HospitalInspections.org

Based on document review, medical record (MR) review and interview, in 3 of 12 (Patient #3, Patient #4, and Patient #5) MRs reviewed for Medicare beneficiary patients, the hospital did not ensure the required form titled "The Important Message From Medicare" (IM) was provided to the patients within 2 days of admission as required. This could cause patients and/or their representatives to be unaware of their patient rights.

Findings include:

-- Review of the hospital's policy and procedure (P&P) titled "Important Message From Medicare (IM or IMM)," dated 1/2018, indicated all Medicare beneficiaries should be provided the IM. The hospital should explain and obtain the signature from the patient or their representative on the IM form on admission or within 2 days of admission by Patient Access. If the form is not signed on admission, Patient Access staff should communicate to clinical staff that the form needs to be signed by the patient or representative. Hospitals should place a copy of the initial notice in the patient's MR.

-- Review of Patient #3's MR revealed, she was admitted on 8/31/2023. There was no signed IM form as of 9/28/2023 (29 days after admission).

-- Review of Patient #4's MR revealed, she was admitted on 9/14/2023. There was no signed IM form as of 9/28/2023 (15 days after admission).

-- Review of Patient #5's MR revealed, she was admitted on 9/25/2023. There was no signed IM form as of 9/28/2023 (3 days after admission).

-- Per interview of Staff K, Director Quality Improvement on 9/28/2023 at 3:00 pm, Corporate Compliance has been auditing 50 MR quarterly for missing IM forms 48 hours after admission since 1/2023. They have not met their target goal of 100 percent. He/she acknowledged the above findings.