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Based on review of facility policy, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to provide Medicare beneficiaries with an Important Message from Medicare at time of admission to the facility for three of five medical records reviewed (MR2, MR5, and MR9).

Findings include:

Review of facility policy "Admission, Discharge, Reservation, And Transfer Of Patients" dated May 29, 2009, revealed "7. At the time of admission/placement into an inpatient bed, patients will be provided with ... Additionally, an Important Message from Medicare (IM) to applicable Medicare patients within two calendar days of admission or no sooner than seven days prior to an elective/planned admission. If applicable Medicare patients are discharged greater than two calendar days from the date of initial IM deliver, a follow-up copy will be delivered to the patient. The follow-up copy of the IM will be delivered by Case Management staff during normal Case Management business hours, and by the nursing staff for unanticipated discharges during non-business hours for Case Management."

Review of facility policy "Delivery Of Follow-Up Copy Of The Important Message From Medicare (IM) And Detailed Notice Of Discharge (DN)" dated July 2, 2007, revealed "1. The hospital will notify Medicare beneficiaries who are hospitalized inpatients (or designated representative) about their discharge appeal rights using the Important Message from Medicare (IM) ... 3. Deliver follow-up IM as far in advance as possible, but not more than two calendar days before discharge."

Review of facility documentation revealed "Important Message from Medicare PAS(Patient Access Service) Process Guidelines ... I. The IMM must be provided to all hospital inpatients effective July 2, 2007 ... II. The IMM must be delivered within 48 hours of any inpatient admission. ... C. Obtain the patient's signature and date of signature on the IMM notice. ... 5. if unable to obtain from NOK(next of kin), (G)(guardian) or POA(power of attorney). Delivery may be completed via phone if witnessed by two employees and documented by both employees. a. A copy of the IMM must be mailed to the NOK, (G) or POA. 6. If unable to obtain via phone, a certified mailing must be sent to the NOK, (G), or POA. ... E. The Hospital's copy (original) must be placed on the patient's chart."

1) Review of MR2, revealed the patient was admitted on January 30, 2010, with no documented evidence that the patient received An Important Message From Medicare About Your Rights within two calendar days of admission as per policy. Further review revealed An Important Message From Medicare About Your Rights dated February 10, 2010.

Interview with EMP7 on February 11, 2010, at approximately 2:00 PM confirmed the above findings and revealed "No it wasn't signed until then(February 10, 2010)."

2) Review of MR5 revealed the patient was admitted on February 4, 2010, with no documented evidence that the patient received An Important Message From Medicare About Your Rights within two calendar days of admission as per policy.

Interview with EMP1 on February 11, 2010, at approximately 12:30 PM confirmed the above findings and revealed "I am not seeing one(An Important Message From Medicare About Your Rights)"

3) Review of MR9 revealed the patient was admitted on August 12, 2009, with no documented evidence that the patient received An Important Message From Medicare About Your Rights within two calendar days of admission as per policy. Further review revealed An Important Message From Medicare About Your Rights with the patient's signature and dated August 19, 2009.

Interview with EMP4 on February 12, 2010, at approximately 10:30 AM confirmed the above findings and revealed "The date is the 19th on the IM(Important Message).

Interview with EMP5 on February 12, 2010, at approximately 11:30 AM confirmed the above findings and revealed "That really looks like the 19th. We didn't meet the standard in this particular case."

Based on a review of facility documents, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to implement surgical policies regarding informed consent for four of ten medical records reviewed (MR1,MR4, MR5, and MR6).

Findings include:

Review of the facility's "Informed Consent" policy, dated May 9, 2009, revealed "A consent form is considered to be properly executed if: (i) it contains the patient's or substitute decision-maker's signature, the date and time of signature, ... "

1) Review of MR1, MR4, MR5, and MR6 revealed that procedure consents were not signed, timed, and/or dated.

Interview with EMP5, February 12, 2010, at approximately 10:30 AM confirmed the above findings and stated "the expectation is that the consents are to be signed, dated, and timed."