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Based on interviews and the review of medical record and other documents, the facility failed to demonstrate compliance with Medicare requirements for the provision of Medicare admission and discharge (IM) notices to patients/representatives within regulatory timeframes. This finding was noted in 4 of 8 medical record reviewed.

Findings include:

MR # 1 was admitted on 9/22/11. The patient's medical history was significant for respiratory failure, cardiac arrest and anoxic brain injury. The facility staff on 9/27/11 documented that the patient is unable to sign the "Important Message from Medicare." Further review found that the patient's children were actively involved in decision making. The daughter signed the general admission consent form on 9/26/11 and consented for an EGD on 3/1/12. There was no evidence that the facility furnished the patient's representative with the information contained in the IM.

CMS requirements include specific criteria for the mode and timeframes for delivery of the Important Message from Medicare (IM) to patients or their representatives. CMS mandates IM provision within 48 hours of admission and requires that a follow up notification be issued within 48 hours in advance of discharge, but not less than four hours prior to discharge.

MR # 2 was admitted on 9/15/10. The General Admission Consent and the IM notice were not acknowledged due to the patient's vegetative state. The admission package which includes the Important Message from Medicare was sent to the patient's mother on 1/11/12, more than a year after the patient's admission. At interview with the Head Nurse, he stated that the patient's mother visited until sometime in 2011 when she became ill. However she calls the unit daily.

MR # 3 is a 79 year-old with medical history of COPD and is ventilator dependent. At interview with the Head Nurse on 8/3/12, it was stated that the patient is awake, oriented to place and person but non verbal. The patient signed his admission consent on 8/15/11. However, the Important Message from Medicare was not acknowledged. There was no indication that the information contained in the IM form was furnished to the patient or his son who is listed as the patient's next of kin.

Similar finding was noted in MR # 4 who was readmitted to the facility on 1/26/12 after a short hospital stay for the treatment of diabetic foot abscess. The patient is alert and oriented to place, person and time. The IM was not furnished within the stipulated time frame. The signature of the patient was dated 2/1/12, six days after admission.

Based on record review, it was determined that the facility did not consistently ensure that all patients' care plans were revised to meet the patients' psychological and medical needs. In addition, the facility did not effectively ensured that all patients were involved in their plan of care.
Findings include:
Review of MR # 5 on 8/2/12 noted that this patient was a 44 year male with a medical history that included Alcoholism, Head Trauma and Seizures. The patient was transferred from this facility to an acute care facility on 12/11/11 for ETOH intoxication. After completing the required substance abuse protocol, the patient was readmitted on 12/14/11 for continuing care of his medical problems.
It was noted that a psychiatrist consultation was requested on 12/15/11. The reason for the consultation was evaluation for further management. The Specialist consultation's opinion/recommendation was dated 12/16/11. The opinion/recommendations were:
1. Substance abuse group 2. Trazodone 50 mg po qhs and 3.Referral to behavior management.
It was noted that on 12/15/11 in the night (around 7:40 PM), the patient had a physical altercation with another patient. The decision was made to transfer the patient to another unit. There was no documentation that there was a psychiatrist follow-up to re- assess the patient's behavior or the reason why this was not necessary.
The Interdisciplinary Care Plan for this patient was reviewed. It was noted that the treatment plan was not revised to include the patient's behavior problems and substance problem. There was no documented evidence that the patient attended any behavioral management program.
It was noted that there were several Interdisciplinary Care Plan (ICP) meetings on 12/15/11, 12/20/11 and 1/24/12 to address the patient's behavior, but the patient did not attend these meetings. It was noted that there were no steps taken to ensure that the patient attend these meetings. There was no documentation that the patient was informed of the consequences for not attending these meetings.
On 12/21/11, the transfer MD noted "will re consult psychiatry if patient continue to alcohol to excess and adverse consequences". There was no documentation in the record that the patient was revaluated by a psychiatrist.
It was noted that on 1/27/12, the substance counselor noted that the patient was seen in the group but the patient was Spanish speaking, " he would not benefit for group because translation is present unavailable". The counselor also noted that the patient was well known to "Psychiatry and Behavioral Management Committee no indication" . This notation is clear. There was evidence that the patient was provided with an alternative treatment /interventions to address the substance abuse problem. It was noted that the staff was monitoring the patient's behavior, but there was no documented evidence that the patient was meeting with a qualified individual who had the expertise to assess the patient's aggressive behavior problem and treat such problem. Consequently, on 1/27/12, the patient broke the window in his room with a soda can. The facility e The filed a police report on 1/27/12. The patient was arrested on 1/31/12 and the patient was involuntary discharged from the facility.

