.). 2. Scope of Social Services Activity: Social worker may provide direct services and resources, or may assist patient and family in gaining access to service and resources by the following means: Provide information, counsel, support and encouragement, gives direction, recommends specific resources, collaborates among professionals/services, assists with application, supplies alternatives and helps to establish eligibility. ... c. Temporary Shelter ... Contact by social worker with agencies providing emergency shelter (Rescue Workers - Salvation Army - Shepherds of the Streets). ..." Review of the facility's electronic medical record (EMR) revealed an area for documenting the "Transition of Care Assessment." This portion of the EMR contained the following areas for documentation by Social Services: Staff Assignment, Review of Record, Contact Information, Legal, Past Medical History, Living Situation, Functional Status Prior to Admission, Functional Status During hospitalization , Referral Reasons, Transition of Care Needs, Transition of Care Plan, Receiving Facility Information, Communications and Core Measures. Review of MR1 on December 10, 2015, revealed the following physician discharge summery dated November 19, 2015. The patient was a [AGE] year old was taken out of a local hotel due to non-payment of rent and taken to the ER after some bizarre behavior was noted. MR1 was evaluated by Psychiatry and diagnosed as having a neurocognitive disorder, but did not meet the criteria for inpatient psychiatric treatment. MR1 had no place to go, was noted to have some chronic medical condition, and was advised to come in for observation to ensure the patient did not have a potentially treatable cause of the altered mental status. Continued review revealed documentation by the physician indicating assistance by Social Services for placement. This physician discharge summary also revealed MR1 was seen by a psychiatrist and was found to be quite lucid and showing good insight and appropriate behavior and that Social Services contacted one of the area local homeless shelters, and MR1 was discharged in stable condition. Continued review of MR1 revealed the Transition of Care Assessment was not completed. Interview with EMP4 and EMP5 on December 10, 2015, at approximately 9:30 AM confirmed social service did not complete the Transition of Care Assessment for MR1. Cross reference 482.43(b)(1), (3), (4) Discharge Planning Needs Assessment 482.43(b)(5) Timely Discharge Planning Evaluations 482.43(b)(6) Discussion Of Evaluations Results 482.43(b)(6) Documentation of Evaluation |
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| VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT | Tag No: A0806 | |
| Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure the patient's Transition of Care Assessment included an assessment of post-discharge care needs for one of 14 medical records reviewed (MR1). Findings include: Review on December 10, 2015, of the facility's "Documenting Social Work Services In The Medical Record" policy, last reviewed September 2014, revealed "I. Policy Documentation in the medical record is required as a standard of social work practice in a medical setting. This documentation is mandated by federal regulations and many standard-setting bodies which serve to accredit medical institutions. The written chart entry should contribute to comprehensive care, diagnostic considerations and therapeutic direction. Documentation should serve also to enhance relationships among members of the health care team. To accomplish the above, it is essential that each chart entry is clear and concise. ... " Review on December 10, 2015, of the facility's "Social Work Assessment" policy, last revised July 2014, revealed "All patients referred to Social Service or who are picked up as a result of 'Huddle' shall be assessed by qualified personnel. The data obtained from the social work assessment shall be organized and documented in the discharge planning section in [name of electronic medical record system]. ... Use Of Data To Determine Care And Prioritize Needs Assessment data shall be used to prioritize needs and determine care and treatment decisions. Data obtained that revealed any of the following would indicate a priority for intervention: ... 12. Lack of adequate food/clothing/shelter ..." 1) Interview with EMP5 on December 10, 2015, at approximately 9:15 AM revealed EMP5 obtained the following history: MR1 and the patient's son lived in an apartment together until they were evicted several months ago. MR1 and the patient's son then went to a local hotel where they stayed for approximately 10 days when they were evicted from this hotel. MR1 stayed at the hotel for several days, following the eviction. The hotel manager notified local police who went to the hotel and broke down the door to remove MR1. The police determined MR1 required a medical assessment and transported MR1 to the facility for an evaluation and treatment. Interview with EMP1, EMP2, EMP3, EMP4 and EMP5 on December 10, 2015, at approximately 9:30 AM confirmed EMP5 did not document the history obtained for MR1 which included: MR1 and the patient's son lived in an apartment together until they were evicted several months ago. MR1 and the patient's son then went to a local hotel where they stayed for approximately 10 days when they were evicted from this hotel. MR1 stayed at the hotel for several days, following the eviction. The