HospitalInspections.org

Based on document review, medical record review, and interviews, the facility failed to provide the required Important Message (IM) notice to four of a sample size of five Medicare patients (P') informing them of their right to appeal a planned discharge. As a result of this deficiency, these patients did not have the specific information needed to fully exercise their rights.

Findings include:

1) Reviewed the facility policy titled "Appeal Rights for Denial of Coverage for Medicare Patients Hospital Case Management & Medical Social Work," review date of 02/2023. The policy included: - "Scope: This document applies to all hospitalized patients...who are Medicare beneficiaries, including enrollees in Medicare Advantage (MS) plans and other Medicare Health plans subject MA regulations." - "Policy Statement: Medicare patients or family members who are issued a letter of non-coverage for admission have a right to an immediate appeal of the denial of coverage issued by the Hospital Case Management and Utilization Management Committee of the hospital." - "Policy/Procedure: ...A. An important Message (IM) Notice is issued at or near the time of admission but no later than two calendar days following the date of admission. B. Follow-up IM notice is issued no more than two days prior to the planned discharge, or if this notice is delivered on the day of discharge, the patient must be given at least four hours to consider their right to request a BFCC-QIO (Beneficiary and Family Centered Care-Quality Improvement Organization) review. C. The patient or family member will be educated of their right to appeal as well as their discharge options. D. If a patient makes a timely request for a BFCC-QIO review, that is prior to discharge, the patient is not financially responsible for inpatient hospital services furnished from the date of appeal through noon of the calendar day after the date the patient receives notification of the expedited determination from the BFCC-QIO."

2) Medical record review of the following Medicare Beneficiary patients revealed the following:
- P1 was transferred to the facility for admission on 01/07/2025 and discharged on 01/09/2025. The facility was unable to provide evidence the IM notice was provided.
- P2 was admitted to the facility on 01/03/2025 and discharged on 01/09/2025. The first notice was signed on 01/05/2025, but there was no evidence the second notice was provided prior to discharge.
- P3 was admitted on 01/05/2025 and discharged on 01/10/2025. The first notice was signed 01/05/2025, but there was no evidence the second notice was provided prior to discharge.
- P4 was admitted on 12/26/2024 and discharged on 01/04/2025. There was no evidence the first notice was provided.

3) On 01/17/25 at 01:45 PM, interviewed the Chief Nurse Executive (CNE) in the conference room. At that time, he confirmed P1 did not receive the IM notice. He went on to say the process is that the registration/admitting office is responsible to give the initial notice. The CNE said if the patient was a direct admit by transfer, registration is supposed to give them the notice the next day. The CNE said it may have been missed because P1 was a transfer from outer island and registration apparently did not give the notice the next day.

On 01/17/2025 at 02:45 PM, interviewed the Manager of Admitting (MA) and the CNE in the conference room. The MA said if a patient comes through the emergency room (ER), the registration staff will give the first notice as part of the "admission packet" and process. She went on to say a copy is given to the patient and they attach a bright orange paper to notify the nursing staff the first Medicare notice had been given. The MA said it is the nurses responsibility to provide the patient/family the second notice if required. The MA said it the patient is transferred in; they often bypass the ER and go directly to the assigned unit. The process is admitting will go to the unit the day after admission to provide the notice and obtain the signature. She said at times, they are not able to give the notice due to patient's medical condition, family not available, or patient is not in the room. The MA said they are supposed to go a second time to attempt to give the notice, but depends on availability of staff. The CNE said when the patient is identified as an anticipated discharge, the ward clerk or primary nurse should provide the second notice with explanation and obtain the patient's signature.