Failure to Submit TPL Forms and Resident Funds Timely
Summary
The facility failed to ensure that Third Party Liability (TPL) forms were completed and submitted to MO Health Net within 30 days of death for three deceased residents and failed to ensure a check with the remaining funds was submitted within 5 days of discharge for one discharged resident. Specifically, Resident #219 passed away with $200.11 in their account, and the TPL form was not submitted within the required 30 days. Resident #220 passed away with $87.30 in their account, and the TPL form was also not submitted within the required timeframe of 30 days. Resident #221 had $498.65 in their account at the time of death, and the TPL form was submitted 70 days after the resident's death. Additionally, Resident #218 was discharged with a balance of $20.00 in their account, and the check for the remaining funds was not submitted within the required 5 days of discharge due to a delay caused by a hair care charge that was known at the time of discharge but not immediately processed. During interviews, the Business Office Manager (BOM) admitted to sending checks to funeral homes and the state but failing to complete and submit the TPL forms within the required 30 days for deceased residents. The BOM also acknowledged the delay in processing the check for the discharged resident due to the hair care charge. The BOM was unaware of the requirement to fill out and submit TPL forms for any resident receiving Medicaid or Medicare, indicating a lack of proper training or understanding of the regulatory requirements. This deficiency potentially affected four discharged residents in a facility with a census of 70 residents.
Penalty
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The facility failed to follow its resident fund management policy requiring closure of discharged residents’ trust accounts and release of funds within 30 days. Two residents, one transferred for psychiatric evaluation and another who died with physician authorization to release the body, both had ongoing open trust accounts with balances documented on a later fund trial balance. Review of their clinical records showed no evidence that their monies were provided within 30 days of discharge, and the Business Office Manager confirmed that the accounts were not closed or funds conveyed as required.
A resident was discharged after their responsible party had paid the facility in advance for the month of discharge, but the facility did not complete and clearly convey a final accounting of the resident’s personal funds within the required 30-day timeframe. An email from the NHA months after discharge stated the account was still pending due to awaited payments, and a later account statement showed a credit balance without confirming it as a final reconciliation. Billing records spanning several months did not document a final, reconciled statement, and the responsible party reported multiple unsuccessful attempts to obtain clear information needed to settle the resident’s estate. During surveyor interviews, the NHA could not provide evidence that a complete final accounting of all charges, credits, and remaining balance had ever been provided, resulting in a violation of resident rights and management regulations.
A resident with multiple chronic conditions and moderately impaired cognition died in the hospital after being transferred from the facility following a seizure and hemorrhagic stroke. After the resident’s death, facility leadership was aware that the resident had a substantial balance in a trust fund account but did not convey these funds within the 30-day period required by facility policy. Staff initially believed the resident had no family, then were informed by a former BOM that family existed but had no contact information, and the facility decided instead to return the funds to the state but had not completed this action. Review of records confirmed the unresolved trust fund balance and a written policy requiring refund and final accounting of personal funds within 30 days of death or discharge.
A deceased resident’s trust fund balance of over $4,700 was not handled in accordance with TPL requirements and the facility’s admission agreement. After the resident’s death, the BOM issued a check for nearly the full balance directly to a family member based on receipts for a repast, clothing, a watch, a slip, and obituary costs, without consulting corporate finance. The Administrator later stated he would have expected any unused funds not legitimately applied to funeral expenses to be sent to TPL or the state, but the funds were instead disbursed at the facility level and the account closed, without proper final accounting and disposition within the required timeframe.
A resident with multiple chronic conditions, including HTN, dementia, and DM2, died while on hospice, leaving a significant balance in their facility account. The facility’s own records and emails showed that staff initially identified a smaller refund amount, later determined that over $10,000 was due, and then delayed issuing the refund after an additional payment required adjusting the amount and obtaining preapproval. The BOM acknowledged there was no refund policy, that private pay refunds were not processed timely, and that the refund should have been completed months earlier, resulting in a failure to promptly return the deceased resident’s funds to the representative as required by the facility’s abuse and misappropriation policy and the admission contract.
The facility did not follow its admission agreement requirement to refund any resident credit balance within 30 days, resulting in a significant delay in returning funds owed to a responsible party after a resident with a history of stroke, CHF, and metabolic encephalopathy died of natural causes. Although the responsible party was clearly documented as authorized for healthcare and financial decisions and was listed on the resident’s private bank accounts, the facility withheld a $1,995.00 refund until a notarized Heirship Affidavit was obtained and then delayed issuing the check for an additional 41 days, leading to the refund being paid more than five months after the resident’s death.