hotel manager notified local police who went to the hotel and broke down the door to remove MR1. The police determined MR1 required a medical assessment and transported MR1 to the facility for an evaluation and treatment. EMP5 revealed the information was provided to this employee close to 4:00 PM, and the information was not documented in MR1 because EMP5 only works until 4:00 PM. 2) Review of MR1 on December 10, 2015, revealed a physician Discharge Summary dated November 19, 2015, indicating the patient was discharged to a local homeless shelter. Review of MR1 on December 10, 2015, revealed no Social Services documentation that the patient was discharged to a homeless shelter or the method of transport on discharge. Interview with EMP4 and EMP5 on December 10, 2015, at 9:55 AM confirmed there was no social service documentation indicating how MR1 was discharged and how this patient was transported to the homeless shelter. Further interview with EMP4 and EMP5 revealed the facility obtained a cab to transport the patient from the facility to the homeless shelter. Cross reference 482.43(a) Criteria For Discharge Evaluations 482.43(b)(5) Timely Discharge Planning Evaluations 482.43(b)(6) Discussion Of Evaluations Results 482.43(b)(6) Documentation of Evaluation |
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| VIOLATION: DOCUMENTATION OF EVALUATIONS | Tag No: A0811 | |
| Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure the patient or an individual acting on his/her behalf was involved in the discharge planning process for one of 14 medical record reviewed (MR1). Findings include: Review on December 10, 2015, of the facility's "Discharge Planning/Continuing Care" policy, last revised August 2014, revealed "Definition: Discharge planning is a coordinated interdisciplinary process by which patients and families are prepared for meeting ongoing care needs. Purpose: To ensure that systems, policies and procedures are in place to facilitate meeting the discharge planning needs of every patient in Susquehanna Health. In doing so, patients will be provided with the appropriate level of information and care at the time of their discharge. Goals: To enable patients and their families to regain, maintain or improve the level of functioning achieved during hospitalization in order that their needs will be met effectively post discharge. ... Method: Coordinated, interdisciplinary discharge planning based on early identification, good patient/family/staff communication, patient/family/preparation/participation and referrals as indicated for ongoing support and/or care. ..." Review of MR1 on December 10, 2015, revealed the following: 1) Social Services documentation dated November 17, 2015, noted the facility made referrals to local Long Term Care facilities. Interview with EMP4 and EMP5 on December 10, 2015, at approximately 11:10 AM revealed the facility referred MR1 to several local Long Term Care facilities, and MR1 was deemed capable to make their own decisions. EMP4 and EMP5 confirmed there was no documentation Social Services discussed Long Term Care Placement with the patient and no documentation MR1 refused admission to a long term care facility. 2) A physician discharge summary dated November 19, 2015, indicated the patient was discharged to a local homeless shelter in stable condition. Social Services documentation dated November 18, 2015, no time indicated, revealed an initial assessment in the Special Care Unit. Social Services met with the patient to discuss discharge planning. The patient refused to talk with Social Services. The patient stated they were not feeling well and asked the social worker to leave. There was no other documentation that Social Services met with the patient or an individual acting on the patient's behalf regarding the discharge to a homeless shelter. Interview with EMP4 and EMP5 on December 10, 2015, at approximately 9:45 AM confirmed there was no Social Services documentation MR1 was involved in the discharge planning process in order to determine if discharge to a homeless shelter was the most appropriate post-hospital arrangement for this patient. Cross reference 482.43(a) Criteria For Discharge Evaluations 482.43(b)(5) Timely Discharge Planning Evaluations 482.43(b)(6) Documentation of Evaluation |
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| VIOLATION: DISCHARGE PLANNING | Tag No: A0812 | |
| Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to complete and document a discharge planning evaluation for one of 14 medical records reviewed (MR1). Findings include: Review of MR1 on December 10, 2015, revealed a physician discharge summary dated November 19, 2015, indicating this patient was discharged to a local homeless shelter in stable condition. Review of MR1 on December 10, 2015, revealed no documentation that Social Services completed a discharge plan evaluation in order to determine if MR1's discharge to a homeless shelter was appropriate. Interview with EMP4 and EMP5 on December 10, 2015, at approximately 9:30 AM confirmed Social Services did not complete a discharge plan evaluation in order to determine if MR1's discharge to a homeless shelter was appropriate. Cross reference 482.43(a) Criteria For Discharge Evaluations 482.43(b)(1), (3), (4) Discharge Planning Needs Assessment 482.43(b)(5) Timely Discharge Planning Evaluations 482.43(b)(6) Discussion Of Evaluations Results |
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