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Based on interviews and record review, the facility failed to follow the discharge planning process in 1 of 10 medical records reviewed (Patient #4). Specifically, the facility failed to ensure the patient was not discharged after an appeal had been filed.

The failure created the potential for patients to be discharged too early and the increased the risk for readmission.

FINDINGS:

POLICY:

According to the facility document, Medicare Notice of Rights Regarding Discharge (Important Message from Medicare), when a Medicare beneficiary requested a Quality Improvement Organization (QIO) appeal of the decision to discharge, the beneficiary would not be discharged prior to the outcome of the appeal process, which included notification from the QIO that discharge is appropriate. The information about discharge appeals rights would be explained to the beneficiary.

REFERENCE

According to the Centers for Medicare and Medicaid Services (CMS) document, An Important Message From Medicare About Your Rights (CMS-R-193), Medicare beneficiaries have the right to a safe discharge and to be part of the decision to discharge. Additionally, in the event a Medicare beneficiary believes they are being discharged too soon, the beneficiary has the right to file an appeal and have their case reviewed by an outside Quality Improvement Organization (QIO) hired by Medicare. Once the beneficiary speaks to someone at the QIO or leaves a message, the appeal has begun.

1. The facility failed to consider the patient's readiness for discharge to ensure a safe transition of care after the Medicare patient filed an appeal to the discharge.

a) On 10/21/15, a review of Patient #4's medical record review was conducted. Patient #4 was admitted on 05/12/15, and discharged on 05/16/15. A discharge summary written by Medical Doctor (MD) #1, dated 05/16/15 at 9:36 a.m., noted the patient was to contact the offices of outpatient physicians for appointment scheduling.

A progress note written by MD #1 dated 05/16/15, at 4:02 p.m., stated, "later informed that patient speaking with Administrative Representative [AR] and wants to appeal d/c [discharge] home."

An addendum titled, Discharge Summary, dated 05/16/15, at 4:02 p.m., written by MD #1 state a discussion regarding Patient #4's elevated blood sugars occurred and Patient #4 was concerned about going home without the ability to monitor his/her blood sugar levels. According to MD #1's documentation, Patient #4 did not need to check blood sugars and needed to meet his/her primary care physician for further management. In addition, MD #1 stated Patient #4 was in agreement of discharge.

Patient #4 was discharged from the facility at 3:59 p.m., on 05/16/15. There was no documentation, within the record of Patient #4, to show that anyone discussed Medicare rights of appeal with Patient #4. Furthermore, there was no documentation, within the medical record, that shows Patient #4 reversed the appeal process.

b) A grievance response letter, dated 07/08/15, sent to Patient #4 listed the patient's concerns which included the patient thought the discharge was occurring earlier than expected; the patient did not feel ready to be discharged; and the patient started an appeal with Medicare.

The grievance response letter stated the investigation had been completed and acknowledged that MD #1 confirmed Patient #4 had filed an appeal against the discharge on Saturday, 05/16/15 prior to discharge.

c) An interview was completed on 10/21/15, at 1:26 p.m., with the Director of Case Management (CM #2). CM #2 stated that when a Medicare beneficiary stated they had requested an appeal of the discharge, the process of discharge was suppose to stop. CM #2 further stated the beneficiary did not need to sign anything to state an appeal had been filed and only needed to verbalize an appeal was requested. CM #2 also stated the Administrative Representative (AR) was able to manage the appeal process when case managers were not present in the facility.

d) On 10/22/15 at 8:50 a.m. during an interview with AR #7 s/he stated the house supervisors had no involvement with paperwork or patient contact when a Medicare appeal was filed and the house supervisor was only made aware of the situation. S/he further stated the process was the responsibility of the assigned registered nurse (RN) and case management (CM).

At 9:58 a.m., on 10/22/15, an interview was conducted with Registered Nurse (RN) #4. RN #4 stated s/he was unaware of the process when a patient filed an appeal with Medicare to prevent a discharge.

On 10/22/15 at 10:02 a.m. an interview was conducted with RN #5. RN #5 stated when a patient appealed a discharge the RN notified the AR and the treating physician. RN #5 stated the AR handled the additional steps of the process. RN #5 further stated if the patient was unsure whether they truly wanted to file an appeal, s/he might discuss the patient's concerns and try to work through them, but if the patient was sure of their decision to file an appeal then s/he provided the appeal information. Additionally, RN #5 stated s/he was unaware of where to document the patient's decision to appeal, but the AR would be expected to document the information.

On 10/22/15 at 10:05 a.m. the Regulatory Consultant (RC #6) stated "we realize we don't have a good process for handling appeals" and the facility will "take the hit."