HospitalInspections.org

Based on record reviews and interview, the hospital failed to ensure each patient or the patient's representative was informed of the patient's rights in advance of furnishing or discontinuing patient care as evidenced by failure to have documented evidence that the patient was presented a copy of the signed IMM in advance of the patient's discharge, but not more than two calendar days before the patient's discharge for 1 (#5) of 4 inpatient records reviewed for presentation of the IMM at admit and discharge from a sample of 5 patients.
Findings:

Review of the policy titled "Patient Rights and Responsibilities", presented as a current policy by S1DAC, revealed for inpatients, hospital admission/registration clerks will present all Medicare patients with a document entitled "An Important Message from Medicare." This document describes specific rights and responsibilities of medicare patients and is presented for their review and signature. A copy becomes part of the patient's medical record, and a copy is provided to the patient. Further review revealed no documented evidence the policy included the requirement that a copy of the signed IMM be given to the patient in advance of the patient's discharge, but not more than two calendar days before the patient's discharge.

Review of Patient #5's medical record revealed the IMM form was signed by Patient #5 on 07/13/18, the day of admit. There was no documented evidence a signed copy had been presented to Patient #5 in advance of his discharge.

In an interview on 08/02/18 at 1:00 p.m., S1DAC confirmed Patient #5's record did not have evidence that a signed copy of his IMM had been presented to him prior to discharge.

Based on record reviews and interviews, the hospital failed to ensure patients who had physician orders for HH were presented a list of home of HH agencies with documentation in the record that the list was presented and have documentation in the record that the patient was informed if the hospital had a disclosable financial interest in the HH agency to which he/she was referred. Patient #3's medical record had no documented evidence that a list of HH agencies was presented and that he was informed that the hospital had a financial interest in the agency to which he was referred. This was evident in 1 (#3) of 2 (#3, #4) patient records reviewed with orders for HH from a sample of 5 patients.
Findings:

Review of the policy titled "Discharge Planning", presented as a current policy by S1DAC, revealed as part of the discharge plan, the hospital will provide all Medicare participants with a list of home health agencies and skilled nursing facilities that are available to the patient, participate in Medicare, and serve the geographic area in which the patient resides. Hospital personnel will document in the patient's record that the list was presented to the patient or to the individual acting on the patient's behalf. The hospital will identify any post-hospital provider in which the hospital has a financial interest. There was no documented evidence that the policy included the requirement that there be documentation in the record that the patient was informed if the hospital had a disclosable financial interest in the HH agency to which he/she was referred.

Review of Patient #3's medical record revealed no documented evidence that Patient #3 or his representative was provided a list of available HHs in his area and that he/representative was informed that the chosen HH agency was owned by the hospital.

In an interview on 08/02/18 at 2:22 p.m., S2CM indicated the topic of HH comes up when the patient's being discharged home. She further indicated they ask the patient if they have a preference of HH or hospice company. If the patient has no preference, they (staff) provide a list of available HH or hospice agencies to the patient. S2CM indicated she documents on a general note in the record that a list was provided. She further indicated she doesn't document that she informs the patient when the HH agency is owned by the hospital. She indicated tells them it's a dept. of the hospital but doesn't document that. S2CM confirmed Patient #3's medical record had no documented evidence that he was provided a list of HH agencies and that the agency to which he was referred was owned by the hospital.

In an interview on 08/02/18 at 3:04 p.m., S3RBCC indicated she informs the patient when the HH agency is an agency of the hospital, but she doesn't document that she's informed the patient that the agency is owned by the hospital.