Observations:
Based on a review of facility documents, medical record review (MR), and staff interview (EMP), it was determined that the facility failed to provide the Important Message from Medicare (IMM) on admission for one of 30 medical records reviewed (MR11); and failed to provide the IMM on discharge for three of 30 medical records reviewed (MR10, MR12, and MR30).
Findings include:
Review of "UPMC Policy and Procedure Manual Policy HS-QM0884* Index Title: Corporate Care Management Subject: Medicare Hospital Issued Notices of Financial Liability and Discharge Appeal Date: December 20, 2023 revealed " ... V. Procedure ... C. Important Message from Medicare (IMM) 1. All Medicare/Medicare Advantage plan enrollees who are hospital inpatients must receive the IMM. 2. The IMM informs hospitalized inpatient beneficiaries/representatives of their rights as a hospital patient, including discharge appeal rights. 3. The IMM must be delivered within 2 calendar days of admission, must obtain the signature of the beneficiary or his/her representative, and a copy must be provided to the beneficiary/representative. Hospitals will also deliver a copy of the signed notice as far in advance of discharge as possible, but not more than 2 calendar days before discharge. ... ."
Review of MR10 revealed that the patient was admitted on May 26, 2024 and discharged on June 1, 2024. There was no evidence of a discharge IMM.
Review of MR11 revealed that the patient was admitted on May 23, 2024 and discharged on June 3, 2024. There was no evidence of an admission IMM.
Review of MR12 revealed that the patient was admitted on June 21, 2024 and discharged on June 27, 2024. There was no evidence of a discharge IMM.
Review of MR30 revealed that the patient was admitted on June 27, 2024 and discharged on June 30, 2024. There was no evidence of a discharge IMM.
Interview on July 16, 2024, at approximately 12:00 PM, EMP2 confirmed the above findings.
Based on a review of facility documentation, medical record (MR) review, and staff interview (EMP), it was determined the facility failed to ensure patients were informed of their rights prior to receiving care for four of 30 medical records reviewed (MR9, MR10, MR11, and MR17).
Findings include:
Review of "UPMC Policy And Procedure Manual Policy: HS-HD-PR-01* Index Title: Patient Rights/Organizational Ethics Subject: Patients' Notice and Bill of Rights and Responsibilities Date: May 29, 2024, revealed " ... III. Purpose The Patients' Notice and Bill of Rights and Patient Responsibilities is made available to patients, their family members* and representatives via patient information materials and postings. ... The following sections of this policy present the information that is provided to patients, family members and their representatives to assure that they are informed of their rights while receiving services at UPMC. ... IV. Patients' Notice And Bill Of Rights ... Attachment A. ... ."
Review of MR9, MR10, MR11, and MR17 revealed no documented evidence that the patients or their representatives were given the admission packet, which contained the patient rights.
Interview on July 16, 2024, at approximately 12:00 PM, EMP2 confirmed the above findings.
| | Plan of Correction - To be completed: 10/31/2024
To ensure compliance with CMS condition of participation 482.13(a)(1) regarding the Important Message from Medicare (IMM), the departments responsible for ensuring the patient is provided with this information on admission and discharge will be provided with education.
The Patient Access department is responsible for providing the admission IMM to patients, or their representatives, and scanning the form into the electronic record. They also are responsible for tracking the patients who, for various reasons, were not provided an IMM upon their registration. Daily alerts are automatically placed in an electronic system at midnight and includes all patients who have not received their IMM the previous day. Patient access staff members make three daily attempts to provide and obtain a signed copy of the IMM. The ultimate goal is to ensure the patient, or their representative, received a copy of the IMM at the time of their admission. The Patient Access Manager, or designee, will be providing all Patient Access staff members with education on policy HS-QM0884: Medicare Hospital Issued Notices of Financial Liability and Discharge Appeal and the Patient Access TPO/IMM Procedure via email communication and through one-on-one conversations. This education will be validated by way of signed attestations indicating the staff were provided and understand the policies and procedures referenced. The goal is for 100% of active Patient Access staff who have responsibility for providing the IMM to patients/their representatives to be educated by August 31, 2023. The results of the education attestations will be reported to the Continuous Process Improvement Committee meeting, a subcommittee of the Board, on September 11, 2024.
