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Based on the facility's policy and procedure, medical record review and staff interviews, it was determined that the facility failed to provide documentation that eligible Medicare patients or their representatives were given a copy of the Important Message From Medicare form at least 2 days prior to discharge for three (3) out of twenty-nine (29) sampled medical records (#'s 19, 24 and 27).

Findings were:

Review of the facility's policy and procedure manual, failed to provide documentation of a policy related to the Important Message From Medicare.

Review of the twenty-nine (29) sampled medical records revealed that three (3) medical records lacked documented evidence that a second copy of the Important Message From Medicare had been given to the patient and or his/her representative at least 2 days prior to discharge.

An interview was conducted on 3/13/2013 at 11:50 a.m. in a vacant Social Worker's office. The Billing Generalist (employee file #21-interview only) stated that he/she gives the patient and or the patient's representative a copy of the Important Message From Medicare information upon admission, but was unaware of a second copy to be given to Medicare patients.

An interview was conducted on 3/13/2013 at 1:45 p.m. in one of the facility's conference rooms. The Consultant for Quality Management (personnel file #23- interview only) stated that patients and/or their representatives received a copy of the Important Message From Medicare, but was unaware that a second copy was required.

Based on the facility's policies and procedures, complaint documentation and staff interview, it was determined that the facility failed to provide documentation that a letter or other form of communication had been relayed to the complainant with regards to the results of the grievance process and date of completion.

Review of the facility's policy entitled, Consumer Complaints and Grievances, No. 3.106, Original Effective Date: July 1, 2002, Section V. Procedures revealed that the Division of Mental Health, Developmental Disabilities and Addictive Diseases (DMHDDAD), would make an initial determination if the complaint or grievance would be processed by the Regional Office or referred to another agency or entity for resolution. The policy further revealed that the complainant would be informed that the complaint or grievance would be promptly forwarded to the provider and the provider would contact the complainant to resolve the matter. There would be a follow-up with the provider within (5) business days of the referral to verify that the complaint or grievance was in the process of being resolved. According to the policy, the Regional office would notify the complainant in writing, within (5) business days of the completion of the complaint or grievance review/investigation, of the findings and recommendations for resolving the complaint or grievance.

Review of the facility's complaint report folder, dated 1/2012 through 2/2013, failed to provide documentation that a follow-up letter or other form of communication had been sent to the complainant, after the facility's investigation had been completed.

An interview was conducted on 3/13/2013 at 11:30 a.m. in the facility's vacant Social Worker's office. The Incident Manager (employee file #22- interview only) stated that he/she was unaware that a letter needed to be sent to the complainant regarding the facility's investigation findings and did not send a follow-up letter.