Based on medical record, it was determined that the facility was not consistently informing patient's representative of patient's rights as required. This deficiency was noted in one of six applicable medical records reviewed.
Findings include:
Reviewed of MR # 6 on 8/2/12 noted that this 72 year old, with history of dementia due to TBI, was transferred from the facility's nursing home site to the hospital site on 4/12/12. Review of Acknowledgment of Receipt of Admission package form noted that it was documented on the form that the patient/resident did not appear to understand the significance of the information. It was documented that the Patient Rights package was left at the bedside.
On 4/12/12 at 12:21 PM, the Social Worker (SW) noted that the patient had a court appointed guardian who resided in Florida. There was no other family involvement. It was noted the copy of IM "Import Massage from Medicare" form was mailed to the guardian. There was no documentation that the patient's rights package was also discussed with and mailed to the guardian or the reason why this was not necessary. It was noted that although the IM form was mailed to the patient's guardian there was no documentation that the guardian was informed of the reason for the transfer to the hospital. There was no documentation that the change in the patient's medical status was fully explained to the patient 's guardian or the reason why this was not necessary.

Based on interview and review of other documents, it was determined that the facility did not ensure that the department of Food and Dietetic Services has a current ongoing quality assessment and performance improvement program.

Findings include:

Review of the Food and Dietetic Department's Quality Assurance and Performance Improvement Program on 8/1/12 noted that the department was only monitoring and maintaining a quality assurance program for the Food Service division of the department not the Nutrition (dietetic) division. The Quality Assurance Program for this department was incomplete. There was evidence that food service indicators were being monitored for quality and safety of foods, however the Nutrition division of the department had no quality assurance program since 12/11. At interview with the Acting Clinical Nutrition Manager and Dietitian Supervisor on 8/1/12 they both acknowledged this finding. Based on the review of the Food and Dietetic Quality Assurance Program, the Service Director is responsible for maintaining a complete, thorough and current Quality Assurance Program for both food service and dietetics.

Based on observation, document review, and staff interview, the hospital did not ensure that the condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured.

Findings include:
During tours of the hospital at various times during the survey from 7/31/2012 to 8/3/2012, the following were identified in the presence of the hospital staff who were accompanying the state surveyor.

