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Based on hospital policy review, "Care Coordination Audits", medical record review and staff interview, the hospital staff failed to inform patients who were Medicare beneficiaries of notification of rights regarding the discharge appeal process (IM notice form CMS-R-193) within two days of the admission and no more than two calendar days before the patients' discharge for 5 of 8 Medicare beneficiary patients admitted for inpatient hospital services (#2, #3, #6, #8, and #10).

The findings included:

Review on 09/01/2020 of a hospital policy titled "Discharge Notification Required by Medicare" effective date 07/2007 last revised 02/2019 revealed "...The Admissions Department will have patients or their representative sign the original IM (Important Message) at admission or within 2 calendar days of admission...Care Coordination staff will identify patients who need a second IM notice as far in advance of discharge as possible, but not more than two calendar days before the planned discharge. The second IM will be delivered by Care Coordination or Nursing Department staff..."

Review on 09/01/2020 of a hospital policy titled "Important Message from Medicare" effective date 07/2020 revealed "...The Admissions Department will deliver the initial Important Message (IM) form Medicare and have patient/representative/POA (Power of Attorney) sign the original IM at admission or within 2 calendar days of admission. When a patient does not sign the IM form at admission, Admissions will visit the patient's room and the family waiting area for family members daily through the first 48 hours of admission. On the 2nd day following admission, the Admissions Department will mail the patient a certified letter with the 2-part IM form enclosed. Attempts to obtain the signature from the patient or a family member representative will continue. Completed forms will be forwarded to Medical Records for scanning and placement in the patient's electronic medical record. When the certified letter patient's IM form is returned, and the patient is still in-house, the form will be forwarded to Medical Records for scanning...Care Coordination staff will identify patients who need a second IM notice as far in advance of discharge as possible, but no more than 48 hours and no less than 4 hours prior to discharge. The 2nd IM will be signed and dated by the patient/patient representative...If the patient has a power of attorney, then the Case Manager/Social Worker (CM/SW) will have the form signed by the appropriate party. If completed telephonically the CM/SW will read the form to the POA, have a witness to the phone consent. If the patient has family that need to be contacted by phone then any care coordination staff member can complete by reading the entire IM and have a witness to the phone consent...Care Coordination and Admission will audit their Important Message compliance on a regular basis and share the audit results with the Compliance Department to ensure the departments are compliant with the regulation..."

Review on 09/01/2020 of a policy titled "Emergency Policy for IM and MOON (Medicare Outpatient Observation Notice) forms" effective date 03/18/2020 revealed "...In light of the COVID-19 national emergency and the national shortage of personal protective equipment, for any situation where personal protective equipment (PPE) is needed to access the patient room, if the communication can be adequately provided by other means, such as telephone or intercom, the hospital employee will utilize that means of communication and not enter the room. If a form requires a patient signature, the employee will note on the form that the information was provided verbally 'due to isolation' and indicate their name and the date and time of the communication. A copy of that completed form will be provided to the patient's nurse to deliver to the patient the next time the room is entered..."

Review on 09/02/2020 of the Care Coordination Audits revealed Care Coordination was tracking "Second IM delivery in compliance." Review of the data revealed the goal was 100%. Review revealed in April the compliance was 23%, in May the compliance was 39% , in June the compliance was 35%, and in July the compliance was 31%.

1. Open medical record review on 09/02/2020 of Patient #2 revealed a 90-year-old male admitted on 08/27/2020 post fall injury and discharged on 09/01/2020. Review revealed Patient #2 was a Medicare beneficiary. Patient #2 was admitted as an inpatient on 08/28/2020 at 1727. Review revealed Patient #2 signed an IM form on 08/31/2020 (3 days after admission, 1 day prior to discharge). Review failed to reveal an IM form provided to Patient #2 within 2 days of hospital admission.

Interview on 09/02/2020 at 1445 with the Admission Manager revealed the registration staff were responsible for providing the first copy of the IM form to the patient upon admission and assuring that the patient or patient's representative sign the form as received and understood. Interview revealed that a copy of the IM notice was given to the patient and a copy was kept in the patient's medical record.

2. Closed medical record review on 09/01/2020 of Patient #3 revealed a 74-year-old male admitted on 07/17/2020 with a fall and discharged on 07/21/2020. Review revealed Patient #3 was a Medicare beneficiary. Review revealed an IM form was signed on 07/20/2020 (3 days after admission, 1 day prior to discharge). Review failed to reveal an IM form provided to Patient #3 within 2 days of hospital admission. Review revealed Patient #3 returned on 07/30/2020 and was discharged on 08/07/2020. Review revealed an IM was delivered on 07/30/2020. Review failed to reveal an IM form delivered 48 to 4 hours prior to discharge.

Interview on 09/02/2020 at 1445 with the Admission Manager revealed the registration staff were responsible for providing the first copy of the IM form to the patient upon admission and assuring that the patient or patient's representative sign the form as received and understood. Interview revealed that a copy of the IM notice was given to the patient and a copy was kept in the patient's medical record.

Interview on 09/02/2020 at 1400 with the Care Coordination Specialist confirmed no IM present for Patient #3 after admission on the 07/17/2020 visit and prior to discharge on the 07/30/2020 visit. Interview revealed normally the Admission staff delivered the first IM and the Care Coordination staff delivered the second IM. Interview revealed the Care Coordination Specialist was tracking compliance with the 2nd IM notice and changes had been made "this summer."

