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Based on interview, medical record review and policy review, the facility failed to inform Medicare beneficiaries, who were hospital inpatients, about their hospital discharge plan review and appeal rights.

Three patients (#1, #4 and #5) of ten patient's medical records reviewed for the required Medicare "Important Message" (IM), a required document that informed patients of their discharge plan review and appeal rights, did not have the IM provided.

The failure of the facility to provide the IM had the potential for inappropriate discharge and/or financial obligations related to their healthcare needs upon discharge from the hospital. The failure affected all Medicare beneficiaries discharged from the hospital. The average number of patients discharged per day is one patient. The average daily census is 30 patients. The facility census was 25.

Findings included:

1. Record review of the facility's policy titled, "Discharge Process: Criteria," reviewed 03/13, showed staff written guidance which included the purpose of evaluating a patient's readiness for discharge and the procedures which were implemented to establish discharge readiness and patient discharge disposition.

The policy did not contain criteria, procedure or any language related the provision of the IM or informing Medicare beneficiaries of their right to a review or appeal of their discharge plan.

Record review of the facility's policy titled, "Medicare Beneficiary Notices," reviewed 06/13, showed staff written guidance for the policy purpose which was to protect the patients from inappropriate discharge and maintain compliance with state government regulations. Staff guidance included:
- Provide the IM to Medicare beneficiaries at the time of admission and at discharge per Centers for Medicare & Medicaid Services (CMS).
- When requested for discharge appeal, provide a copy of a detailed notice of discharge to the patient.
- The CMS Internet web address was provided for staff to find details of regulations to be implemented.
The policy did not provide written guidance for staff to provide the IM within prescribed time frames which allowed for patients to be informed of review and appeal information and time to carry out their rights.

2. Record review of Patient #1's admission record showed the primary insurance carrier was "Coventry (Gold Advantage)", a Medicare managed care insurance plan.

Record review of Patient #1's medical record showed no IM found in the record. The lack of IM in the medical record was confirmed by Staff H, Director of Quality Improvement.

Record review of Patient #1's initial Physician History and Physical dated 04/02/14 showed the 65 year old patient was admitted for care and treatment of an abdominal fistula (an abnormal connection between an organ, vessel or intestine and another structure), and abdominal wound from recent bowel/intestinal surgical procedures at a previous hospital.

Record review of Patient #1's discharge planning notes dated 04/02/14 through 06/19/14 (dates through discharge) showed:
- the patient required total parenteral nutrition (TPN, a sterile formula of total nutrition supplements administered through a vein, used for patients who cannot or should not get their nutrition through eating) administration every 18 hours.
- Daily abdominal wound care and dressing changes were needed.
- The patient was unable to demonstrate competence in providing her own wound and or dressing changes.
- The patient needed a machine for home use for intermittent suction of wound drainage.
- Family members were not willing to provide assistance with patient's care if discharged to home.
- No documentation of information regarding Medicare beneficiaries IM or discharge review or appeal rights.

During an interview on 06/25/14 at 10:45 AM, Staff H, Director of Quality Management (DQM), stated that Patient #1 was discharged to home with home health services after the insurance benefits ran out. She stated that the patient was not a Medicare beneficiary and was provided the option to assume personal responsibility for facility charges when her insurance carrier refused additional payment.

During an interview on 06/26/14 at approximately 1:00 PM Staff K, Social Worker, stated that Patient #1 lived alone in her own home,and did not believe the patient had the ability to provide her own wound care or provide for her own parenteral nutrition. He stated that he thought Patient #1 had community support that could provide help. Staff K stated that the patients discharge was driven by her insurance carrier's refusal to pay for additional care and that it was extremely hard to discharge patients who needed the level of care Patient #1 needed at the time of discharge because skilled nursing facilities did not accept patients who required TPN and complicated frequent wound care. He stated that the facility Case Manager was primarily responsible for Patient #1's final discharge.

During an interview on 06/30/14 at 3:40 PM, Staff J, Case Manager stated that Patient #1's discharge was driven "mostly by insurance". Staff J stated that on "06/12/14 at 3:00 PM she gave the patient two options for discharge; training to go home with home health or be immediately discharged for refusal to participate in the plan of care." Staff J stated that the patient was not provided the IM or any information to appeal the discharge because she was not a Medicare patient. She stated that the facility did the best they could do and the patient was given the opportunity to pay for the services herself.

During an interview on 06/60/14 at 4:14 PM, Staff U, Wound Care Nurse stated that Patient #1's discharge was driven by "her insurance, they wouldn't pay for a longer stay". She stated that Patient #1 was discharged to home with physician orders for intermittent wound care, dressing changes and administration of TPN every 18 hours by a home health care nurse. She stated that the patient lived alone in her own home and had not demonstrated competency for her own wound care or administration of TPN. Staff U was not aware of a discharge appeal process, and stated "I don't usually do discharges, I just call the insurance companies to get approval for dressing and equipment supplies for wound care". Staff U stated that she was aware of concerns that the patient and others had concerns about the patient being discharged to her home.

3. Record review of Patient #4's Admission Record showed the patient's primary insurance carrier was Humana Gold (a Medicare managed care plan).

Record review of Patient #4's medical record showed no IM found in the record after the patient was admitted to the facility on 04/14/14. The patient was discharged 05/02/14. The lack of IM in the medical record was confirmed by Staff H.

4. Record review of Patient #5's Admission Record showed the patient's primary insurance carrier was Medicare.

Record review of Patient #5's medical record showed no IM in the record after the patient was admitted to the facility on 05/02/14. The patient was discharged 05/29/14. The lack of IM in the medical record was confirmed by Staff H.

5. During an interview on 06/30/14 at 4:40 PM Staff H stated that the facility identified a problem with consistently recognizing CMS beneficiaries upon admission and discharge.