HospitalInspections.org

Based on review of a hospital policy, 4 medical records of Medicare recipients, and other pertinent documentation, as well as interviews with staff, it was determined that the hospital failed to follow its policy for distributing the Important Message from Medicare (IMM) and, as a result, failed to notify multiple Medicare recipients of their rights in advance of discontinuation of their care.

The findings included:

Review of hospital policy "Medicare- Follow-Up Important Message from Medicare", (revised 11/2020), stated in part:

The Discharge Planner or Psychiatric Social Worker will deliver and explain the IM notice to the beneficiary, and obtain his or her signature, date, and time. The Discharge Planner or Psychiatric Social Worker will then initial and date/time the notice, ensure copy is readable, and give the original IM notice to the beneficiary. A copy will be placed in the beneficiary's medical record... If a beneficiary is incompetent and is unable to sign the IM notice, the beneficiary's legal representative will be presented with the IM notice on the beneficiary's behalf for signature, date, and time...The follow-up IM notice will be delivered to all Medicare beneficiaries who have been an inpatient three or more days. Delivery should be as far in advance of discharge as possible, but not more than 2 calendar days of the anticipated date of discharge.

Review of 4 Medicare recipient records during the onsite survey determined that at least 2 Medicare recipients did not receive all required IMMs prior to their discharge.

Patient #4 (P4) was a 70+ year old who presented to the hospital's Emergency Department with shortness of breath for 2 days and an acute breathing condition. P4 was assessed and admitted for treatment. Nursing documentation recorded P4 as "alert and oriented x 3" (oriented to person, place, and time). A patient's orientation status is documented to help to establish an individual's ability to receive information/education and provide consents for treatment. P4 was presented with an Important Message from Medicare (IMM) form which he/she signed and dated. Six days later, P4 was discharged from the hospital to home. No documentation was found to support that the patient received a second IMM in a timely manner prior to discharge.

Patient #5 (P5) was a 60+ year old, who was admitted to the hospital for treatment of an acute respiratory condition. P5's nursing assessment documentation within the medical record, stated that P5 was alert and oriented to person, place, time, and situation. In addition, P5 was identified to be his/her own decision maker and signed "The Consent for Treatment, Financial Responsibility and Healthcare Operations" and the "Patient Billing and Financial Assistance Information Sheet," during this admission. Review of the Important Message form for P5 revealed the following notation: "Verbal from [adult child] on phone." There was no documentation found to explain why P5 was unable to sign or any attempts to obtain a signature from P5.

On August 18, 2022, the surveyors interviewed the Director of Case Management about the process of delivering IMMs to Medicare recipients and whether the hospital monitored this process. The Director of Case Management stated that audits were taking place and did identify multiple instances of non-compliance where the second IMM had not been delivered timely or at all. At surveyor's request, the Director presented the IMM audit data for June 2022. The review of the document determined that there were at least 15 instances of non-compliance identified. When asked if any corrective action had taken place in response to identified non-compliance, the Director responded that he/she spoke with some employees. The surveyors did not find any evidence that the hospital had a formal process improvement plan in place to address this issue at the time of the survey.