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Based on medical record review and document review, it was determined that the facility failed to adequately promote the rights of patients. Findings include:

The facility failed to inform patients of their rights in advance to providing care [see A 117].
The facility failed to provide patients with the information for filing a complaint/grievance [ see A 118].
The facility failed to identify a process for timely referral of patient concerns regarding quality of care to the Utilization and Quality Control Improvement Organization. [A 120].
The facility failed to provide care in a safe setting [see A 144].

Based on interview and medical record review the facility failed to inform 9 of 17 Medicare patients (patients #10-12, #15-17, #19-21) of their discharge appeal rights as stated in "An Important Message from Medicare." Findings include:

On 10/7/10 from 1400-1800, record review revealed that current patients #10 (admitted 9/28/10) and #11 (admitted 10/4/10) did not have documentation that a copy of "An Important Message from Medicare" had been provided to the patients upon admission. Patient #12 (admitted 10/1/10) had been discharged. Patient #12 had documentation that only one (provided at admission) of two required notifications of "An Important Message from Medicare" were provided. Documentation of provision of the second notice, to be provided at discharge, was not provided. On 10/7/10 from 1400-1800, these findings were verified by the Director of Nursing.



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On 10/7/10 from 1400-1800, record review revealed that patient #15 (admitted 09/03/10) had a copy of the Important Message from Medicare (IMM) in their record that was signed but not dated making it so this surveyor is unable to determine if the document was signed within the requirements of 2 calendar days of admission. Patients #16 (admitted 09/28/10), patient #17 (admitted 09/15/2010), patient #19 (admitted 10/02/2010) and patient #20 (admitted 09/23./2010) did not have documentation that a copy of the IMM had been provided to the patients upon admission. Patient #21's (admitted 09/23/10) and (discharged on 10/04/2010) record did not contain an IMM for the time of admission or discharge. On 10/7/10 from 1400-1800, the Director of Programing was unable to locate any further documentation regarding these patients IMM so the findings were verified at this time.

Based on interview, document review, and observation, the hospital failed to inform admitted patients whom to contact to file a grievance. Findings include:

During observation of the 4 South and 4 North units on 10/07/2010 at 1230, postings to inform medicare patients on how to file a grievance with the State of Michigan were reviewed. The findings revealed a document that contained a phone for the CMS 800 complaint hotline but did not identify it as such.

Interview with Director of Programing at time of observation he confirmed that this was the notification to patients for filling a grievance.



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During observations of the 2 North and 3 North units on 10/07/2010 at 1230, postings to inform Medicare patients on how to file a grievance with the State of Michigan were reviewed. A document under the heading "Call 1-800 Medicare 1-800-882-6006 To:" contained a phone number for the CMS 800 complaint hotline was posted but did not identify it as such. The Director of Nursing confirmed these observations.

Based on policy review the facility failed to provide evidence of a grievance process that included a mechanism for timely referral of patient concerns regarding quality of care to the Utilization and Quality Control Quality Improvement Organization. Findings include:

A policy titled "Recipient Rights" speaks of a patient's right to request referral of a quality concern to the Michigan Quality Improvement Organization but does not specify the facility's responsibility in the referral process.

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-710.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on November 5, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated April 29, 2010, for Life Safety Code.