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Based on record review and interview, the facility failed to provide copies of the "Important Message from Medicare" (IM) for for five (5) patients (#1, #8, #21, #26 and #28) of the sampled twenty-one (21) patients.

Findings include:

The policy (CM-502) titled: "Notifying Patients of Discharge Appeal Rights" was reviewed. This letter is given to patients or their representatives to inform them of their right to appeal an early discharge from the hospital. Review of page two of the policy revealed, that either the registration clerk in admissions or (after hours) the ER clerk 'will inform the beneficiary or their representative of the process and will obtain the required signature". Upon discharge the "original IM will be sent home with the patient" and "the copy of the IM will be filed with the patient's permanent medical record."

Review of the following patient medical records revealed patients #1, #8, #21, #26 and #28 had no evidence of the IM.

Interview on 1/9/14 at 10:00 a.m., the Process Improvement Officer confirmed the findings.

Based on record review and interview, the facility failed to assure that the physician had ordered a discontinuation of restraints for two (2) patients (#9 and #29) of the twenty-one (21) sampled patients.

Findings include:

Review of the facility's policy #PC-034 entitled, "Restraints, Acute Medical/Surgical", revised on 07/2012, revealed a physician order is required to discontinue the use of restraints.

Record review of patient #9 and patient #29, revealed no evidence of a physicians' order to discontinue the use of restraints.

Interview on 01/09/2014 at 9:30 a.m., the director of quality assurance confirmed the findings.

Based on facility records and interviews the facility failed to have Utilization Review (UR) Committee.

Findings include:

Review of the Utilization Management Plan, revision date of 09/2013, revealed that the facility has an organized UR program, adopted by the Medical Executive Staff, to assure the appropriate allocation of resources and to provide quality patient care in a cost-effective manner. Corporate, Senior Administration and Medical Executive Committees have the responsibility for the UR Committee. The UR is recognized as a section of the overall Performance Improvement Plan, and will report to the Medical Executive Committee quarterly and/or as needed. Review of page 3 revealed that the Medical Executive Committee will appoint the UR Committee members.

Conitnued review revealed the committee will include two physicians, one of which will serve as chairperson, others will serve as physician advisors and will act on behalf of the UR Committee. Review of page 4, revealed that other non-physician members may include representatives from Case Management, the CNO, the CFO, Patient Care Services Risk Management/Quality Improvement, Infection Control, Business Office, Admission Department and others as determined. Continued review of page 4 revealed that "Frequency of Meetings" will be held at least quarterly (four times a year)".

Review of the UR Committer Minutes dated 02/21/2013, revealed that the minutes of 06/12/2012 were approved, however there was no evidence that any other meetings had been conducted.

Interview on 1/8/14 at 10:30 a.m. the Director of Case Management (DCM)
confirmed that the UR committee is directed to meet quarterly. The DCM confirmed that there were no additional meetings during the year of 2013. The DCM revealed, that new members have not been appointed for 2014 and discussions had included out-sourcing the UR function, but no final decision had been made.