Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 530025 (X3) Date Survey Completed 08/21/2012
Name of Provider or Supplier Ivinson Memorial Hospital Street Address, City, State 255 N 30th, Laramie, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0831 DISCLOSING FINANCIAL INTEREST
CFR(s): 482.43(c)(8)

The discharge plan must identify any HHA or SNF to which the hospital has a disclosable financial interest, as specified by the Secretary, and any HHA or SNF that has a disclosable financial interest in a hospital under Medicare. Financial interests that are disclosable under Medicare are determined in accordance with the provisions of Part 420, Subpart C, of this chapter.


This STANDARD is not met as evidenced by:
Based on staff interview and medical record review, the facility failed to ensure the discharge plans for 1 of 3 sample patients (#2) identified that the hospital had a disclosable financial interest in the skilled nursing facility (SNF) to which the patient were discharged. The findings were: According to the medical records, patient #2 was discharged to the hospital's extended care facility (ECF, a SNF) on 5/18/12. Review of the discharge plans showed no evidence the patient was informed prior to his/her discharge that the hospital owned the facility. During an interview on 8/21/12 at 1:25 PM, the discharge planner stated she did not know whether the staff person responsible for informing the patient that the hospital had a disclosable financial interest in the ECF had done this. At that time she verified the financial disclosure information had not been included in the documented discharge planning process for this patient.