HospitalInspections.org

Based on the review of medical records, it was determined that in nine of ten medical records, medical records #1, 2, 3, 4, 6, 7, 8, 9, and 10, the hospital failed to ensure the provision of all patients' rights information that includes the Important Message From Medicare for Medicare beneficiaries. Based on the review of medical records, it was determined that in seven of ten medical records, medical records # 2, 3, 4, 6, 7, 8, and 9, the hospital failed to ensure the provision of the initial Important Message From Medicare (IMM) within two days of admission according to hospital policy procedure. Based on the review of medical records, it was determined that in six of ten medical records, medical records # 1, 2, 3, 6, 8, and 10, the hospital failed to ensure the provision of the second IMM within two days of discharge according to hospital policy procedure. Findings:

The Salem Hospital Administrative Housewide Policy and Procedure entitled Important Message from Medicare was reviewed. The policy procedure was very detailed and addressed the hospital's obligation for provision of the form and how to provide it under multiple circumstances. The policy procedure included, but was not limited to, the following direction:
" I. Day of Admission Important Message from Medicare[,] Access Services Representative will obtain signature of patient on the 'Important Message from Medicare' form CMS-R-193 in person, with date of signature upon inpatient admission for all Medicare A patients primary or secondary."
"i. [The form] May be obtained within 2 calendar days of admission";
"v. If a patient is unable to sign, a representative of the beneficiary may sign"; and
"v. 3. Access Services representative may telephone a beneficiary representative if not present". The policy procedure required that confirmation of the telephone contact must be documented on the notice; identified all the information that had to be provided to the representative by staff; and required documentation of the staff person initiating the contact, the date and time of the contact, and the name of the patient representative contacted.

The policy procedure also stated the following at "1. v. 3. i. When direct phone contact cannot be made, the notice to the representative will be sent by certified mail, return receipt requested."

The policy procedure stated the following at "II. Second Notice of the Important Message from Medicare [,] a. A follow-up copy will be delivered to the patient within 2 days of planned date of discharge by Medicare Specialist/Care Management." The policy also stated that "If the patient is discharged 2 days after signing the initial message (this is based on the actual delivery date of the initial copy, not the admission date), no additional follow-up signature is required."

Medical record # 2: Patient # 2 was admitted on 06/19/2009 and discharged on 06/21/2009. The medical record lacked evidence of the provision of the IMM.

Medical record # 4: Patient # 4 was admitted on 06/17/2009. Documentation reflects the IMM was signed by the patient's representative on 06/22/2009, five days after admission.

Medical record # 3: Patient # 3 was admitted on 06/19/2009. Documentation reflects the IMM was signed on 06/23/2009, four days after admission.

Medical record # 7: Patient # 7 was admitted on 08/19/2009. Documentation reflects the IMM was signed by the patient's representative on 08/23/2009, four days after admission.

Medical record # 9: Patient # 9 was admitted on 08/20/2009. Documentation reflects the IMM was signed on 08/24/2009, four days after admission.

Medical record # 6: Patient # 6 was admitted on 08/16/2009. Documentation reflects the IMM was signed on 08/19/2009, three days after admission.

Medical record # 8: Patient # 8 was admitted on 08/16/2009. Documentation reflects the IMM was signed on 08/19/2009, three days after admission.

Medical records # 1, 2, 3, 6, 8, and 10 lacked evidence of the provision of a second or follow-up copy of the IMM according to hospital policy: "II. Second Notice of the Important Message from Medicare[,] a. A follow-up copy will be delivered to the patient within 2 days of planned date of discharge by Medicare Specialist/Care Management."