HospitalInspections.org

Based on review of the facility policy and procedures, medical record review and hospital staff interviews, the hospital staff failed to demonstrate evidence of the provision of the "Important Message from Medicare" to the patient and/or the designated medical decision maker for the patient (Patient #1,4,7,8 and 11).

The findings included:

Review of the hospital policy, Important Message from Medicare (IMM) last approved 06/16/2020 revealed, "PURPOSE: It is the policy of (Named Hospital) to provide all Medicare patients with the Important Message from Medicare form upon to admission of the hospital. POLICIES: (Named Hospital) business office employees will use the following policy in obtaining signature of the Important Message from Medicare and then representing form to patient prior to discharge. 1. The Registration Clerk will obtain a signature form from all Medicare patients being admitted to inpatient services ....3. Case Management will present to the patient within two calendar days of discharge ..."

1. Medical record review revealed Patient #1 presented to the Emergency Room (ER) on 10/30/2022 with a chief complaint of COVID-19, increased weakness. Review revealed Patient #1 was an 86-year-old female admitted to the hospital for treatment under Medicare insurance. Record review revealed a "Next to Kin/family member" was documented in the medical record. Record review revealed the Registration Staff member documented "COVID POSITIVE" on the Important Message from Medicare form. Review of the medical record failed to reveal evidence of provision of the Important Message from Medicare within 48 hours of admission.

Interview with the Director of Business Services and Revenue Cycle on 11/03/2022 at 0950 revealed the Director had worked at the hospital over 27 years. Interview revealed the Business Services and Revenue cycle was the department that handled the registration process. Interview revealed the staff would obtain Informed Consent and Important Message from Medicare forms with patient or Next to Kin signature to be included in each Medicare insured patient's medical record. Interview revealed the registration staff were responsible for the provision of the admission IMM and Case Management staff were responsible to provide the IMM within 2 days prior to the discharge of the patient. Interview revealed there were several medical records included in the survey sample that failed to demonstrate evidence of compliance with the regulatory requirements.

Telephone interview with the Registration staff member on 11/03/2022 at 1455 revealed the Registration staff member had worked at the hospital for approximately 21 years. Interview revealed the process was for the Registration staff member to obtain the signature of the patient or the Next to Kin/family member for the provision of the admission Important Message from Medicare document for admitted patients under Medicare insurance. Interview revealed the registration staff were responsible for the provision of the admission IMM and Case Management staff were responsible to provide the IMM within 2 days prior to the discharge of the patient. Interview revealed there was a process to inform and obtain the signature of the Next to Kin/family member on the document for Important Message in the event the patient was unable to sign for themselves.

2. Medical record review revealed Patient #4 presented to the Emergency Room (ER) on 08/02/2022 with chief complaint of Tachycardia (rapid beating of the heart), chest pain and shortness of breath. Review revealed Patient #4 was admitted to the hospital for treatment under Medicare insurance. Record review revealed a "Next to kin/family member" was documented in the medical record. Record review revealed the Registration Staff member documented (not dated or timed) "PT UNABLE TO SIGN ... (named initials) on the Important Message from Medicare form. Review of the medical record failed to reveal evidence of the delivery of the Important Message from Medicare within 48 hours of admission.

Interview with the Director of Business Services and Revenue Cycle on 11/03/2022 at 0950 revealed the Director had worked at the hospital over 27 years. Interview revealed the Business Services and Revenue cycle was the department that handled the registration process. Interview revealed the staff would obtain Informed Consent and Important Message from Medicare forms with patient or Next to Kin signature to be included in each Medicare insured patient's medical record. Interview revealed the registration staff were responsible for the provision of the admission IMM and Case Management staff were responsible to provide the IMM within 2 days prior to the discharge of the patient. Interview revealed there were several medical records included in the survey sample that failed to demonstrate evidence of compliance with the regulatory requirements.

Telephone interview with the Registration staff member on 11/03/2022 at 1455 revealed the Registration staff member had worked at the hospital for approximately 21 years. Interview revealed the process was for the Registration staff member to obtain the signature of the patient or the Next to Kin/family member for the provision of the admission Important Message from Medicare document for admitted patients under Medicare insurance. Interview revealed the registration staff were responsible for the provision of the admission IMM and Case Management staff were responsible to provide the IMM within 2 days prior to the discharge of the patient. Interview revealed there was a process to inform and obtain the signature of the Next to Kin/family member on the document for Important Message in the event the patient was unable to sign for themselves.

3. Medical record review revealed Patient #7 presented to the ER on 10/26/2022 with a chief complaint of concern for dehydration due to COVID. Record review revealed Patient #7 was a 70-year-old male admitted to the hospital for treatment under Medicare insurance. Record review revealed a "Next to Kin/family member" was documented in the medical record. Record review revealed the Registration Staff member documented on 10/26/2022 at 0704 "pt. unable to sign COVID POSITIVE" on the Important Message from Medicare form. Review of the medical record failed to reveal evidence of provision of the Important Message from Medicare within 48 hours of admission and within 48 hours prior to discharge for Patient #7 in the medical record.

