HospitalInspections.org

Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined that the facility failed to provide Medicare beneficiaries with an "Important Message from Medicare" within two calendar days (48 hours) of discharge from the facility for eight of eight medical records reviewed (MR1 through MR8).

Findings include:

A review of Facility Document "Important Message from Medicare [IMM]," reviewed May 27, 2009, revealed "...Purpose: To establish a process to ensure patients are properly notified of their Medicare appeal rights in compliance with CMS regulations...Procedures...The admitting registrar will provide the IMM to all eligible Medicare and Medicare HMO recipients and obtain a signature from the patient of [sic] next of kin (NOK)...The original (white) and yellow copy of the IMM must be retained with the clinical record and sent to the floor with the admissions paperwork...If a patient or NOK refuses to or is unable to sign the IMM, the registrar must clearly document that on the IMM, sign, and date it...The yellow IMM notice will be given to the patient by Case Management no more than 2 days prior to discharge when the length of stay exceeds two days. Patient must sign the original (white) copy...If a patient or NOK is unable to or refuses to sign the IMM, a second attempt will be made to deliver the IMM by Case Management..."

1) A review of MR1 revealed that the patient was admitted on April 30, 2010, and was discharged May 24, 2010. Further review of MR1 revealed no documented evidence that the the first IMM signed form was given to the patient or NOK on admission or the second IMM form was given to the patient or NOK two days prior to discharge.

2) A review of MR2 revealed that the patient was admitted on August 22, 2010, and was discharged August 28, 2010. Further review of MR2 revealed no documented evidence that the second IMM form was given to the patient or NOK two days prior to discharge.

3) A review of MR3 revealed that the patient was admitted on August 22, 2010, and was discharged September 2, 2010. Further review of MR3 revealed no documented evidence that the the first IMM signed form was given to the patient or NOK on admission or the second IMM form was given to the patient or NOK two days prior to discharge.

4) A review of MR4 revealed that the patient was admitted on August 23, 2010, and was discharged August 27, 2010. Further review of MR4 revealed no documented evidence that the the first IMM signed form was given to the patient or NOK on admission or the second IMM form was given to the patient or NOK two days prior to discharge.

5) A review of MR5 revealed that the patient was admitted on August 25, 2010, and was discharged August 29, 2010. Further review of MR5 revealed no documented evidence that the second IMM form was given to the patient or NOK two days prior to discharge.

6) A review of MR6 revealed that the patient was admitted on August 25, 2010, and was discharged August 31, 2010. Further review of MR6 revealed no documented evidence that the second IMM form was given to the patient or NOK two days prior to discharge.

7) A review of MR7 revealed that the patient was admitted on August 26, 2010, and was discharged August 30, 2010. Further review of MR7 revealed no documented evidence that the second IMM form was given to the patient or NOK two days prior to discharge.

8) A review of MR8 revealed that the patient was admitted on August 27, 2010, and was discharged August 30, 2010. Further review of MR8 revealed no documented evidence that the the first IMM signed form was given to the patient or NOK on admission or the second IMM form was given to the patient or NOK two days prior to discharge.

9) An interview with EMP3 on November 15, 2010, at approximately 2:30 PM confirmed that MR1 through MR8 revealed no documented evidence of either the first IMM signed form was given to the patient or NOK on admission or the second IMM form was given to the patient or NOK 2 days prior to discharge.