HospitalInspections.org

Based on facility policy review, medical record review, and interviews, the facility failed to provide a signed and dated notice of Medicare Rights within 2 days prior to discharge for 4 patients (#1, #2, #3, and #9) of 4 discharged patients reviewed.

The findings included:

Review of the facility's Patient Rights and Responsibilities policy, last reviewed on 1/30/15, revealed "...patients and/or family members will be provided a copy of the Medicare Hospital Patient Rights..."

Review of the medical record revealed Patient #1 was a Medicare Beneficiary and was admitted to the facility on 2/29/16 with diagnoses including: Generalized Deconditioning and Debility, Congestive Heart Failure, and Colitis. Continued review revealed the patient was discharged home with home health services on 3/12/16. Further review revealed no documentation of a signed and dated Medicare Important Message (IM) letter to the beneficiary in advance of the patient's discharge.

Review of the medical record revealed Patient #2 was a Medicare Beneficiary and was admitted on 3/1/16 with diagnoses including: Encephalopathy, Intracranial Hemmorhage, and Hypertension. Continued review revealed the patient was discharged home with home health services on 3/17/16. Further review revealed no documentation of a signed and dated Medicare IM letter to the beneficiary in advance of the patient's discharge.

Review of the medical record revealed Patient #3 was a Medicare Beneficiary and was admitted on 3/23/16 with diagnoses including: Right Hip Fracture, Metabolic Encephalopathy, Dementia, and Urinary Tract Infection. Continued review revealed the patient was discharged to a long term care facility on 4/5/16. Further review revealed no documentation of a signed and dated Medicare IM letter to the beneficiary in advance of the patient's discharge.

Review of the medical record revealed Patient #9 was a Medicare Beneficiary and was admitted on 3/21/16 with diagnoses including: Encephalopathy, Seizure Disorder, and End Stage Renal Disease. Continued review revealed the patient was discharged home with out patient services on 4/6/16. Further review revealed no documentation of a signed and dated IM letter to the beneficiary in advance of the patient's discharge.

Interview with the Vice President of Quality on 10/18/16 at 10:00 AM, in the administration conference room, confirmed there were no Medicare IMs signed and dated within 2 days prior to discharge in the medical records of patients #1, #2, #3, and #9. Further interview confirmed Medicare Beneficiaries must have a signed and dated Medicare IM within 2 days prior to discharge.

Interview with the Case Manager on 10/18/16, at 10:30 AM, in the administration conference room, confirmed all patients that are Medicare Beneficiaries are not provided a Medicare IM prior to discharge.




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