Interview with the Director of Business Services and Revenue Cycle on 11/03/2022 at 0950 revealed the Director had worked at the hospital over 27 years. Interview revealed the Business Services and Revenue cycle was the department that handled the registration process. Interview revealed the staff would obtain Informed Consent and Important Message from Medicare forms with patient or Next to Kin signature to be included in each Medicare insured patient's medical record. Interview revealed the registration staff were responsible for the provision of the admission IMM and Case Management staff were responsible to provide the IMM within 2 days prior to the discharge of the patient. Interview revealed there were several medical records included in the survey sample that failed to demonstrate evidence of compliance with the regulatory requirements.

Telephone interview with the Registration staff member on 11/03/2022 at 1455 revealed the Registration staff member had worked at the hospital for approximately 21 years. Interview revealed the process was for the Registration staff member to obtain the signature of the patient or the Next to Kin/family member for the provision of the admission Important Message from Medicare document for admitted patients under Medicare insurance. Interview revealed the registration staff were responsible for the provision of the admission IMM and Case Management staff were responsible to provide the IMM within 2 days prior to the discharge of the patient. Interview revealed there was a process to inform and obtain the signature of the Next to Kin/family member on the document for Important Message in the event the patient was unable to sign for themselves.

4. Medical record review revealed Patient #8 presented to the ER on 03/13/2022 with a chief complaint of general weakness. Review revealed Patient #8 was a 75-year-old male admitted to the hospital for treatment under Medicare insurance. Record review revealed a "Next to Kin/family member with contact telephone number" was documented in the medical record. Record review revealed the Registration Staff member documented "UNABLE TO SIGN" on the Important Message from Medicare form. Review failed to reveal evidence of provision of the Important Message from Medicare within 48 hours of admission and within 48 hours prior to discharge of Patient #8 in the medical record.

Interview with the Director of Business Services and Revenue Cycle on 11/03/2022 at 0950 revealed the Director had worked at the hospital over 27 years. Interview revealed the Business Services and Revenue cycle was the department that handled the registration process. Interview revealed the staff would obtain Informed Consent and Important Message from Medicare forms with patient or Next to Kin signature to be included in each Medicare insured patient's medical record. Interview revealed the registration staff were responsible for the provision of the admission IMM and Case Management staff were responsible to provide the IMM within 2 days prior to the discharge of the patient. Interview revealed there were several medical records included in the survey sample that failed to demonstrate evidence of compliance with the regulatory requirements.

Telephone interview with the Registration staff member on 11/03/2022 at 1455 revealed the Registration staff member had worked at the hospital for approximately 21 years. Interview revealed the process was for the Registration staff member to obtain the signature of the patient or the Next to Kin/family member for the provision of the admission Important Message from Medicare document for admitted patients under Medicare insurance. Interview revealed the registration staff were responsible for the provision of the admission IMM and Case Management staff were responsible to provide the IMM within 2 days prior to the discharge of the patient. Interview revealed there was a process to inform and obtain the signature of the Next to Kin/family member on the document for Important Message in the event the patient was unable to sign for themselves.

5. Medical record review revealed Patient #11 presented to the ER on 10/28/2022 with a chief complaint of respiratory distress. Record review revealed Patient #11 was a 79-year-old male admitted to the hospital for treatment under Medicare insurance. Record review revealed a "Next to Kin/family member" was documented in the medical record. Record review revealed the Registration Staff member documented "PT UNABLE TO SIGN" on the Important Message from Medicare form. Review of the medical record failed to reveal evidence of provision of the Important Message from Medicare within 48 hours of admission and prior to 48 hours of discharge for Patient #11 in the medical record.

Interview with the Director of Business Services and Revenue Cycle on 11/03/2022 at 0950 revealed the Director had worked at the hospital over 27 years. Interview revealed the Business Services and Revenue cycle was the department that handled the registration process. Interview revealed the staff would obtain Informed Consent and Important Message from Medicare forms with patient or Next to Kin signature to be included in each Medicare insured patient's medical record. Interview revealed the registration staff were responsible for the provision of the admission IMM and Case Management staff were responsible to provide the IMM within 2 days prior to the discharge of the patient. Interview revealed there were several medical records included in the survey sample that failed to demonstrate evidence of compliance with the regulatory requirements.

Telephone interview with the Registration staff member on 11/03/2022 at 1455 revealed the Registration staff member had worked at the hospital for approximately 21 years. Interview revealed the process was for the Registration staff member to obtain the signature of the patient or the Next to Kin/family member for the provision of the admission Important Message from Medicare document for admitted patients under Medicare insurance. Interview revealed the registration staff were responsible for the provision of the admission IMM and Case Management staff were responsible to provide the IMM within 2 days prior to the discharge of the patient. Interview revealed there was a process to inform and obtain the signature of the Next to Kin/family member on the document for Important Message in the event the patient was unable to sign for themselves.
NC00187986