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 record review and interview, facility failed to ensure a complete transfer of patient ID# 1 from inpatient treatment to outpatient services for follow-up care. Failed practice prevented the patient from receiving necessary aftercare and could cause a relapse in patient ' s recovery.


Review of Patient ID# 1 ' s medical records on 10/17/13 revealed a [AGE] year old female admitted on [DATE] with the diagnoses: Bipolar Disorder, Polysubstance abuse. Patient was off medications for two months, abusing alcohol and illicit drugs, and worsening depression with suicidal ideation and a plan to overdose on medications.

Patient ' s treatment plan and updates revealed that patient required continued outpatient treatment post discharge for optimal recovery.

Physician ' s discharge orders on 7/15/13 at 9:30am read " Discharge. F/U needed. Admit to PHP. "

Patient was discharged to Personal Care Home (PCH) on 7/15/13 because home environment was not conducive to patient ' s recovery.

Review of the Partial hospitalization Program (PHP) log for July 2013 showed that the patient was not entered on the log.

Review of a copy of computer Care Management note by Staff ID# 58, LSMC dated 7/15/13 at 11:50am read " Pt d/c today to f/u with West Oaks PHP. Pt auth. 10 days for PHP and PHP CM to call ... ....for auth. Number when pt admits to PHP. ' '

Review of Discharge Plan and Patient/Family Instruction Sheet showed that this form and medication list were faxed to the facility ' s PHP fax number.

Interview with Staff ID# 54, Clinic Manager for the Partial hospitalization Program (PHP) on 10/17/13 at 3:00pm in the conference room, he stated that following: Patient ID# 1 was not entered on the PHP log and a copy of her medical records was not found in the outpatient clinic. Case Managers (CM) are required to fax inpatient medical record and a completed transportation request form to PHP when a patient is stepping down from inpatient treatment to PHP. Patient is then entered on the PHP log by the receptionist. Transportation is provided by the program for patients with no means of transportation and within twenty miles radius, and usually arranged when a patient is discharged from inpatient to a Personal Care Home (PCH) for continued outpatient treatment with the hospital ' s PHP. PHP staff follow up with phone calls if expected patients did not show up for appointment.

Interview with Staff ID# 58, LSMC, Patient ID# 1 ' s CM, on 10/17/13 at 4:05pm over the phone, she stated that the initial plan was to discharge patient to residential treatment care (RTC) but the insurance only approved patient for outpatient treatment. Patient did not want to go home at this time and was discharged to PCH with follow up outpatient treatment at the hospital. Staff stated that she faxed patient ' s medical record to PHP and notified PHP Case Manager, Staff ID# 55 over the phone. Staff was unsure if transportation was arranged.

Interview with Staff ID# 55, on 10/18/13 at 9:50am in the conference room, he stated that he only handles Utilization Review with the insurance company and is not responsible for adding patients on the PHP log or making follow-up calls with patients. He explained that when a CM notifies him of an expected patient to the program, he writes the patient ' s name on a piece of paper and if the patient did not show up for three days, he discards the paper. He added that he could not recall whether he was notified by Staff ID# 58 him of patient ID# 1 ' s potential admit to PHP.

There was no documentation in patient ' s medical record to indicate whether patient had available transport or if transportation was arranged for the patient.

Review of the facility ' s policy title " Discharge Planning " dated 4/2013 identified the purpose of the policy as:

" 1. To ensure a seamless transition in continuity of care when a patient ' s condition, as determined by the attending physician and interdisciplinary treatment team, no longer meets criteria for inpatient treatment. "

" 3. To reintegrate the patient into his/her pre-hospital environment in an expedient manner that enhances the probability of attaining optimal functioning. "