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Based on policy review, medical record review, and staff interview facility staff: failed to provide the Medicare Important Message prior to discharge in 1 of 5 patients (Patient #17); failed to provide the 2nd notice of the Medicare Important Message prior to discharge in 3 of 5 patients (Patients #15, #17, and #18); and failed to provide a written copy of the 2nd notice of the Medicare Important Message in 4 of 5 patients (Patients #14, #15, #16, and #17).

The findings included:

Review of the policy titled, "Delivery of 2nd Important Message from Medicare" effective date 10/14/2019 revealed,"...CMS (Centers for Medicaid and Medicare Services) has mandated that acute care hospitals issue an Important Message from Medicare, to explain the Message to patients and or designees and have the patients and/or designees sign indicating their understanding of their discharge rights ... This policy pertains to all Medicare ... patients and is applicable when Medicare insurance is present ... A follow-up copy must be delivered to the patient and/or designee as far in advance of discharge as possible, but no more than two calendar days before the planned date of discharge..."

Review of the policy titled "Important Message for Medicare Patients" effective date 08/06/2020 revealed, "...In accordance with guidelines established by the Department of Health and Human Services, it is required that each Medicare patient admitted to the hospital receives a directive which explains their rights as a Medicare patient..."

A. Closed medical record review revealed Patient #17 was a 94-year-old male admitted to the facility on 07/12/2021 with a diagnosis of transient ischemic attack. Review confirmed Patient #17 was a Medicare patient. Patient #17 was discharged on 07/15/2021 and review revealed no evidence Patient #17, or his designee received the 1st Medicare Important Message prior to discharge.

Staff Interview was conducted with the Director of Complex Discharges on 07/20/2021 at 1315. Interview confirmed there was no evidence Patient #17, or his designee received the 1st Medicare Important Message prior to his discharge.

B. 1. Closed medical record review revealed Patient #15 was a 94-year-old female admitted to the facility on 06/27/2021 with a diagnosis of acute pancreatitis. Review confirmed Patient #15 was a Medicare patient. Patient #15 was discharged on 07/06/2021 and review revealed no evidence Patient #15, or her designee received the 2nd Medicare Important Message prior to discharge.

Staff Interview was conducted with the Director of Complex Discharges on 07/20/2021 at 1315. Interview confirmed there was no evidence Patient #15, or her designee received the 2nd Medicare Important Message prior to his discharge.

2. Closed medical record review revealed Patient #17 was a 94-year-old male admitted to the facility on 07/12/2021 with a diagnosis of transient ischemic attack. Review confirmed Patient #17 was a Medicare patient. Patient #17 was discharged on 07/15/2021 and review revealed no evidence Patient #17, or his designee received the 2nd Medicare Important Message prior to discharge.

Staff Interview was conducted with the Director of Complex Discharges on 07/20/2021 at 1315. Interview confirmed there was no evidence Patient #17, or his designee received the 2nd Medicare Important Message prior to his discharge.

3. Closed medical record review revealed Patient #18 was a 91-year-old male admitted to the facility on 07/17/2021 with a diagnosis of anemia. Review confirmed Patient #18 was a Medicare patient. Patient #18 was discharged on 07/20/2021 and review revealed no evidence Patient #18, or his designee received the 2nd Medicare Important Message prior to discharge.

Staff Interview was conducted with the Director of Complex Discharges on 07/20/2021 at 1315. Interview confirmed there was no evidence Patient #18, or his designee received the 2nd Medicare Important Message prior to his discharge.

C. 1. Closed medical record review revealed Patient #14 was a 79-year-old female admitted to the facility on 11/08/2019 with a diagnosis of acute kidney injury and bladder hemorrhage. Review confirmed Patient #14 was a Medicare patient. Patient #14 was discharged to a rehabilitation facility on 11/13/2019 and review revealed no evidence Patient #14, or her designee received a physical copy of the 2nd Medicare Important Message prior to discharge.

Staff Interview was conducted with the Director of Complex Discharges on 07/20/2021 at 1315. Interview revealed when a patient is discharged to another facility, common practice is if the designee is not physically present to receive the 2nd Medicare Important Message, it is provided via telephone, and the physical copy of the message was sent to the receiving facility in the patient's discharge paperwork. Interview confirmed there was no evidence Patient #14, or her designee was provided, or mailed a copy of the 2nd Medicare Important Message prior to her discharge.

2. Closed medical record review revealed Patient #15 was a 94-year-old female admitted to the facility on 06/27/2021 with a diagnosis of acute pancreatitis. Review confirmed Patient #15 was a Medicare patient. Patient #15 was discharged to a rehabilitation facility on 07/06/2021 and revealed no evidence Patient #15, or her designee received a physical copy of the 2nd Medicare Important Message prior to discharge.

Staff Interview was conducted with the Director of Complex Discharges on 07/20/2021 at 1315. Interview revealed when a patient is discharged to another facility, common practice is if the designee is not physically present to receive the 2nd Medicare Important Message, it is provided via telephone, and the physical copy of the message was sent to the receiving facility in the patient's discharge paperwork. Interview confirmed there was no evidence Patient #15, or her designee was provided, or mailed a copy of the 2nd Medicare Important Message prior to her discharge.

3. Closed medical record review revealed Patient #16 was a 104-year-old female admitted to the facility on 06/23/2021 with a diagnosis of acute metabolic encephalopathy. Review confirmed Patient #16 was a Medicare patient. Review revealed Patient #16 was discharged to a rehabilitation facility on 07/08/2021 and revealed no evidence Patient #16, or her designee received a physical copy of the 2nd Medicare Important Message prior to discharge.

Staff Interview was conducted with the Director of Complex Discharges on 07/20/2021 at 1315. Interview revealed when a patient is discharged to another facility, common practice is if the designee is not physically present to receive the 2nd Medicare Important Message, it is provided via telephone, and the physical copy of the message was sent to the receiving facility in the patient's discharge paperwork. Interview confirmed there was no evidence Patient #16, or her designee was provided, or mailed a copy of the 2nd Medicare Important Message prior to her discharge.

4. Closed medical record review revealed Patient #17 was a 94-year-old male admitted to the facility on 07/12/2021 with a diagnosis of transient ischemic attack. Review confirmed Patient #17 was a Medicare patient. Patient #17 was discharged to a rehabilitation facility on 07/15/2021 and review revealed no evidence Patient #17, or his designee received a physical copy of the 2nd Medicare Important Message prior to discharge.
Staff Interview was conducted with the Director of Complex Discharges on 07/20/2021 at 1315. Interview revealed when a patient is discharged to another facility, common practice is if the designee is not physically present to receive the 2nd Medicare Important Message, it is provided via telephone, and the physical copy of the message was sent to the receiving facility in the patient's discharge paperwork. Interview confirmed there was no evidence Patient #17, or his designee was provided, or mailed a copy of the 2nd Medicare Important Message prior to her discharge.

NC00179051; NC00177777