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Based on interview, record review and policy review the facility failed to ensure staff delivered the second Important Message (IM) from Medicare (a government notice provided to the patient to inform them of their discharge appeal rights) and ensure it was signed, dated, and placed in the patient's medical record within 48 hours of discharge for three (#8, #31, #10) of 16 Medicare eligible patients reviewed and 178 of 178 of patients discharged and transferred to another Medicare facility in the last 12 months. This had the potential to affect all Medicare eligible patients by denying them their right to appeal their discharges. The facility's Medicare eligible patient census was 154. The facility census was 308.

Findings included:

1. Record review of the facility's undated policy titled, "Important Message From Medicare CDM [Charge Description Master-an electronic entry system for patient charges] Final rule: Discharge Notification Appeal For Medicare Advantage Inpatients," showed Social Workers (SW) are responsible for delivering the copy of the scanned IM letter within 48 hours prior to the patient's discharge. If the patient's discharge date changes beyond two days, another letter is delivered within two days of discharge. The policy did not address the patient's signature, date, and/or the placement of it in the record.

During an interview on 09/13/16 at 9:08 AM, Staff Q, Case Manager, stated that Patient #8's anticipated discharge date was 09/12/16. Staff Q stated that the SW delivered the discharge IM to the patient.

2, Record review of Patient #8's medical record, on 09/13/16 at 9:08 AM, showed the patient was not discharged on 09/12/16, but was still an anticipated discharge. There was no evidence of a discharge IM provided to the patient.

During an interview on 09/13/16 at 9:45 AM, Staff P, Social Worker, confirmed that Patient #8 had not received her discharge IM yet. Staff P stated that she would deliver it that day. Staff failed to deliver the second IM letter by 09/10-11, 2010, or two days prior to the anticipated discharge.

3. Record review of Patient #31's medical record, on 09/13/16 at 2:40 PM, showed no evidence of a discharge IM provided.

During an interview on 09/13/16 at 2:45 PM, Staff GG, SW, was able to show in her documentation that Patient #31 was pending discharge on 09/13/16, and recived the discharge IM on 09/12/16 at 4:18 PM. Staff GG stated that a copy of the discharge IM was given to the patient, and a copy was not retained for their records, but that they documented in the electronic medical record that it was given.

During an interview on 09/14/16 at 10:00 AM, Staff C, Chief Nurse Executive (CNE), stated that they had to have a standardized process for delivering the discharge IM because so many patients did not actually discharge when anticipated, causing another IM delivery.

4. Record review of discharged Patient #10's medical record showed that he was admitted to the facility on 04/24/16 and subsequently transferred to a Medicare Long Term Acute Care Facility on 05/10/16. There was no evidence in the patient's medical record of the discharge IM.

During an interview on 09/13/16 at 3:00 PM, Staff Z, Clinical Coordinator Information Services, stated that Patient #10's discharge IM was not in the patient's medical record.

During concurrent interviews on 09/13/16 at 3:05 PM, Staff AA, Compliance Analyst, and Staff C, CNE, stated that when patients are transferred to another Medicare facility that they are not given a new IM. Staff C stated, "We will need to change that process. Patients aren't given a new one [IM]".

5. Record review of the facility's report for patients transferred to another Medicare facility from 09/01/15 to 09/14/16 showed 178 patients did not receive the IM upon discharge.

During an interview on 09/14/16 at 10:30 AM, Staff A, Director of Quality and Patient Safety, stated, "Under the current process we won't have the evidence that these patients received the second IM".








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Based on observations, interviews, record reviews and policy and procedure reviews the facility failed to ensure that the patient or the patient's representative was provided a phone number and address for lodging a grievance with the State agency. This failure had the potential to affect all patients who received the Patient Rights admission packet after being admitted to the facility. The facility census was 308.

Findings included:

1. Record review of the facility's undated policy titled, "Patient Rights and Responsibilities," showed the following:
Policy/Procedure Requirements:
- The hospital provides a guide to Rights and Responsibilities to all patients with the expectation that observance of their rights will contribute to more effective patient care and greater satisfaction for the patient and his/her family.
- The patient has the right to receive notification of patient rights in writing and information concerning important hospital policies and a list of available supportive resources . . .
- All patients have a right to voice their concerns.

2. Record review of the facility's patient admission packet obtained from Staff D, Program Manager, on the 3rd Floor contained a brochure titled, "Your Rights Regarding Your Health Information," showed the following:
COMPLAINTS
- We welcome an opportunity to address any concerns that you may have regarding the privacy of your health information. If you believe the privacy of your health information has been violated, you may file a complaint with our Patient Care Advocate/Representative, Health Insurance Portability and Accountability Act (HIPAA, an acronym that stands for a United States (US) law designed to provide privacy standards to protect patients' medical records and other health information provided to health plans, doctors, hospitals and other health care providers) Liaison or with the Secretary of the U.S. Department of Health and Human Services.
- To obtain assistance from the Patient Advocate/Representative or HIPAA Liaison, contact the Operator at any of our facilities or offices and request the Patient Advocate/Representative or HIPAA Liaison. The Patient Advocate/Representative or HIPAA Liaison may also be contacted for any questions concerning this Notice.
- It is important to note that requests or complaints must be made to the hospital or office where your privacy concern arose. Any requests or complaints made will not be deemed to be filed with any of the other hospitals or providers covered by or addressed in the Joint Notice.

The brochure did not contain the following contact information required for regulatory compliance to file a complaint or grievance:
Department of Health and Senior Services, Post Office Box 570, Jefferson City, MO 65102-0570 telephone number (573)751-6303.

3. Observation on 09/12/16 at 3:30 PM on the main floor in the hospital's main surgical waiting room showed the same brochure available to patients and did not contain the required State Agency contact information.

During an interview on 09/12/16 at 3:30 PM, Staff D, Program Manager, stated that the State Agency contact information was not in the brochure that was given to patients.