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Based on interview and document review, the hospital failed to provide the Important Message from Medicare (IM) within two days of admission, or two calendar days prior to discharge for 10 of 12 patients (P2, P3, P11, P12, P13, P14, P15, P16, P17, and P18) reviewed who had Medicare coverage while at the hospital. In addition, the facility failed to provide the Centers for Medicare & Medicaid Services (CMS) designated IM that identified Minnesota's current appeal Quality Improvement Organization (QIO) information for 2 of 2 patients (P19, P20) reviewed who received an IM upon admission.

Findings include:

The CMS Beneficiary Notices Initiative (BNI) website dated 9/6/23, directed hospitals were "required to deliver the [IM form], formerly CMS-R-193 and now CMS-10065 to all Medicare beneficiaries ..." who were hospital inpatients. "The new versions must be used no later than April 27, 2023." This form informed patients of their hospital discharge appeal rights. CMS-10065 form instructions directed the facility to insert the name and toll-free number of the QIO for the state where the hospital was located.

The CMS QIO website dated 9/6/23, identified Minnesota's QIO was Livanta and provided the phone number 1-888-524-9900.

A State Operated Services Community Behavioral Health Hospital - Fergus Falls admission packet was provided. The packet included numerous forms. One form was a CMS-R-193 (Exp. 03/31/2020) form. The form identified the QIO was "KEPRO" at 1-855-408-8557 and was a two-sided form that explained Medicare covered services and discharge appeal rights. The folder lacked the current approved CMS-10065 form.

On 3/7/24 during the abbreviated medical record review process, P2 and P3's medical records lacked an admission provided signed and dated CMS-10065, or documentation to support attempt(s) to provide the notice.

On 3/7/24 at approximately 2:18 p.m., social worker (SW)-A identified P2 and P3 were Medicare beneficiaries. In addition, she identified current inpatients P11, P19, and P20 were also Medicare beneficiaries.

On 3/7/24, P11, P19, and P20's medical records were reviewed and identified the following:
-P11's record lacked a completed or declined to sign CMS-10065 form.
-P19's record contained a CMS-R-193 (outdated form) signed and dated upon admission.
-P20's record contained a CMS-R-193 (outdated form) signed and dated upon admission. The back side of the double-sided form was blank.

A list of patients discharged since 1/1/24, was requested along with payer source identification and evidence the IM was provided upon discharge for any Medicare beneficiaries discharged within this time frame. The provided forms identified 12 discharged patients. Seven patients (P12, P13, P14, P15, P16, P17, and P18) were Medicare beneficiaries. A provided word document, Discharges since Jan 1, 2024, indicated, "We reviewed 7 Medicare discharges, this form [IM] was not included in all 7."

During an interview on 3/7/24, at 2:42 p.m., registered nurse (RN)-A stated if she were aware of a patient's Medicare status, she provided the form to them that was in the admission folder. She explained upon P2's admission, P2 informed her he was kicked off all his insurance and thus did not have him sign the IM. She denied she questioned his insurance information. Upon a patient's admission, she reviewed admission paperwork for insurance information; however, this information was not always available. She stated the IM was a "funding piece" and it was, "Medicare rights information for a patient to know."

When interviewed on 3/7/24, at 2:53 p.m., RN-B stated she checked the admission paperwork for insurance information, or she asked the patient. If a patient was a Medicare beneficiary, she was expected to provide the patient with the IM. She denied she has provided a patient with this notice since she started in 2022. RN-B was unsure of the IM's purpose or requirements; however, she stated she thought it had "something to do with money."

During interview on 3/7/24, at 3:03 p.m., RN-E stated there were times where a patient's insurance upon admission was unknown. The IM was expected to be provided to Medicare beneficiaries; however, she was unsure as to the reason for its issuance other than informing the patient of their Medicare rights.

When interviewed on 3/7/24, at 3:06 p.m., RN-F stated there were times where a patient's insurance upon admission was unknown and thus, she provided the IM to everyone. She explained she used the form in the admission packet. She was unsure of the reason for its issuance other than it was used "for funding."

On 3/7/24, at 3:14 p.m., RN-G and RN-H were interviewed together. As RN supervisors, both thought the admitting RNs provided the IM to all patients, no matter insurance coverage. Both were unaware of any concerns related to the issuance of the IM. Upon admission, there were times insurance information was in the record or the patient presented insurance cards; however, this information was not always known by nursing staff upon admission. RN-H indicated audits were conducted on admission paperwork and processes; however, the IM was not included in this process. RN-G explained the IM at discharge was a responsibility of social services, and this was not something the nurses currently provided to the patients when discharge approached.

On 3/7/24, at 3:31 p.m., SW-A and SW-B were interviewed together. SW-B stated insurance information could be found "in the system" and everyone should know how to find it. She explained social services, in the past, was responsible for the admission IM; however, this process currently was a nursing responsibility. Both explained they were never responsible for providing, or have provided patients with, the IM two or more days prior to discharge. Neither were able to express the IM requirements or the form's purpose, but stated the facility's current IM form may not be the most up to date form.

During separate follow-up interviews on 3/7/24, from 4:04 p.m. to 4:10 p.m., RN-A, RN-B, RN-C, RN-D, RN-E, and RN-F denied they have provided any patients with an IM two or more days prior to discharge.

A Patient Rights and Documents Provided Upon Admission policy dated 2/6/24, directed admission staff to provide and explain the "Important Message from Medicare Form (CMS 10065) ..." and provided a downloadable form link. A policy section dedicated directives related to the IM and all applicable Medicare patients. This instructed within 48 hours of admission, the Medicare beneficiary (or his/her guardian) was to sign and date the IM form and provided guidance if they declined to sign. In addition, this section directed "A copy of the form is given to the patient or guardian no more than 48 hours before discharge." The policy link opened the CMS-10065 (exp. 12/31/25) form. This form directed staff to insert the QIO name and phone number in multiple designated areas before use.

A Discharge policy dated 11/1/22, identified a purpose to ensure all patients participated to the extent they desired and were able in discharge evaluation, decision-making, and planning processes. The policy provided guidance and direction on how to facilitate this coordination; however, the policy lacked direction related to the issuance of the IM.