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.

NORTHSHORE UNIVERSITY HEALTHSYSTEM - EVANSTON HOSPITAL 2650 RIDGE AVE EVANSTON, IL 60201 April 7, 2021
VIOLATION: DISCHARGE PLANNING - PT RE-EVALUATION Tag No: A0802
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, it was determined that for 1 of 4 (Pt. #2) open clinical records reviewed for discharge planning on 5 North Unit, the Hospital failed to ensure that the patient's condition was re-evaluated by the discharge planner to identify changes that require modification of the patient's discharge plan.

Findings include:

1. On 4/6/2021, the Hospital's policy titled, "Discharge Planning: Implementation and Documentation" (approved on 2/2021) was reviewed and included, "... Discharge planning services are provided to patients... 3. Care Management Assessment and Care Coordination... Care Management will reassess and document updates to the patient's discharge plans as interventions affect continuing care needs or the appropriateness of the discharge plan. Such reassessment and documentation shall occur no less than every 3 days during acute care hospitalization ..."

2. On 4/6/2021 at approximately 11:00 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted on [DATE] with a diagnosis of COVID-19. The clinical record indicated that Pt. #2 was evaluated by the discharge planner on 3/26/2020. However, as of survey date, 4/7/2021 (approximately 12 days), Pt. #2's condition has not been re-evaluated by the discharge planner to identify any changes that would require modification of Pt. #2's discharge plan.

3. On 4/7/2021 at approximately 9:30 AM, findings were discussed with E #2 (Director of Value-Based Acute Care Management). E #2 stated that the Care Management should have conducted and documented Pt. #2's re-evaluation every 3 days. E #2 was unable to provide documentation regarding a care management's re-evaluation for Pt. #2.