Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
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)
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..."