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Based on document review and interview, it was determined in 6 of 12 (Pt #1, Pt #3, Pt #4, Pt #6, Pt #9 and Pt #10) observation patients records reviewed, the CAH (Critical Access Hospital) failed to ensure notice was provided informing the patient of being placed in observation status.

Findings include:

1. The Illinois Licensure Administrative Code Title 77: Public Health Chapter 1: Department of Public Health Subchapter b: Hospitals and Ambulatory Care Facilities Part 250 Hospital Licensing Requirements Section 250.240 Admission and Discharge" stated under (f) "patient Notice of Observation Status. Within 24 hours after a patient's placement into observation status by a hospital, the hospital shall provide that patient with an oral and written notice that the patient is not admitted to the hospital and is under observation status. The written notice shall be signed by the patient or the patient's legal representative..."

2. On 3/12/2024 at 10:00 AM, the policy titled "Observation Service Determination and Start Time" (effective 3/22/2023) was reviewed. The policy indicated under "Medicare/Medicaid: ... 9. The patient and/or person acting on behalf of the patient will be notified of the determination for observation services in writing via the Medicare Outpatient Observation Notice. The notification conversation will be documented in the patient's record."

3. On 3/12/2024 the following observation patient records were reviewed and lacked notification of observation admission.
-Pt #1 was admitted to Observation status with a diagnosis of "frequent falls and right distal fibula fracture" on 12/28/2023 at 4:40 PM. Pt #1 was discharged from observation status on 1/3/2024 at 5:02 PM.

-Pt #3 was admitted to Observation status with a diagnosis of "HHS (Hyperosmolar Hyperglycemic State)" on 1/192024 at 5:29 PM. Pt #3 was discharged from observation status on 1/21/2024 at 7:16 AM.

-Pt #4 was admitted to Observation status with a diagnosis of "COPD (Chronic Obstructive Pulmonary Disease) Exacerbation, and debility" on 1/1/2024 at 10:52 PM. Pt #4 was discharged from observation on 1/5/2024 at 12:54 PM.

-Pt #6 was admitted to Observation status with a diagnosis of "diverticulitis and sepsis" on 2/26/2024 at 5:57 PM. Pt #6 was discharged from observation status on 2/27/2024 at 7:35 PM.

-Pt #9 was admitted to Observation status with a diagnosis of "falls,generalized weakness and sacral fracture" on 12/28/2023 at 3:55 PM. Pt #9 was discharged from observation status on 1/1/2024 at 10:35 PM.

-Pt #10 was admitted to Observation status with a diagnosis of "Colitis and Diarrhea" on 2/6/2024 at 11:04 PM. Pt #10 was discharged from observation status on 2/10/2024 at 10:02 AM.

All six records lacked documentation of a MOON (Medicare Outpatient Observation Notice).

4. On 3/13/2024 at approximately 4:30 PM an interview was conducted with the Discharge Planner (E #4). E #4 reviewed Pt #1, Pt #3, Pt #4, Pt #6, Pt #9 and Pt #10's record and confirmed a MOON was not completed on these observation patients.

Based on document review and interview, it was determined that the CAH (Critical Access Hospital) failed to ensure adherence to Federal Laws and State Regulations. As a result, the Condition of Participation (485.608) Compliance With Federal, State, and Local Laws and Regulations was not met as evidenced by:.

Findings include:

1. The Hospital failed to ensure notice was provided informing the patient of being placed in observation status. See deficiency at C-0812.

Based on document review and interview, it was determined that the CAH (Critical Access Hospital) failed to ensure adherence to the total number of inpatient beds. As a result, the Condition of Participation (485.620) Number of Beds and Length of Stay was not met as evidenced by:.

Findings include:

1. The Hospital failed to follow Federal Regulations in maintaining an average daily census of 25 inpatients. See deficiency at C-0902.

Based on document review and interview, it was determined the CAH (Critical Access Hospital), failed to follow Federal Regulations in maintaining an average daily census of 25 inpatients.

Findings include.

1. The policy titled, "Observation Service Determination and Start Time" (effective 03/22/22) was reviewed. The policy stated, "... Medicare/Medicaid: 1. Outpatient Observation Services should be ordered by the practitioner when he/she anticipates the patient's length of stay is less than two midnights, requires medically necessary monitored care and/or short-term hospital treatment.... 6. Observation Services end when the patient is medically ready for discharge and no longer requires monitoring or treatment, regardless of whether a discharge order has been written by a practitioner, or the patient is admitted as an inpatient..."

2. The Census log (Inpatient and Observation Admissions) dated 02/01/24 through 02/29/24 was reviewed. On February 22nd, the log indicated the facility had 28 inpatients and 13 observation patients. The log also indicated the average daily inpatient census was 20 and the average daily observation census was 11 (greater than 50% of the average inpatient census).

3. The Discharge Observation log dated 12/01/23 through 03/06/24 was reviewed. From February 1, 2024 through March 6, 2024, the log indicated:
- 62 patients were admitted for observation in February with a length of stay that totaled 3,108 hours (Average length of observation stay per patient is 50 hours).
- 11 patients were admitted for observation in March with a length of stay that totaled 485 hours (average length of observation stay per patient is 44 hours).
- 5 observation patients length of stay was greater than 96 hours (100 hours, 109 hours, 112 hours, 121 hours and 168 hours).

4. The census on 3/12/24 during the survey indicated there were 22 inpatient and 8 observation patients. Of the 8 observation patients, 4 patients had a length of stay greater than 50 hours (52 hours, 64 hours, 66 hours and 95 hours).

5. On 3/12/2024 at approximately 4:15 PM an interview was conducted with the Discharge Planner (E #4). E #4 reviewed both logs and confirmed the findings. E #4 stated, "if the observation patients require more than 2 midnights (48 hours) the patient should be admitted as an inpatient. In most cases, the patients that are here greater than 48 hours after medicare stops paying or exceed 96 hours is because we do not have a safe discharge plan, or we are waiting for insurance authorization for Nursing Home placement or skilled Nursing Rehabilitation admission."







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