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The Department of Mental Health Did Not Effectively Manage the Discharge of Some Clients From Its Psychiatric Hospitals to Less Restrictive Community-Based Settings

From a sample of 67 DMH clients, Bump’s audit found 27 clients did not have anticipated discharge dates recorded, making it difficult for DMH to effectively monitor its client discharge process and identify any problems in an appropriate time frame.

Table of Contents

Overview

Of the 67 clients in our sample who were deemed clinically stable and therefore ready for discharge from Department of Mental Health (DMH) facilities during our audit period, 4 were not placed in less restrictive settings by DMH within 60 days. One client was not discharged until almost a year after being designated as ready for discharge. Further, for 27 of these clients, anticipated discharge dates were not documented in the files.

Not ensuring that all clients who are ready for discharge are placed in a timely manner may negatively affect clients’ mental health and may deprive other clients of the opportunity to be placed in DMH facilities. Further, without ensuring that an anticipated discharge date is documented in each client’s file, DMH cannot monitor its client discharge process and identify any problems in this process so they can be addressed in a timely manner.

Authoritative Guidance

According to Section 27.09(1)(a) of Title 104 of the Code of Massachusetts Regulations (CMR),

A facility shall arrange for necessary post-discharge support and clinical services. Such measures shall be documented in the medical record.

According to 104 CMR 27.05(4) and 27.11(6), a client’s mental illness must be documented at scheduled treatment plan meetings, which include reviews of his/her discharge status. Each facility has procedures that provide further details on discharge planning. For example, Worcester Recovery Center and Hospital’s “Discharge Planning” protocol states,

Discharge Planning is a dynamic process that begins soon after a patient’s admission into the hospital and continues throughout the patient’s stay. The treatment team seeks input and participation from all members of the team.

The Office of the State Auditor (OSA) believes that the discharge status should be more clearly defined when the client’s health has improved to the point where s/he is approaching discharge. DMH management told us that the goal was to discharge clients within 30 days after they are deemed “discharge ready.” For the purpose of compliance, the audit team used 60 days as a threshold for deeming a discharge untimely.

Reasons for Issues

DMH attributed the placements that took more than 60 days to a lack of placement options and issues with client medication that that delayed the discharge planning process. However, in one case, when a client was discharged 354 days after being deemed discharge ready, DMH found that the case manager did not properly manage the discharge process (e.g., failed to organize meetings on behalf of the client or work with the client’s social worker to identify a suitable discharge location). DMH attributed the missing anticipated discharge dates to human error. Finally, DMH has not established any monitoring controls to ensure that anticipated discharge dates are properly recorded or that discharge is as timely as possible.

Recommendations

  1. DMH should modify its standard protocol to include identifying and/or modifying the anticipated discharge date in the treatment plan meeting notes as the client approaches discharge.
  2. DMH should establish monitoring controls to ensure that anticipated discharge dates are properly recorded or that discharge is as timely as possible.

Auditee’s Response

DMH disagrees with the finding that DMH “did not effectively manage the discharge of some clients from its psychiatric hospitals to less restrictive community-based settings.” Out of 67 clients sampled, the auditors found only 4 who were not discharged within a 60-day time period set by the auditors for their measurement. This is less than .5% of the sample. The auditors reference [27] other records which did not have dates for anticipated discharge specified. Respectfully, there are many reasons why such dates may not have been specified, including lack of consensus among the treatment team as to whether the patient was in fact discharge ready.

The audit report does not cite any evidence to suggest that DMH failed to effectively manage the discharge of these clients.

DMH agrees that there is always opportunity for continuous improvement of its processes for identifying and/or updating an anticipated discharge date in the treatment plan meeting notes as the client improves and approaches discharge, and that internal monitoring controls should be established to ensure that anticipated discharge dates are properly recorded or that discharge is as timely as possible. Accordingly, in the time period following the audit period (7/1/16–9/30/18), DMH has implemented a standardized discharge readiness tracking tool in the Mental Health Information System (MHIS). This tool is completed by the Social Work department which is the professional discipline responsible for coordinating the discharge planning process. As part of the continuous quality improvement effort with the discharge readiness tool, DMH is removing the discharge date from the treatment plan and utilizing the Discharge Readiness tool for tracking discharge planning dates. This tool will be accessible in MHIS to all inpatient disciplines.

Auditor’s Reply

As noted above, our audit showed that in some cases, DMH did not effectively manage the discharge of clients living in its facilities to less restrictive settings. Although DMH management told us that their goal was to discharge clients within 30 days after they are deemed “discharge ready,” for our analysis we used double this period (60 days) and still found four instances (6%) where DMH did not meet its target discharge timeframe. We also found that for 27 clients who were discharged, DMH did not indicate a “discharge ready” date in the files. OSA believes that these problems were largely the result of DMH not establishing any monitoring controls to ensure that anticipated discharge dates were properly recorded or that discharge was as timely as possible. Based on its response, DMH is taking measures to address our concerns in this area.

Date published: August 1, 2019

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