HospitalInspections.org

Based on document review and interview, the facility failed to ensure the Important Message from Medicare (IMM) contained the required contact information for the Quality Improvement Organization (QIO) for twelve out of twelve (P-1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12) medical records reviewed resulting in the potential for denying all discharged and current Medicare patients their right to report concerns to the QIO. Findings include:

On 1/30/2024 and 1/31/2024 during medical record review, it was revealed that the IMM for 12 out of 12 records reviewed did not have the Quality Improvement Organization (QIO) information included. The area designated on the form under "Rights as a Hospital Inpatient" was not complete and had "(insert QIO name and toll-free number of QIO)" rather than the actual contact information for the QIO.

During an interview with the Director of Revenue Cycle, Staff M on 1/30/2024 at 1451 the IMM was reviewed. Staff M agreed the IMM was incomplete and the QIO name and toll-free number were not provided as the form states and as required. Staff M stated she is responsible for making sure the information on the IMM is correct and would have the form revised immediately. An updated and corrected IMM was provided prior to departure from facility on 1/31/2024. It was also observed the new form was being utilized in the Emergency Department for patients and includes QIO address and phone number.

On 1/31/2023 at 0900 review of policy titled Patient/Resident Bill of Rights, Policy #002.18J, effective May 26, 2021 states under Purpose, "...will inform patients, staff, and visitors of the rights of all patients who receive care at the organization."