The Clinical Care Coordination and Discharge Planning department is responsible for providing the IMM to patients prior to their discharge. In most cases, the IMM is presented to the patient/representative while the patient remains in the hospital and is then scanned into the medical record. There are instances when the patient is unable to comprehend the information within the IMM and their appropriate representative is not present to receive the IMM in person. In such instances, the Clinical Care Coordination and Discharge Planning staff members make attempts to contact the appropriate representative via phone and follows up by mailing the signed IMM. Documentation of such attempts are placed within the patient's electronic medical record. The Director of Clinical Care Coordination and Discharge Planning will be providing education on policy HS-QM0884: Medicare Hospital Issued Notices of Financial Liability and Discharge Appeal, as well as education specific to the IMM process via a staff meeting on August 21, 2024. This education will be validated by way of signed attestations indicating the staff were provided and understand the policies and procedures referenced during the meeting. Any Clinical Care Coordination and Discharge Planning staff who are unable to attend the staff meeting will be provided with this education directly and will be required to attest to their understanding of the education. The goal is for 100% of Clinical Care Coordination and Discharge Planning staff members to receive the education by August 31, 2024. The results of the education attestations will be reported to the Continuous Process Improvement Committee meeting, a subcommittee of the Board, on September 11, 2024.
To validate the reeducation provided to both the Patient Access department and the Clinical Care Coordination and Discharge Planning department was effective and that proper documentation is present for both admission and discharge IMMs, both departments will be required to audit 75 records per month beginning in September 2024. The goal will be to achieve 95% compliance for the presence of the admission IMM being provided and signed, as well as the discharge IMM being provided to the patient prior to their discharge, or documented in the chart that attempts were made to contact the patient/their representative and that the IMM was mailed out. Identified fallouts will be addressed directly with the staff member responsible for the noncompliance. The results of monthly IMM audits will be reported to the Continuous Process Improvement Committee meeting, a subcommittee of the Board, beginning on October 9, 2024 and will be reported out monthly until each department achieves at least 95% compliance.
To ensure compliance in providing patients with their Bill of Rights and Responsibilities, education will be provided to all active registered nurses on the process for providing patients with their Bill of Rights. The process begins with Registered Nurses providing inpatients with an admission packet that includes this information. The Registered Nurse who is assigned to the patient upon their admission, whether it be a direct admission, admission from the Emergency Department, or admission from a procedural area, is required to complete an Admission Assessment within the electronic health record. Within the Admission Assessment is a field requiring a selection on whether the patient received an admission packet containing their Patient Rights. If the patient is an inpatient, it is required that they are provided with this information and the appropriate selection within the admission assessment should be completed indicating either that the patient was provided with the information or that the patient is unable to communicate their understanding of the material given. To bring awareness to this requirement, all active Registered nurses will be required to complete an electronic educational module that covers the process of providing patients with their Bill of Rights documentation, as well as the process for properly documenting it in the electronic health record. Additionally, the education will include information on what is included in the Bill of Rights documents by way of UPMC policy HS-HD-PR-01: Patients' Notice and Bill of Rights and Responsibilities. Education will be released to all active Registered Nurses, including agency Registered Nurses, by August 31, 2024 with a deadline for completion of September 30, 2024. Education completion will be validated by electronic attestations for UPMC Registered Nurses and by written attestations for external agency Registered Nurses. The results of the education attestations will be provided to the Continuous Process Improvement Committee meeting, a subcommittee of the Board, beginning on October 9, 2024.
To validate compliance in documentation of patients receiving their Bill of Rights and Responsibilities via admission packets, each inpatient unit will be responsible for auditing 20 records per month beginning in October 2024. The Unit Director, or designee, of each unit will be reviewing the admission assessment form to validate the admission packet was received by the patient. The goal will be for each individual unit to achieve 100% compliance in providing and documenting the admission packet was provided to the patient or their representative. The results of monthly audits will be reported to the Continuous Process Improvement Committee meeting, a subcommittee of the Board, beginning on November 13, 2024, and will be reported on until all inpatient units have achieved compliance with their audit.
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