3. Closed medical record review on 09/01/2020 of Patient #6 revealed an 89-year-old female admitted on 07/17/2020 with dizziness and discharged on 07/27/2020. Review revealed Patient #6 was a Medicare beneficiary. Review revealed an IM form was signed on 07/20/2020 (3 days after admission, 7 days prior to discharge). Review revealed on 07/23/2020 (4 days before discharge) it was documented Patient #6's representative refused to sign the IM form. Record review failed to reveal an IM form signed by Patient #6 or their representative within 2 calendar days of admission and within 48 to 4 hours of discharge.

Interview on 09/02/2020 at 1445 with the Admission Manager revealed the registration staff were responsible for providing the first copy of the IM form to the patient upon admission and assuring that the patient or patient's representative sign the form as received and understood. Interview revealed that a copy of the IM notice was given to the patient and a copy was kept in the patient's medical record.

Interview on 09/02/2020 at 1400 with the Care Coordination Specialist revealed normally the Admission staff delivered the first IM and the Care Coordination staff delivered the second IM. Interview revealed the Care Coordination Specialist was tracking compliance with the 2nd IM notice and changes had been made "this summer."

4. Closed medical record review on 09/02/2020 of Patient #8 revealed an 88-year-old female admitted on 06/03/2020 with pneumonia and discharged on 06/09/2020. Review revealed Patient #8 was a Medicare beneficiary. Review revealed an IM form was signed on 06/04/2020. Review failed to reveal a signed IM form within 48 to 4 hours of discharge.

Interview on 09/02/2020 at 1400 with the Care Coordination Specialist confirmed no IM present for Patient #8 prior to discharge. Interview revealed normally the Admission staff delivered the first IM and the Care Coordination staff delivered the second IM. Interview revealed the Care Coordination Specialist was tracking compliance with the 2nd IM notice and changes had been made "this summer."

5. Closed medical record review on 09/02/2020 of Patient #10 revealed a 76-year-old male admitted on 06/29/2020 with leg swelling and redness and discharged on 07/01/2020. Review revealed Patient #10 was a Medicare beneficiary. Review failed to reveal an IM form delivered to Patient #10 within 2 days of admission or 48 to 4 hours prior to discharge.

Interview on 09/02/2020 at 1445 with the Admission Manager revealed the registration staff were responsible for providing the first copy of the IM form to the patient upon admission and assuring that the patient or patient's representative sign the form as received and understood. Interview revealed that a copy of the IM notice was given to the patient and a copy was kept in the patient's medical record.

Interview on 09/02/2020 at 1400 with the Care Coordination Specialist confirmed no IM present for Patient #10. Interview revealed normally the Admission staff delivered the first IM and the Care Coordination staff delivered the second IM. Interview revealed the Care Coordination Specialist was tracking compliance with the 2nd IM notice and changes had been made "this summer."

Based on medical record review, and staff interview facility staff failed to ensure a patient's discharge plan included the ability of a patient to perform activities of daily living (ADL) by occupational therapy as ordered prior to discharge for 1 of 7 discharged medical records reviewed (Patient #4).

Closed medical record review on 09/02/2020 of Patient #4 revealed a 62-year-old male admitted on 07/23/2020 for a scheduled right knee arthroplasty. Review revealed Patient #4 had surgery on 07/23/2020. Review of the physician orders dated 07/23/2020 revealed an order for "Occupational Therapy (OT) Evaluate and Treat." Review failed to reveal Occupational Therapy evaluated the patient post-operatively. Review revealed Physical Therapy saw the patient on 07/24/2020. Review of the Physical Therapy note revealed assessments of the patient's ability to ambulate, transfer, and ascend/descend steps. Review of the Physical Therapy recommendations revealed " ...PT (physical therapy) Recommendations: Home with 24/7 supervision and PRN (as needed) assist with mobility, HHPT (home health physical therapy) at discharge ...Problem List: Pain, Impaired balance, Impaired activity tolerance, Decreased strength, Poor family support, Decreased range of motion, Decreased flexibility, functional mobility, Impaired skin integrity ..." Review of the physical therapist's assessment of the patient's "Social Factors" revealed " ...Patient Lives (with): Alone Prior to admission, patient resided at: Private residence Home Layout: Multi-level, Able to live on main level with bedroom/bathroom (4 steps with single rail into home) Person(s) Available to assist at discharge: Family members, Friends Amount of assistance available at discharge: PRN assistance, PRN supervision ...Prior Function Level of Independence: Independent with ADLs and functional transfers, Independent with homemaking with ambulation ...ambulation with SPC (single point cane) prior to surgery ..." Review failed to reveal an assessment of Patient #4's ability to perform activities of daily living including, personal hygiene, grooming, dressing, undressing, and feeding.

Interview on 09/02/2020 at 0918 with Physical Therapist #2 revealed the "Social Factors" assessed a patient's resources prior to their hospital admission.

Interview on 09/02/2020 at 1730 with the Director of Clinical Compliance revealed OT did not see Patient #4 on 07/24/2020 because the Occupational Therapist was out sick. Interview revealed if there was a physician order for OT the patient should be seen by OT prior to discharge. Interview revealed the process for OT seeing patients needed to be "worked on."

NC00167559