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.

WOODLAND HEIGHTS MEDICAL CENTER 505 SOUTH JOHN REDDITT DRIVE LUFKIN, TX 75904 Aug. 9, 2017
VIOLATION: CRITERIA FOR DISCHARGE EVALUATIONS Tag No: A0800
Based on review of records and interview, the facility failed to ensure 3 patients (Patient #1, #4, and #5) out of 10 patients received accurate or complete High Risk screenings or comprehensive discharge planning assessments.

Policies for discharge planning were reviewed. Policies were from the corporate office and had not been individualized to the hospital.

Review of Community Health Systems Professional Service Corporation Policy Title "Discharge Planning High Risk Screening Procedures for MCCM" was as follows:

"PURPOSE:
To identify inpatients who may have high risk discharge planning needs necessitating case management intervention."

"PROCESS:
1. The Case Manager will screen all inpatients, within one working day of admission, for potential discharge planning needs, utilizing a High-Risk Screening tool. This screen will take place during the initial clinical review for medical necessity and will be in conjunction with the initial screening completed by Nursing in the Admission Assessment process.

2. The adult screening criteria to be used include the following:
a. Age
b. Prior hospitalization
c. ED visit History
d. Health Barriers (those other conditions/situations that may impact health status, i.e. cognitive deficits, financial concerns, home/environmental issues, etc)
e. Medications
f. Principal diagnosis
g. Comorbidities
h. Functional impairment

3. The pediatric screening ...

4. The screening uses a scoring methodology to determine high risk needs. The scale for scoring of the high risk screen is:
Low Risk: total score less than or equal to 5
Moderate Risk: total score between 6-11
High Risk: total score between 11-19

5. If the patient has a total score that indicates the patient is a low risk discharge planning needs, the case manager will enter a note in the medical record indicating "The patient was screened for high risk discharge planning needs; no needs identified at this time."

6. If the patient has a total score that indicates the patient has moderate to high risk discharge planning needs, the discharge planning evaluation will be completed in a timeframe no greater than one business day after identification of need by the Case Management/[<Social Worker>] or referral from other source.

7. This assessment will be used to develop the patient's plan for care."

Review of Community Health Systems Professional Service Corporation Policy Title "Case Management Plan for Discharge Planning Policy" was as follows:

"Discharge Planning is a systematic, organized and interdisciplinary approach to identify and provide for post discharge needs of all patients and their families. It is the policy of [<INSERT HOSPITAL NAME>] to provide an interdisciplinary hospital-wide mechanism for providing post discharge continuity of care to patients and their families.

...

II. Discharge Planning Assessment

A. A comprehensive assessment will be completed by the Case Manager/[<Social Worker>] if the screening determines the patient has discharge planning needs.

B. The physician and/or any member of the healthcare team may make a referral to Case Management for evaluation and discharge plan development when a potential or actual need is identified."


Review of Patient #1 and Patient #4 charts showed that the Case Manager did not apply the High Risk Assessment scoring accurately. Each patient had Emergency Department visits within the previous 6 months that were not included in their High Risk Screening score. One patient (Patient #4) received a total score of 5, indicating she did not need discharge planning. Patient #4 did not receive a comprehensive discharge planning assessment due the Emergency Department visit not being included in the score.

At a later time, Patient #4 had been identified as possibly needing Home Health Services at discharge. The comprehensive discharge planning assessment for Patient #4 was not completed at that time. The Case Manager referred the patient for Home Health Services without completing a comprehensive discharge planning assessment to determine the scope of discharge needs.

Patient #5's chart was reviewed. Patient #5 had a completed High Risk Screening that was scored with a total score of 7, Moderate Risk. Patient #5 had been admitted from a Skilled Nursing Facility. The Case Manager documented that the patient would be returning to the Skilled Nursing Facility without completing a comprehensive discharge planning assessment to determine if the patient had any further discharge needs.

Interviews were conducted with Staff #11, Staff #13, and Staff #16. All staff confirmed that a comprehensive discharge planning assessment was required whenever the High-Risk Screening indicated or a discharge need was identified.
VIOLATION: DOCUMENTATION OF EVALUATIONS Tag No: A0811
Based on review of records and interview, the facility failed to ensure 1 patient (Patient #10) out of 10 patients contained evidence in the patient record that discharge planning results had been discussed with the patient or patient representative.

Policies for discharge planning were reviewed. Policies were from the corporate office and had not been individualized to the hospital.

Review of Community Health Systems Professional Service Corporation Policy Title "Case Management Plan for Discharge Planning Policy" was as follows:

"Discharge Planning is a systematic, organized and interdisciplinary approach to identify and provide for post discharge needs of all patients and their families. It is the policy of [<INSERT HOSPITAL NAME>] to provide an interdisciplinary hospital-wide mechanism for providing post discharge continuity of care to patients and their families.

...

II. Discharge Planning Assessment

A. A comprehensive assessment will be completed by the Case Manager/[<Social Worker>] if the screening determines the patient has discharge planning needs.

B. The physician and/or any member of the healthcare team may make a referral to Case Management for evaluation and discharge plan development when a potential or actual need is identified."

C. The patient of family/significant other acting on the patient's behalf can also request an assessment for discharge planning needs.

...

G. Discharge planning evaluation documented in the patient's medical record for use in establishing an appropriate discharge plan and the results of the evaluation will be discussed with the patient or individual acting on his or her behalf."


Review of Patient #10's chart showed that the High Risk screening had been completed and the patient was screened at a moderate risk. The discharge planning assessment was documented with a plan for the patient to be discharged home with self-care. There was no documentation found that this plan had been discussed with the patient, that the patient agreed with the plan, or that the patient had been provided instructions on how to request services should conditions change.

Interviews were conducted with Staff #11, Staff #13, and Staff #16. All staff verbalized that Case Managers were to provide patients with a business card. The business card had contact information for the Case Manager. All confirmed that they do not document that the plan is discussed with the patient, that a business card was provided or that the patient had been informed of how to request additional discharge planning services after the initial evaluation indicated the patient is not going to receive any services after discharge.