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Based on review of facility policy, medical records (MR), and staff interviews (EMP), it was determined the facility failed to provide the Important Message from Medicare to Medicare patients in a timely manner in keeping with the facility policy for three of seven medical records reviewed (MR15, MR16 and MR21).

Findings include:

Review of the "Important Message from Medicare (IMM)" policy reviewed January 2015, revealed, "I. During the admission process an admissions representative will provide the patient or his/her representative the Important Message from Medicare (IMM) for review and signature. ... If the patient is coming from OR this form will be initiated in outpatient registration. The IMM must be provided at admission but no later than two calendar days following the date of the admission to the hospital. ...III. If the beneficiary or his/her representative's signature is not able to be obtained within two business days, the attempts for signature must be documented on the notice. ...VIII. If the discharge is unanticipated, the second notice can be given on the day of discharge or as early as possible allowing for ample time for the patient or beneficiary to be aware of their rights."

1. On June 17, 2015, at approximately 12:00 PM review of MR15 revealed the patient was admitted to the facility on June 3, 2015, and discharged June 11, 2015. The medical record indicated the patient's medical status was unstable at the time of admission. However the patient was much improved by June 4, was alert and oriented and participated in the plan of care throughout the rest of the admission.

The IMM said the patient was unable to sign due to medical condition. There were no signatures of either the patient or the patient's representative within 48 hours of admission or at the time of discharge. There was no other documentation to indicate that attempts were made to obtain a signature on this document.

On June 17, 2015, at approximately 2:30 PM, EMP1 confirmed the IMM for this patient was unsigned.

2. On June 17, 2015, at approximately 12:20 PM review of MR16 revealed the patient was admitted to the facility on June 8, 2015, and discharged on June 12, 2015. Further review of the record revealed the patient's representative was involved in making decisions regarding the patient's plan of care.

The IMM was dated June 8, 2015, and stated the patient was unable to sign due to medical condition. There was no indication the patient representative was made aware of the patient's rights under the Important Message from Medicare. There was no documentation to indicate that attempts had been made to obtain a signature on this document.

On June 17, 2015, at approximately 2:30 PM EMP1 confirmed the IMM for this patient was unsigned.

3. On June 17, 2015, at approximately 1:45 PM review of MR21 revealed the patient was admitted to the facility on May 16, 2015, and was still currently an inpatient. In the front of the patient's medical record was an IMM which was dated May 17, 2015. The form was not signed by the patient or the patient's representative at the time of the observation.

EMP5 confirmed the above findings at the time of the observation.

Based on review of facility policy and medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure documentation related to the patient's discharge evaluation and plan was made available for review by other disciplines on the medical record in one of 11 medical records reviewed (MR21).

Findings include:

Review of the "Discharge Planning" policy reviewed January 2015 revealed, "Social Work Services will chart all findings and plans for discharge planning on the Medical Record form #CP-SS-002 and CP-SS-003, to keep the treatment team abreast of the discharge plans."

1. On June 17, 2015, at approximately 1:45 PM a review of MR21 revealed the patient was admitted to the facility on May 16, 2015, and was currently still an inpatient.

Continued review of the medical record revealed there was no Case Management or Social Worker documentation on the medical record.

2. At the time of the MR review, EMP15 provided the surveyor with a packet of papers with hand written documentation related to the patient's discharge plan.

3. At the time of the review EMP5 and EMP15 confirmed there was no documentation on the patient's medical record related to discharge planning.

Based on medical record review (MR) and staff interview (EMP), it was determined the facility failed to ensure there was documented evidence in the medical record that the patient or his/her representative was provided freedom of choice (FOC) related to selection of either a Home Health Agency (HHA) or Skilled Nursing Facility (SNF) for ongoing care post-discharge for one of seven medical records reviewed (MR19).

Findings include:

1. On June 17, 2015, at approximately 1:30 PM a request was made to review a facility policy related to the provision of FOC. None was provided.

2. On June 17, 2015, at approximately 12:00 PM review of MR19 revealed the patient was admitted to the facility on June 11, 2015, and discharged to a SNF on June 13, 2015. There was no FOC form identified on the medical record.

3. On June 17, 2015, at approximately 2:30 PM, EMP1 confirmed there was no FOC form on this medical record.

4. On June 18, 2015, at approximately 9:50 AM, EMP1 confirmed the facility has no written policy or procedure related to providing patients FOC or documenting the same.