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.

THE PAVILION 809 W CHURCH ST CHAMPAIGN, IL 61820 Jan. 9, 2020
VIOLATION: DISCHARGE PLANNING- TRANSMISSION INFORMATION Tag No: A0813
A. Based on document review and interview, it was determined for 1 of 1 (Pt #1) adolescent/youth patient who utilized discharge transportation services, it was determined the hospital failed to ensure its policy was followed. This has the potential to affect all adolescent/youth patients who receive services from the Hospital which has a current census of 23.

Findings include:

1. Policy #: HR-23, Fleet Policy (last reviewed by the hospital 09/12/2019) was reviewed on 01/09/2020 at approximately 12:00 PM. On page 4, the policy indicated, "2. Transportation Plan a. Employees must verify the correct point of contact ( e.g., parent, guardian)... with the nurse prior to leaving..." On page 5, the policy indicated, "13. When dropping off... Staff will ensure that the person receiving the resident is the same person as documented on the discharge documentation... Under no circumstances will the patient be dropped off to anyone other than the authorized person..."

2. Pt #1 admitted : 11/14/2019
Diagnosis: Aggression. Pt #1's medical record was reviewed throughout the survey.
a. On 11/22/2019, the discharge patient progress note indicated a social worker had spoken with Pt #1 about discharge. The discharge date was set for 11/25/2019. Pt #1 was to be transported to parent's home via the hospital's transportation services.
b. On 11/23/2019, the case management family meeting note, with Pt #1 and Pt #1's parent, indicated, "Plan (discharge date if set... Schedule dischagre (misspelled) appoitnments (misspelled)." The family meeting note lacked documentation as to who the point of contact person would be when the Pt #1 arrived home.
c. On 11/25/2019, the "Discharge and Continuing Care Plan" indicated Pt #1 was being transported home via the hospital transport services. The plan lacked who the point of contact person was for Pt #1 to be dropped off to upon arrival at the destination.

3. An interview was conducted with the Masters Social Worker/case manager (E#4) on 01/08/2020 at approximately 12:50 PM, E#4 stated recollection of Pt #1 and Pt #1's parent and discussing the discharge plans. E#4 stated, "As for the transportation home, I call the staffing department and they tell me if insurance (commercial, Medicare, or Medicaid) will cover the ride home. If not, then we have staff that will be assigned to take them home. I tell them when to take them and who is suppose to be there when they get home. I spoke with (Pt #1's parent) and (Pt #1's parent) said they (Pt #1's grandparent) would be home. No, I did not write that (Pt #1's grandparent) being the one to be there when (Pt #1) got home."

4. An interview was conducted with the Registered Nurse (E#5) on 01/08/2020 at approximately 12:00 PM, E#5 had reviewed Pt #1's record and stated recollection of Pt #1 and Pt #1's parent. E#5 stated, "My responsibility is to call (the parent) and tell what the child and staff member (if transporting) will be bringing with them. The case manager sets up the times. I wouldn't do that. I just set up the transport, once I know the times. I have to have the parents permission to set up transport. I did review the discharge paperwork with the (parent). No, I didn't write in who would be there when (Pt #1) got home. The discharge papers are sent with the transporter, but I don't believe we put that anywhere (in the chart)."

B. Based on document review and interview, it was determined for 1 of 2 (Pt #1) adolescent/youth patients who's discharge instructions were given via phone to the parent/care provider, the Hospital failed to ensure verbal telephone discharge instructions were witnessed by two individuals, in accordance with its document instructions and that a copy of the instructions were provided to the parent/care provider. This has the potential to affect all adolescent/youth patients who receive services from the Hospital which has a current census of 23.

Findings include:

1. Pt #1 admitted : 11/14/2019
Diagnosis: Aggression. Pt #1's medical record was reviewed throughout the survey.
a. On 11/25/2019, the "Discharge and Continuing Care Plan" indicated the follow up appointments with the psychiatrist, individual therapist, school, and human services center and that Pt #1 was being transported home via the hospital transport services and "Signature that Discharge and Continuing Care Plan reviewed and received ... Reviewed by phone (indicate who; have second staff witness verbal)" was checked as the mode of discussing the care plan. The care plan lacked a second staff witness.
b. On 11/25/2019, the "My Discharge Crisis Safety Plan" indicated "Support Person: (parent name printed in and received copy as checked)... Reviewed by phone (indicate who; have second staff witness verbal)" was checked as the mode of discussing the crisis safety plan. The entry was dated 11/25/19; however, the crisis safety plan lacked any staff signatures for 11/25/19.

2. An interview was conducted with the Registered Nurse (E#5) on 01/08/2020 at approximately 12:00 PM. E#5 had reviewed Pt #1's record and stated, "I did review the discharge paperwork with the (Pt #1's parent) and (Masters Social Worker/case manager - E#4). I forgot to have (E#4) sign the sheet." E#5 voiced uncertainty as to why the crisis safety plan lacked any staff signatures. "That's my handwriting (printed name of Pt #1's parent), but I didn't sign it for some reason. I give the discharge papers to the transporter and they give them to the parent/care giver. We don't chart it anywhere."