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5501 OLD YORK ROAD

PHILADELPHIA, PA 19141

PATIENT RIGHTS: NOTICE OF RIGHTS

Tag No.: A0117

Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined that the facility failed to provide Medicare beneficiaries with an "Important Message from Medicare" on admission and within two calendar days (48 hours) of discharge from the facility for one of four medical records reviewed (MR1).

Findings include:

A review of Facility Document "Important Message from Medicare [IMM]," reviewed May 27, 2009, revealed "...Purpose: To establish a process to ensure patients are properly notified of their Medicare appeal rights in compliance with CMS regulations...Procedures...The admitting registrar will provide the IMM to all eligible Medicare and Medicare HMO recipients and obtain a signature from the patient of [sic] next of kin (NOK)...The original (white) and yellow copy of the IMM must be retained with the clinical record and sent to the floor with the admissions paperwork...If a patient or NOK refuses to or is unable to sign the IMM, the registrar must clearly document that on the IMM, sign, and date it...The yellow IMM notice will be given to the patient by Case Management no more than 2 days prior to discharge when the length of stay exceeds two days. Patient must sign the original (white) copy...If a patient or NOK is unable to or refuses to sign the IMM, a second attempt will be made to deliver the IMM by Case Management..."

1) A review on September 12, 2011, of MR1 revealed the patient (PT1) was admitted to the facility on December 28, 2010, July 14, 2011, August 10, 2011, and September 1, 2011. A further review of the patient's medical records admissions on December 28, 2010, July 14, 2011, August 10, 2011, and September 1, 2011, revealed no documented evidence that the IMM was given to the patient on admission.

2) A request on September 12, 2011, for IMM's for PT1's admissions for December 28, 2010, July 14, 2011, August 10, 2011, and September 1, 2011, revealed there was no documentation that the patient was given IMM notice.

An interview conducted on September 12, 2011, at approximately 1:00 PM with EMP1 confirmed that the IMM's for the PT1's admissions on December 28, 2010, July 14, 2011, August 10, 2011, and September 1, 2011, were not available.