1. Interview with the Fire Safety Director and the Senior Associate Executive Director of the hospital revealed that the fire alarm system was tested and found to be defective on 6/27/2012. The three buildings of the hospital (C, D and E) were under fire watch.
2. Although, the documentation of the fire alarm testing that detailed the problem was requested repeatedly, they were not provided for review. Therefore the exact problem of the fire alarm system in each building was not determined.
3. The hospital staff said that the fire alarm company was still working to fix the problem and that fire alarm panels need to be changed. Also, the staff said that they had a purchase order for the defective panel and other parts and that the fix of the fire alarm system is awaiting the required parts.
4. Per interview with the Associate Director of Safety and Administrator, the coding system of the fire alarm was not functioning, the smoke doors did not hold (open and close properly as per function and design), and that the audible alarm is not working. The staff member stated that the hospital performs a fire watch using the hospital Police Officers and Fire Watch Personnel.
5. Almost all the patient rooms that are four bed rooms, three bed rooms, two bed rooms and single bed rooms in all the hospital units did not have patient bathrooms.
6. The multipurpose room of D21 was used for storage of clean linen, patient chart cabinets, equipment, and portable x ray machine and oxygen tank.
7. The electrical closet D21-11 was observed to be very dirty and dust laden.
8. The soiled utility room D21-25 was found to have a positive air pressure instead of the required negative air pressure for this type of room.
9. The medication room D21-19 was found to have negative air pressure instead of the required positive air pressure for this type of room.
10. The area of the wall (smoke barrier) above the door of the electrical closet (E2-24) was found to have multiple penetrations around the electric wiring.
11. Eleven (11) big boxes full of compostable material (foam) were observed to be stored in the occupational Therapy area (OTE area) in E2-9. Storing compostable material outside a storage room without the proper fire rating walls and door is a potential for fire hazards.
12. Three cabinets full of patient medical records were found in the area of the OTE where the medical records were accessible to unauthorized people and were not secured against loss or fire.
13. The hydro collator on the physical therapy area was found to be dirty and rusty from inside.
14. Many items used for exercise in the Gym area were found to be dirty; example includes but was not limited to the ankle weights.
15. No patient bathroom was provided for the Gym area and the physical therapy patients.
16. There were signs of leaking on the wall behind the CT machine and walls surrounding its window. Additionally, the paint was chipping on these walls.
17. No soiled utility room was provided for the dental clinic.
18. No soiled utility room was provided for the radiology department.
19. The soiled linen chute room on the basement was found to have positive air pressure instead of the required negative air pressure for this type of room. The door of this room was across the corridor from the door of the central sterile supply room.
20. The preparation room of the central sterile supply room (DC-23C) was found to have negative air pressure in comparison to the corridor, instead of the required positive air pressure required for this type of room.
21. The clean room of the central sterile supply area (DC-32B) ) was found to have negative air pressure in comparison to the corridor, instead of the required positive air pressure required for this type of room.

Based on record staff interview and review of medical records, it was determined that the hospital personnel did not consistently ensure that discharge evaluations were complete and timely in order to avoid delays in discharge. This deficiency is noted in two of ten applicable records reviewed (#7 & #8).
Findings include:
The Charge Nurse for the unit (D21) was interviewed on the unit on 7/31/12 and theDirector of Social Work were interviewed on 8/2/12. Both reported that the physician makes the decision regarding a patient's discharge plan but the social worker coordinates the discharge plan.
Review of MR # 7 on 8/1/12 noted that this 63 year old patient was transferred from the facility's nursing home site on 12/1/11 to the hospital site for management of bilateral thighs wound care.
The Psychosocial Evaluation & Spiritual Assessment Database form dated 12/2/11 was reviewed. It was noted that the social worker (SW) indicated that the tentative discharge plan was discussed with the patient and the discharge plan was to NF (nursing home). The SW noted that the discharge plan was to return to Goldwater Nursing Facility when medically stable. The assessment did not include if there was a discussion with the patient regarding how she felt about returning back to the same nursing home. In addition, the discharge planning assessment did not include if the patient was offered a range of realistic options to consider for her post-hospital care.
It was noted that on 2/6/12 the physician placed the patient on -Alternate Level of Care (ALOC). The plan for ALOC was to nursing home. This document indicated that the patient no longer require hospital level of care as of 2/6/12.
On 2/24/12 at 9:40 AM, the SW noted "provided doctor with shelter screen for patient to be screened for shelter placement." The SW also noted " MD has given screen back and at this time patient does not qualify for shelter placement." The SW noted "will discuss with the patient has requested to go to shelter at discharge plans need to be explored at this time." It was noted that the decision to explore the discharge plan with the patient was eighteen days after the patient was placed on ALOC. It was also noted that the date and time of the request shelter for placement and the discussion with the patient regarding the request was not documented.
It was noted that the patient was scheduled for discharge on 3/9/12. On 3/9/12 at 8:30 AM, SW noted "came to see patient to discuss discharge to GW NF B12." The SW noted that the patient was upset and stated she did not want to go back to B12. It was noted that the patient was offered another unit but the patient refused. It was noted there was no documentation that prior to the day of discharge that the patient was given the choice of another unit. In addition, it was noted that there was no documentation that the patient was given a choice to be discharged to another facility or the reason why this was not necessary.
Review of MR # 8 on 8/2/12 noted that this 55 year old status post spinal cord injury with surgery was admitted to the facility on 4/22/11 and discharged on 3/8/12.
It was noted that the discharge plan was to a nursing facility (NF). It was noted that on 4/28/11 the social worker (SW) noted when placed on ALOC patient will go to a nursing facility. This patient was placed on ALOC on 11-10-11.
On 12/16/11 at 12:05, SW noted "patient's wife gave names of outside NF's. SW faxed papers (PRI) to several NFs." On 1/18/12 at 12 PM, SW noted patient was accepted at a NF but his Medicaid reported as inactive. SW noted called patient accounts to re-certify his Medicaid for discharge. Due to insufficient discharge planning, even though a nursing bed was available on 1/18/12, the patient remained in the hospital until 3/8/12.

