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Based on review of the facility's policy and procedure, medical records review, and staff interviews, it was determined that the facility failed to provide documentation that Medicare recipients were given a copy of the Important Message from Medicare within two (2) days of admission, for thirteen (13) of the seventeen (17) patients sampled.

Findings include:

Review of the facility's policies and and procedures failed to reveal evidence of a policy related to the notification of patients that were medicare recipients of their rights contained in the Important Message from Medicare.

Review of the facility's policy entitled Admission Consent Form Process, no effective date or policy number, failed to address providing medicare patients with the Important Message From Medicare.

Review of the current patient census for the date of April 17, 2013 revealed that the current census was twenty-six (26) patients. Review of seventeen (17) records revealed that the patients were covered under the medicare insurance plan. Continued review revealed that thirteen (13) of the seventeen (17) sampled patients medical records had no evidence to confirm that the patients were notified of the Important Message from Medicare within the required two (2) days of admission..

During an interview on April 18, 2013, at 2:00 p.m., the facility's compliance officer (Employee #23) confirmed that the facility did not have a policy related to providing medicare patients with a copy of the Important message From Medicare.

Based on review of facility policies and procedures, staff interviews and review of the facility grievance log, it was determined that the facility failed to demonstrate an effective process for the timely resolution of grievances filed by patients or on behalf of patients.

Findings were:

Review of the facility's policy entitled Handling Patients Complaints/Concerns, number PRB-6102, no effective date, revealed that all grievances would receive a written communication with the patient or their representative within seven (7) working days. This written communication would include the resolution and outcome of the grievance investigation or the steps being taken to resolve the grievance. The policy did not include a time frame for completion of the full investigation process. The policy also revealed that upon completion of the investigation, all paper work will be forwarded to risk management for retention.

During an interview on April 16, 2013, at 11:56 a.m., the facility's patient relations director (Employee #24) stated that the person filing the grievance would receive notification of receipt of the grievance within twenty-four (24) to forty-eight (48) hours after receipt of the grievance. Continued interview revealed that the facility did not have a time frame for the completion of the investigation and notification to the patient, or their representative, of the resolution of the grievance.

Review of the grievance log revealed that the three (3) grievances selected for review contained no evidence that copies of the letters had been sent to patients or their representatives signifying the receipt of the grievance or the resolution of that grievance.

Based on review of facility policies, observation, and staff interview, it was determined the facility failed to have an effective system for ensuring the confidentiality of patient records.

Findings were:

Review of facility policy PRB-1120 Physical Access to Confidential Information and Equipment in Public Areas, undated, revealed that medical records and charts should be kept and updated in secure areas with appropriate access controls or supervision.

Observation on 4/16/2013 at 9:45 am, and again on 4/17/2013, on the 5th floor unit, revealed that patient medical records were stored in unsupervised, unlocked, wall-a-roos (small hinged-door cabinet to store medical charts) located on walls outside patient rooms.

Interview on 4/16/2013 at 4:30 p.m. with the Joint Commission (JC) Coordinator (employee #24) and the Directors of Patient Care Services (employee #1), revealed that the charts were kept in the wall-a-roos for ease of access by care providers, and further stated that they were unsure of how to handle the situation since all patient care providers needed access to the patient's medical records, and did not have keys for the wall-a-roo locks.