The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

OLD VINEYARD YOUTH SERVICES 3637 OLD VINEYARD ROAD WINSTON SALEM, NC 27104 March 14, 2019
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and staff interviews, the facility failed to provide a copy of the Important Message from Medicare to patients/patient representatives within forty-eight hours of discharge from the facility for 2 of 2 Medicare beneficiary patients reviewed. (Patient #3, and Patient #6).

The findings included:

Review of the "An Important Message from Medicare About Your Rights" (IM), expiration date 03/31/2020 revealed "As a hospital inpatient, you have the right to: Receive Medicare covered services ...Be involved in any decisions about your hospital stay ...If you think you are being discharged too soon: You can talk to the hospital staff, your doctor ...about your concerns. You also have the right to an appeal ...If you want to appeal, you must contact the QIO (Quality Improvement Organization) no later than your planned discharge date , and before you leave the hospital ..."

Review of the facility's "Administrative Policies and Procedures" dated 03/14/2013, "Nursing Services Policy and Procedure (sic)" dated 11/21/2018, and "Interdisciplinary Policies and Procedures" dated 03/18/2013 revealed no evidence of a facility policy related to the IM.

1. Review of the medical record revealed the patient, Patient #3, was a [AGE] year old male admitted to the facility under an involuntary commitment (IVC) order on 01/23/2019 for suicidal ideation and alcohol abuse. Review of the admission paperwork revealed the presence of the facility "Patient Bill of Rights," and "An Important Message from Medicare About Your Rights." Review revealed the IM was stamped with the words "Patient Refused" and signed by a nurse on 01/23/2019 at 1200. Review revealed Patient #3 was discharged from the facility with continued outpatient psychiatric services on 02/07/2019. Review of the record revealed no documentation that a copy of the IM was provided to Patient #3, or discussed with his caregivers prior to discharge.

Interview on 03/14/2019 at 0945 with the Director of Clinical Services (CM #1) revealed the IM was provided with an intake packet at the time of admission which contained the IM, the patient was asked to sign the acknowledgement of receipt for each form, and if the patient refused to sign, the form was stamped "refused to sign" and the reason for refusal was indicated on the admission forms. Interview revealed staff had not been trained to provide the IM again to patients or support persons prior to discharge.

2. Review of the medical record revealed Patient #6, was a [AGE] year old male admitted to the facility under an involuntary commitment (IVC) order on 01/25/2019 for suicidal ideation. Review of the admission paperwork revealed the presence of the facility "Patient Bill of Rights" and "An Important Message from Medicare About Your Rights (IM)." Review revealed the IM was stamped with the words "Patient Refused" and signed by a nurse on 01/25/2019 at 1330. Review revealed Patient #6 was discharged from the facility with continued outpatient psychiatric services on 02/05/2019. Review of the record revealed no documentation that a copy of the IM was provided to Patient #6 or discussed with his caregivers prior to discharge.

Interview on 03/14/2019 at 0945 with the Director of Clinical Services (CM #1) revealed the IM was provided with the intake packet at the time of admission, the patient was asked to sign the acknowledgement of receipt of the information, and if the patient refused to sign, the form was stamped "refused to sign" and the reason for refusal was indicated on the admission forms. Interview revealed staff had not been trained to provide the IM again to patients/support persons prior to discharge.

NC 613
NC 898
NC 140