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LEHIGH VALLEY HOSPITAL

1200 SOUTH CEDAR CREST BOULEVARD

ALLENTOWN, PA 18103

PATIENT RIGHTS: NOTICE OF RIGHTS

Tag No.: A0117

Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to provide Medicare beneficiaries with "An Important Message from Medicare (IMM)" within two days of admission and/or within two days prior to discharge for three of 10 of medical records reviewed for IMM provided for Medicare beneficiaries in the Behavior Health Unit (MR13, MR14, MR15) and for eight of ten medical records reviewed for IMM provided for Medicare beneficiaries located at the Cedar Crest campus (MR23, MR24, MR25, MR26, MR27, MR28, MR29, MR30).

Findings include:

Review on October 5, 2016, of facility policy "Medicare Notification Inpatient Hospital Discharge Rights," approved March 27, 2015, revealed " ... IV. A. Delivery of Important Message ... The Inpatient Case Manager will provide the letter (IMM) at or near admission, but no later than two (2) calendar days after admission .... Psych Eval Service will provide "Important Message from Medicare" in the EBH [Emergency Behavior Health] prior to admission to the Behavioral Health Unit ... D. A copy of the signed "Important Message from Medicare" is to be reissued to the patient no more than two days before the discharge ... "

1) Review on October 6, 2016, of MR13, MR14 and MR15 revealed no documentation that these Behavioral Health Unit (BHU) Medicare beneficiaries were provided with an IMM at or near admission or prior to or at the time of discharge.

Interview with EMP1 on October 6, 2016 at 11:30 AM confirmed there was no documentation that these BHU Medicare beneficiaries were provided with an IMM at or near admission or prior to or at the time of discharge in MR13, MR14 and MR15.

2) Review on October 6, 2016, of MR23, MR24, MR25, MR26, MR27, MR28, MR29 and MR30 revealed no documentation that an IMM was provided to these Medicare beneficiaries prior to or at the time of discharge.

Interview with EMP1 on October 6, 2016, at 10:30 PM confirmed there was no documentation that an IMM message was provided to these Medicare beneficiaries prior to or at the time of discharge for MR23, MR24, MR25, MR26, MR27, MR28, MR29 and MR30.