HospitalInspections.org

Based on review of the facility policies and procedures, medical records and staff interviews, it was determined that the facility failed to ensure that all Medicare patients received notice of their rights as hospital patients, as it related to the initiation and termination of hospital care.

Findings were:

Review of the facility's policy entitled "Medicare Important Message Notification," no policy number, effective 03/2013, revealed that the policy ensured that all Medicare patients received an original and a second notification of the "Important Message from Medicare" (IM) form. The policy dictated that the initial notification would be given to the patient within 48 hours of admission. The second notification would occur no more than two (2) days prior to discharge.

Review of ten (10) sampled medical records (#s 1-10) revealed that four (4) medical records (#s 4, 5, 9, and 10) of ten (10) medical records (#s 1-10) failed to have the required IM notifications forms. Number four (4) and number five (5) failed to receive a second notice; and numbers nine (9) and (10) failed to receive either notice.

During an interview on 09/25/2015 at 3:30 p.m. in the conference room, the director of quality assurance/performance improvement confirmed that these patients failed to received the required notifications.