HospitalInspections.org

Based on policy review, medical record review, and staff interview, the hospital staff failed to provide the standardized notice, "An Important Message from Medicare" (IM), within 2 days of admission for 4 of 6 sampled Medicare patient's medical records reviewed (#1, #2, #5, and #6).

Findings included:

Review on 07/10/2019 of the facility policy "Corporate Compliance," (CORP-17, revised 07/27/2016), revealed "...2. Important Message from Medicare about Your [sic] Rights a. All inpatients who are Medicare beneficiaries will receive a copy ...b. Requirements for the delivery of the initial copy 1) Delivered within 2 calendar days of admission or at readmission but not more than 7 calendar days before admission ...2. Beneficiary signs and dates the form and keeps one copy. Hospital retains a signed copy ..."

1. Review on 07/10/2018, of Patient #1's medical record, revealed an admission date of 07/06/2019. Review revealed no documented evidence the patient had received and signed the IM within 2 days of admission.

Interview on 07/11/2019 at 1410 with the Director of Transitions of Care, revealed the IM was one of the admission documents that printed out along with all the other consents at the time of registration. The documents were signed, then scanned into the electronic medical record. The Director of Transitions of Care stated the IMs were "just not getting signed." Interview revealed the facility had identified a problem with the IMs not being signed on admission, and she worked with the former Director of Registration to audit the admission IMs. Interview revealed the new Director of Registration was still on orientation, and at present, nobody was auditing the IMs.

Interview on 07/11/2019 at 1433 and 1520 with the Vice President of Administration, revealed the New Director of Registration was in orientation. Interview revealed the facility had a PI (Performance Improvement) project to try and see where the problem lied. However, since the former Director of Registration resigned, "We haven't had a system in place" for auditing to be sure the initial admission IMs were being signed by patients. Interview revealed "We aren't compliant and lost the focus piece when the Registration Director resigned ... We will do it now and will monitor."

2. Review on 07/10/2018, of Patient #2's medical record, revealed an admission date of 07/06/2019. Review revealed no documented evidence the patient had received and signed the IM within 2 days of admission.

Interview on 07/11/2019 at 1410 with the Director of Transitions of Care, revealed the IM was one of the admission documents that printed out along with all the other consents at the time of registration. The documents were signed, then scanned into the electronic medical record. The Director of Transitions of Care stated the IMs were "just not getting signed." Interview revealed the facility had identified a problem with the IMs not being signed on admission, and she worked with the former Director of Registration to audit the admission IMs. Interview revealed the new Director of Registration was still on orientation, and at present, nobody was auditing the IMs.

Interview on 07/11/2019 at 1433 and 1520 with the Vice President of Administration, revealed the New Director of Registration was in orientation. Interview revealed the facility had a PI (Performance Improvement) project to try and see where the problem lied. However, since the former Director of Registration resigned, "We haven't had a system in place" for auditing to be sure the initial admission IMs were being signed by patients. Interview revealed "We aren't compliant and lost the focus piece when the Registration Director resigned ... We will do it now and will monitor."

3. Review on 07/10/2018, of Patient #5's medical record, revealed an admission date of 05/05/2019. Review revealed no documented evidence the patient had received and signed the IM within 2 days of admission.

Interview on 07/11/2019 at 1410 with the Director of Transitions of Care, revealed the IM was one of the admission documents that printed out along with all the other consents at the time of registration. The documents were signed, then scanned into the electronic medical record. The Director of Transitions of Care stated the IMs were "just not getting signed." Interview revealed the facility had identified a problem with the IMs not being signed on admission, and she worked with the former Director of Registration to audit the admission IMs. Interview revealed the new Director of Registration was still on orientation, and at present, nobody was auditing the IMs.

Interview on 07/11/2019 at 1433 and 1520 with the Vice President of Administration, revealed the New Director of Registration was in orientation. Interview revealed the facility had a PI (Performance Improvement) project to try and see where the problem lied. However, since the former Director of Registration resigned, "We haven't had a system in place" for auditing to be sure the initial admission IMs were being signed by patients. Interview revealed "We aren't compliant and lost the focus piece when the Registration Director resigned ... We will do it now and will monitor."

4. Review on 07/10/2018, of Patient #6's medical record, revealed an admission date of 07/01/2019. Review revealed no documented evidence the patient had received and signed the IM within 2 days of admission.

Interview on 07/11/2019 at 1410 with the Director of Transitions of Care, revealed the IM was one of the admission documents that printed out along with all the other consents at the time of registration. The documents were signed, then scanned into the electronic medical record. The Director of Transitions of Care stated the IMs were "just not getting signed." Interview revealed the facility had identified a problem with the IMs not being signed on admission, and she worked with the former Director of Registration to audit the admission IMs. Interview revealed the new Director of Registration was still on orientation, and at present, nobody was auditing the IMs.

Interview on 07/11/2019 at 1433 and 1520 with the Vice President of Administration, revealed the New Director of Registration was in orientation. Interview revealed the facility had a PI (Performance Improvement) project to try and see where the problem lied. However, since the former Director of Registration resigned, "We haven't had a system in place" for auditing to be sure the initial admission IMs were being signed by patients. Interview revealed "We aren't compliant and lost the focus piece when the Registration Director resigned ... We will do it now and will monitor."