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 531311 (X3) Date Survey Completed 04/28/2022
Name of Provider or Supplier Crook County Hospital Street Address, City, State 713 Oak Street, Sundance, 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)
C1404 DISCHARGE PLANNING PROCESS

The CAH's discharge planning process must identify, at an early stage of hospitalization, those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient's representative, or patient's physician.


This STANDARD is not met as evidenced by:
Based on medical record review, staff interview, review of the facility strategic plan, and review of policy and procedures, the facility failed to implement a process to identify patient risk and needs for discharge planning at an early stage of hospitalization. The process was lacking for a sample of 20 inpatient records (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #13, #14, #15, #16, #17, #18, #19, #20, #21). The findings were: 1. Review of the medical records showed a lack of discharge planning documentation for the following inpatients who were admitted/discharged within the past year: #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #13, #14, #15, #16, #17, #18, #19, #20, #21. 2. Interview with the DNS on 4/27/22 at 12 PM revealed there was an open position for a discharge planner. There was a CNA/Activity aide who was helping out with discharge planning to the extent possible and the medical records were lacking any initial screening to identify discharge planning needs. She further confirmed the information related to post-acute care needs and resource information was not always documented in the medical records. Many times the information was documented in emails between the staff. 3. Review of the policy and procedures for discharge planning showed it was last revised August 19, 2008. The policy showed the facility "...will identify at an early state of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate Discharge Plan." The policy included the need for social services, director of nursing or other appropriately qualified staff to conduct the discharge planning and for the discharge planning form to be completed "on a timely basis so appropriate arrangements for post hospital care are made before discharge and to avoid unnecessary delays in discharge." The policy further showed the facility "...will include the Discharge Planning Form in the patient's medical record..." and "...Advanced Directives Forms and Home Health/Hospice Agency Referral Forms will be discussed with the patient or the person acting on the patient's behalf..." 4. Review of the June 2021 Strategic Plan showed developing a discharge planning process was included. Review of the February 10, 2022 Manager Meeting Minutes showed the position for a "care manager" had been posted. The plan was to have the position filled and then do further work on the discharge planning process.