| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 530025 | (X3) Date Survey Completed 08/21/2012 |
| Name of Provider or Supplier Ivinson Memorial Hospital | Street Address, City, State 255 N 30th, Laramie, WY | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| A0000 | This complaint survey was conducted using the Discharge Planning Worksheet. Pilot Surveyor Worksheets are part of the Patient Safety Initiative. Any findings cited below were identified using the new survey tool(s) and cited only at the standard level in this pilot survey. We expect that hospitals will use the findings to evaluate the areas of non-compliance and implement necessary changes to assure compliance. |
| A0824 | LIST OF SKILLED NURSING FACILITIES CFR(s): 482.43(c)(6) The hospital must include in the discharge plan a list of HHAs or [SNFs] that are available to the patient, that are participating in the Medicare program, and that serve the geographic area (as defined by the HHA) in which the patient resides, [or in the case of a SNF, in the geographic area requested by the patient.] HHAs must request to be listed by the hospital as available. This STANDARD is not met as evidenced by: Based on medical record review and staff interview, the facility failed to develop and implement a discharge plan that included the provision of a list of available skilled nursing facilities (SNFs) for 1 of 3 sample patients (#2) who required SNF services after discharge from the hospital. The findings were: Review of the medical record for patient #2 showed s/he was admitted on 5/16/12. Further review showed the patient was discharged to the hospital's extended care facility (ECF), a SNF, on 5/18/12. During an interview on 8/21/12 at 1:25 PM, the discharge planner stated the discharge plan for all patients who require SNF services should include information about staff providing a list of available facilities. She further revealed that this part of the discharge plan was most likely omitted because patient #2 had selected the hospital's ECF during a previous admission, and staff assumed the patient wanted the same facility. At that time she verified the 5/16/12 to 5/18/12 discharge plan failed to include information about a list of available facilities. Review of the medical record revealed documentation that addressed this issue was lacking. According to the Discharge Planning Policy and Procedure, revised July 2011, "As a standard of practice, patients will be informed of their freedom to choose among providers when planning to discharge from the hospital into another agency's/providers' care. This includes, but is not limited to, ensuring that the patient and family members are provided with information on all participating agencies that are available..." |
| A0827 | DISCHARGE PLANNING DOCUMENT CFR(s): 482.43(c)(6)(iii) The hospital must document in the patient's medical record that the list was presented to the patient or to the individual acting on the patient's behalf. This STANDARD is not met as evidenced by: Based on medical record review and staff interview, the facility failed to include documentation in the medical record that a list of available skilled nursing facilities (SNFs) was given to 1 of 3 sample patients (#2) who required SNF services. The findings were: Review of medical records showed patient #2 was admitted on 5/16/12. Further review showed the patient was discharged to the hospital's extended care facility (ECF), a SNF, on 5/18/12. During an interview on 8/21/12 at 1:25 PM, the discharge planner stated that, although her staff was aware of the requirement to provide a list of SNFs, she did not have evidence to show it was provided for patient #2. Review of the medical record revealed no documentation about giving the patient a list of available SNFs prior to discharge. |
| A0831 | DISCLOSING FINANCIAL INTEREST CFR(s): 482.43(c)(8) The discharge plan must identify any HHA or SNF to which the hospital has a disclosable financial interest, as specified by the Secretary, and any HHA or SNF that has a disclosable financial interest in a hospital under Medicare. Financial interests that are disclosable under Medicare are determined in accordance with the provisions of Part 420, Subpart C, of this chapter. This STANDARD is not met as evidenced by: Based on staff interview and medical record review, the facility failed to ensure the discharge plans for 1 of 3 sample patients (#2) identified that the hospital had a disclosable financial interest in the skilled nursing facility (SNF) to which the patient were discharged. The findings were: According to the medical records, patient #2 was discharged to the hospital's extended care facility (ECF, a SNF) on 5/18/12. Review of the discharge plans showed no evidence the patient was informed prior to his/her discharge that the hospital owned the facility. During an interview on 8/21/12 at 1:25 PM, the discharge planner stated she did not know whether the staff person responsible for informing the patient that the hospital had a disclosable financial interest in the ECF had done this. At that time she verified the financial disclosure information had not been included in the documented discharge planning process for this patient. |
| A0843 | REASSESSMENT OF DISCHARGE PLANNING PROCESS CFR(s): 482.43(e) The hospital must reassess its discharge planning process on an on-going basis. The reassessment must include a review of discharge plans to ensure that they are responsive to discharge needs. This STANDARD is not met as evidenced by: Based on medical record review and staff interview, the facility failed to develop and implement a system for identifying preventable readmissions. The findings were: During an interview on 8/20/12 at 1:15 PM, the discharge planner revealed all readmissions were flagged for her review. She further stated discharge planning concerns were discussed with the physicians, nursing staff and other healthcare professional; but the facility did not have a formalized systematic approach for identifying preventable readmissions. Review of the discharge planning policies and procedure also revealed the lack of a system for identifying preventable readmissions related to the discharge planning process. |