Based on staff interview and review of medical record, it was determined that the facility did not ensure that the discharge planning evaluation documented in patients' medical records were complete and addressed the patients discharge needs. This deficiency was noted in two of twelve applicable records reviewed (#9 & #10).
Findings include:
Review MR # 9 on 8/2/12 noted that this 39 year old patient diagnosed elbow sepsis; osteomyelitis was admitted to the facility on 3/14/12 for antibiotics therapy. The patient was discharged on 4/23/12.
The Psychosocial evaluation Assessment & Spiritual Assessment Database form dated 3/16/12 was reviewed. This assessment tool indicated that prior to admission the patient was a bike messenger/delivery person and he resided alone. This document indicated that the prior living arrangement was still available after discharge. The social worker documented in the narrative summary that the patient had an apartment in Manhattan and he will return there once done with IV therapy.
On 4/23/12 at 12 PM, the social worker documented that the patient will be discharged to a shelter today. There was no documentation why the patient no longer had an apartment. The discharge planning evaluation did not include why there was a change in the patient's place of residence or why this was not necessary
Review of MR# 10 on 8/1/12 noted that this 50 year old patient with diagnoses of acute myocardial infraction was admitted to the facility on 6/1/12 for cardiac rehab.
The Alternate Level of Care (ALOC)/Hospital Level of Care Certification form located in the record was reviewed. It was noted that on 6/21/12 the physician indicated that as of 6/18/12 the patient no longer required hospital level of care. The physician noted that the plan for alternative level of care was home/community. It was noted that on 6/16/12 the ALOC was changed from 6/18/12 to 6/27/12. It was noted that on 6/27/12 the physician noted "change of plan of care from shelter to NF " .
On 6/27/12 at 10:20 AM, the social worker (SW) noted informed by MD that patient is to be transferred to D11. SW noted "SW is working on shelter discharge ". There was no documentation that there was a discussion between the SW and the treating physician regarding the change of discharge plan. There was no documentation that there was a discussion with the patient regarding the possible change in plan of care or the reason why this was not necessary. The patient was discharged to Bellevue Men's Shelter on 6/29/12. The reason why the physician changed the plan of care from a shelter to a nursing facility and why the patient was discharged to a shelter was not documented in the medical record.

Based on staff interview and the review of documents, it was determined that the facility was not assessing and reassessing its discharge planning process in order to determine if the discharge plans were responsive to discharge needs.
Findings include:
The Department of Social Work QA/PI for July-September 2011, October- December 2011, January- March 2012 and April - June 2012 were reviewed on 8/3/12. It was noted that the document submitted for review indicated that the Department of Social Work Quality Assurance Performance Improvement (QA/PI) program involved contacting patients after discharges to determine if these patients were adjusting to the community. There was no QA/PI program in place to identify whether the discharge plans were adequate and whether the plans were effectively executed.
The Director of Social Work was interviewed on 8/3/12. This staff reported that discharge planning QA (Quality Assurance) was only done at the departmental level. According to this staff, issues regarding discarge planning are discussed at staff meetings but the discharge issues are not reported up to the hospital wide QA.
There was no evidence that the facility had a mechanism in place to monitor and evaluate the quality and timeliness of the discharge planning evaluations and discharge plans.