HospitalInspections.org

Based on medical record review and staff interview the facility did not ensure that all Medicare patients admitted to the facility received "An Important Message from Medicare" (IM) notice within two (2) days as per regulatory requirements. This was evident in four (4) of fourteen (14) medical records reviewed. (MR's #1, 11, 12, & 14)

Findings include:

Review of MR#1 revealed that this patient was admitted on 7/31/17. The IM filed in the record noted that the patient was unable to sign the form. There was no documentation that a completed IM was signed by this patient's representative.

Review of MR #11 & MR# 12 identified that there were no IM notices filed for these two (2) patients.

Review of MR#14, identified that the patient was admitted on 5/26/18. The IM signed by this patient's representative was dated 5/30/18 and not within forty-eight (48) hours as per regulatory requirement.


Staff S, the Director of Utilization Management was interviewed on 5/31/18 at 1:30 p.m. Staff S stated that the IM is given to all Medicare patients by a Health Care Investigator upon admission. If the patient is unable to sign the form, then the form is sent to the patient's family for signature. It is the facility's practice to ensure that all signed IM messages are filed in the medical record within 48 hours of admission.
Staff S stated that while the facility does not have a written Policy and Procedure, they do have this practice.

These findings were brought to the attention of Staff I the Associate Director of Regulatory Affairs on 5/31/18.

Based on interview and document review, there was no evidence that the facility kept a record of all resolved complaints and that resolved complaints are included in the data collected.

Findings include:

Staff E, the Director of Patient Relations was interviewed on 5/29/18 at 11 a.m. concerning the Complaints/Grievance Process. Staff E was asked for Compliant/Grievance received by the facility from January 2018 to the present 2018.

Staff E presented the surveyor with a document titled "Summary Report of Incidents, 1/1/18 to 5/29/18." This document showed four (4) entries classified as Grievances. Staff E stated that these four Grievances were originally logged as complaints. Since these complaints were not resolved within 24 hours, they were converted to Grievances.

Staff E also stated that for all complaints received, either verbal or written, a "Fact Sheet" is completed. The date of complaint, the source of the complaint and the mode of the complaint, are recorded, for example verbal or written. The "Fact Sheet" should document if the complaint was resolved. If the complaint was not resolved within 24 hours, then the complaint is converted to a Grievance.
Staff E was unable to provide "Fact Sheets" for the four (4) Grievances.

When asked about complaints that were resolved within 24 hours, staff E stated that there were no resolved complaints for 2018.

Review of the facility's Policy & Procedure titled "Procedure for Coordinated and Formal Resolution of Patient Complaints and Grievances" approved on 11/15/16 identified the steps to be taken if a complaint can be resolved promptly:
"b. provide the patient/patient's representative with a verbal and/or written report of the steps taken to resolve the care complaint."
"c. Staff that is authorized to make entries in the medical record will the nature of the care complaint: the corrective actions taken: and note that a verbal and/or written response was provided to the patient/patient representative."

The Policy and Procedure did not include the completion of a "Fact Sheet" to document the complaint and if the complaint was resolved. The policy does not include a process for the tracking of resolved complaints.