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Based on a review of facility documents, medical record (MR) and interviews with facility staff (EMP), it was determined that the facility failed to provide the second (discharge) notice of the Important Message from Medicare [IMM] within two calendar days of discharge from the facility for one of one medial record (MR12) and the IMM on discharge was provided less than four hours from actual patient discharge in four of four medical records (MR17, MR18, MR20 and MR21).

Findings Include:

Review of "Notification of Hospital Discharge Appeal Rights" policy and procedure dated February 2013, revealed, " ... Procedure: Initial Patient Notification: (IM 1) he [sic] Unit Clerk will identify those patients admitted to their nursing unit who require an IM 1 form to be completed based on the insurance and patient type. ... Review of charts for the completed IM form occurs during the Unit Clerks scheduled shifts. Admission 1. The Unit Clerk will obtain the IM 1 for for patient's signature, date and time. ... 4. The patient or a patient representative must sign the form. Date and time of signature must be documented on the form. ... 8. An IM 1/IM 2 sticker is placed on every KARDEX upon admission. This serves as a reminder for the Unit Clerk to check if an IM 1 and IM 2 will need to be signed by the admitted patient. ... The Unit Clerk will check the KARDEX'S daily for patients requiring the IM 1 and IM 2. The Unit Clerk will follow through to validate that all IM 1 and IM 2 forms for this specific Medicare population have been signed/dated /timed prior to the patient's physical discharge. ... Any other Insurance with Medicare in the Title The initial IM form cam be issued at the time of pre-registration (up to 7 days prior) or at the time of admission. The initial notice should be delivered as close to admission as possible, but no later than 2-calendar days after admission. ... Discharge (IM 2) Follow up notification prior to discharge: The follow-up 'Important Message' (IM 2) notice prior to discharge is not required to patients discharged to: -Another acute facility - Acute inpatient rehabilitation facility ... Acute inpatient psychiatric facility - Long term acute care facility ... Patient deceased - Behavioral Health. Unit Clerks will work proactively with patients, families, the medical staff, and Case Management to identify patients nearing discharge or approaching readiness for transfer to the next level of care. 1. The IM 2 should be issued to the patient or patient representative as early in the discharge process as possible but no more than 2 calendar days before discharge. Delivery of the IM 2 should not be routinely delivered immediately prior to actual discharge. Information discussed during discharge planning rounds involving the patient's potential discharge date will be discussed with the Unit Clerk. 2. It is the Unit Clerk's daily responsibility to check all patient charts on their nursing unit for completion of the IM 1 (admission) and IM 2 (discharge) forms. ... Case Management Compliance The Case Management Department will monitor compliance of the initial and follow-up delivery of the IM form on a monthly basis ... Responsibility Case Management is responsible for the implementation of this policy. ... ."

1) "Case Management Performance Improvement Quarterly Report FY13" revealed, "Item Reviewed for documentation ... Initial CM/SS visit [July 2012-March 2014, average 98%] ... Initial CM visit within first five days of stay [July 2012-March 2014, average 57%] ... IPOC (Qtrly) [July 2012, October 2012, January 2013 and June 2013, average 88%] ... IM1 Signed [July 2012-February 2013, average 59%] ... IM2 Signed [July 2012-February 2013, average 69%] ... Rounds Conducted (Qrtrly) [July 2012, October 2012, January 2013 and June 2013, average 98%] ... Freedom of Choice [July 2012-March 2013 and June 2013, average 94%]."

"Case Management Performance Improvement Report IM Audit 2014" revealed, "January IM1 Compliance # 72/93 ... 77% ... IM2 Compliance # 69/93 ... 74% ... February IM1 Compliance # 132/149 ... 89% ... IM2 Compliance # 112/149 ... 75% ... March IM1 Compliance # 94/106 ... 89% ... IM2 Compliance # 81/106 ... 76% ... ."

3) 3) A review of sample Medicare inpatient medical records (MR12-MR21) was conducted on May 7, 2014, to ascertain completion of the Important Message from Medicare on admission and discharge for inpatients admitted greater than five days. MR12 revealed documented evidence that the Important Message from Medicare was completed on admission however, failed to reveal documented evidence that the Important Message from Medicare was completed on discharge as required. Continued medical record (MR17, MR18, MR20 and MR21) review revealed, the IMM on discharge was provided less than four hours from actual patient discharge.

An interview was conducted with EMP2 and EMP5 on May 7, 2014, following the review of medical records (MR12-MR21), at approximately 2:30 PM. EMP2 and EMP5 confirmed that medical record (MR12) revealed no second (or discharge) Important Message from Medicare and that one should have been completed. EMP2 and EMP5 also confirmed that the IMM on discharge was completed on the day of discharge in medical records MR17, MR18, MR20 and MR21.