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Based on record review and interview, the facility failed to provide a second 'Important Message from Medicare' (IMM) notification of patient rights prior to discontinuing services, for 3 (P-8, P-9, P-10) of 11 patients reviewed for patient rights, resulting in the potential for poor outcomes for all medicare beneficiaries receiving services at the facility. Findings include:

On 01/23/24 at 1000, a review of medical records was conducted with Child Unit Manager Staff H and Nurse Executive Staff B. Staff H was asked to demonstrate IMM's provided to P-8. Staff H searched the electronic medical record and found only the initial IMM. Staff H next demonstrated an initial IMM for P-9, but could not locate a second IMM. Staff H reviewed P-10's chart next, and again demonstrated an initial IMM document (signed and dated) but not a second IMM.
Staff B confirmed the findings and stated that she would confirm with Social Work department, that we were looking in the correct location for discharge documentation. Staff B confirmed that the documentation for the second IMM was not present in the medical record at approximately 1030 on 01/24/23.
An interview was conducted with Placement Specialist Staff N. Staff N was questioned about her role, which she described as 'I handle difficult placement discharges.' Staff N was asked how patients are informed about their rights. Staff N stated that the 'Health Unit Clerk' (HUC) provides the 'form' to the patient and instructs them that they 'may appeal' a discharge. Staff N stated that "I used to be a HUC, so I know how it worked. Staff N was asked if the HUC gets a signature? Staff N stated, "yes, they sign it. Then we scan it and store it in a book on the unit. You should find them under 'scanned images' in the EMR." Staff N was questioned if a second IMM was provided. Staff N stated, "An IMM is signed only at admission, then a check-mark is placed to confirm. At discharge, they again confirm that a check-mark is present before discharge."
Staff B was requested to provide the policy related to IMM provision and patient rights information. Staff B returned with the policy document titled " Medicare Important Messages", #6.46, effective 05/18. The policy document states under 'Procedure 1', "The assigned personnel for all admissions to (facility) and for delivery of IMM from Medicare form shall be the admitting Mental Health Technician (MHT). (Procedure 3) 'Delivery Timeframe' states, "The facility must deliver the original copy of the IM at or near admission , but no later than 2 calendar days following the date of the patient's admission to the hospital. As such, the responsible admission team member or Health Unit Coordinator (HUC) shall deliver the IM during the admission process. The IM must be delivered to the patient in person. However, if the patient is not able to comprehend the notice, it must be delivered to and signed by the patient's representative. 'Procedure 11' states, "The Follow-Up copy must be delivered as far in advance of discharge as possible, but no more than 2 calendar days before the planned date of discharge. The primary therapist will notify the team of the anticipated discharge via the Outlook Discharge Calendar. The HUC will ensure the form is given to the RN who will deliver the copy to the patient. When discharge cannot be predicted in advance, the follow-up copy of the notice must be delivered on the day of discharge, hospitals must give the patient or legal representative who need it at least 4 hours to consider their right to request a QIO review.."
Staff B was questioned if the facility was currently following this policy. Staff B responded, "Our current practice has varied a bit." Staff B was requested to clarify how the practice has varied. Staff B explained that the 'discharge form' has a box in the upper right corner, which is used to indicate whether a staff member confirmed that a signed IMM was present on admission. While reviewing medical records for P-9 and P-10, the 'check marks' were not documented as expected. For example, P-9 did not have a check mark, but should have. P-10 had a check mark next to "N/A" (not applicable) when that patient should be 'applicable'. . Staff B stated that "N/A" was for patient who are not receiving Medicare. Review of 'face sheet' for P-8, P-9 and P-10 confirmed that all three patients had Medicare listed as their primary payor.
A second review of the policy # 6.46, "Medicare Important Messages" was conducted. 'Procedure 6' confirmed the documentation procedure for HUC's, "Once delivery had been made during the admission process, subsequent delivery by the HUC and /or Charge RN after patient is stable, or via phone, fax or e-mail by the HUC, the HUC shall place a checkmark in the "MC Form" column on the Floor Census to indicate completion. HUC's are responsible for following up on all incomplete forms during the admission process."