Failure to Timely Convey Resident Trust Funds After Discharge or Death
Penalty
Summary
The deficiency involves the facility’s failure to convey resident funds and close resident trust accounts within 30 days of discharge, as required by its own resident fund management policy and applicable regulations. The facility policy, last reviewed on 5/20/25, stated that discharged resident accounts are to be closed following reconciliation and that funds are to be released after completion of an audit and reconciliation. Review of the resident fund trial balance dated 3/18/26 showed that two discharged residents still had open accounts with balances: one with $384.68 and another with $7,430.63. The clinical records for these residents did not contain documentation that their monies were provided within 30 days after discharge. The first closed record (CR1) was for a resident with diabetes, schizophrenia, and hypertension, whose progress note on 1/4/26 documented acute psychiatric distress, including refusal of medications and repeated verbalizations to be killed, leading to a 302 involuntary commitment and transfer from the facility with EMT and police escort. The second closed record (CR2) was for a resident with diabetes, hypertension, and Alzheimer’s dementia, whose progress note on 1/25/26 documented that she was found without pulse or respirations, the physician was notified, and an order was given to release the body to the funeral home, with a nephew notified. Despite these discharges—one due to transfer for psychiatric evaluation and one due to death—there was no indication in either clinical record that their funds were conveyed within 30 days, and the Business Office Manager confirmed that the facility failed to close these accounts and release the funds as required.
Failure to Provide Timely Final Accounting of Discharged Resident’s Personal Funds
Penalty
Summary
The deficiency involves the facility’s failure to complete and convey a final accounting of a discharged resident’s personal funds within 30 days of discharge, as required by regulation. The resident, identified as CR1, was admitted on an unspecified date and discharged on September 12, 2025. Financial documentation showed that the responsible party had paid the facility in advance for the month of September 2025. An email dated November 12, 2025, from the Nursing Home Administrator to the responsible party indicated that the resident’s account had not yet been reconciled because the facility was awaiting payments from other sources and that the account remained pending. The facility’s records included an account statement dated December 31, 2025, reflecting a credit balance, but the facility could not demonstrate that this statement represented a final accounting of all charges, credits, and the remaining balance. Review of billing documentation from April 2025 through February 2026 did not show evidence that a final, reconciled accounting of the resident’s personal funds was provided or clearly explained to the responsible party within 30 days of discharge. During an interview, the responsible party reported contacting the facility multiple times to inquire about the status of the account and stated that she did not receive clear information regarding the final status of the account after discharge, noting that the last communication received was the December 31, 2025 statement. She indicated that this information was needed to complete financial matters related to the resident’s estate. In a separate interview, the Nursing Home Administrator was unable to provide documentation that a final accounting of the resident’s personal funds, including all charges, credits, and remaining balance, had been completed and conveyed within the required timeframe. The surveyors determined that, as of March 2026, the facility had not provided evidence that the final accounting and status of the resident’s personal funds had been completed and communicated within 30 days of discharge, in violation of 28 Pa. Code 201.18(b)(2)(e)(1) and 201.29(a).
Failure to Convey Deceased Resident’s Trust Funds Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to convey a deceased resident’s personal funds within 30 days as required by policy. An 87-year-old female resident with unspecified dementia, chronic kidney disease, convulsions, depression, atrial fibrillation, and anemia was admitted to the facility and had a care plan noting incontinence, fall risk, and pain complaints. A quarterly MDS documented a BIMS score of 8/15, indicating moderately impaired cognition. Review of the admission packet showed no listed family members or power of attorney. Nurse’s notes documented that the resident had a seizure during peri care and was sent to the hospital, where hospital records indicated she had a hemorrhagic stroke and died. Following the resident’s death, the Corporate CEO acknowledged awareness that the resident had a balance in her trust fund account that had not been conveyed. The CEO stated that the resident had no visitors and was believed to have no family, but at the time of death the former BOM suddenly stated the resident did have family and that the money needed to go to them, although the facility had no information on the family. The CEO reported the facility had decided to send the money back to the state but had not yet done so and admitted knowing there was a 30-day timeframe to return the funds. Record review showed the resident’s trust fund account balance was $13,946.81, and the facility’s “Refunds” policy required that within 30 days of death or discharge, the facility refund the resident’s personal funds and provide a final accounting to the resident, the resident’s representative, or the resident’s estate.
Failure to Properly Account for and Disburse Deceased Resident’s Trust Funds
Penalty
Summary
The facility failed to ensure that third party liability (TPL) requirements and its own admission agreement regarding resident funds were followed for a deceased resident with a trust fund balance. The admission agreement stated that residents have the right to manage their personal financial affairs or designate someone to do so, and that the facility would provide an accounting of funds upon request and at least quarterly. Record review showed that the resident had a trust fund balance of $4,708.23 at the time of death. Subsequent account activity included a large debit of $4,698.95 for personal needs, closing interest of $1.36, and a final debit of $10.64 to close the account. The Business Office Manager (BOM) reported that, upon the resident’s death, the family requested funds for funeral expenses and that a check in the amount of $4,698.95 was issued to a family member after receipts were provided. Review of the resident’s trust records and receipts showed that the expenditures submitted by the family included a repast at a banquet center, a Fossil watch from a department store, clothing items (jacket, blouse, pants) from a high-end retailer, a full slip and another unidentified item from another store, and obituary costs from a funeral home. The BOM stated that the regional manager had indicated it was acceptable to give the resident’s money to the family as long as receipts were provided, and that anything left over should be sent to TPL. The BOM acknowledged not consulting with the corporate BOM before issuing the check and confirmed that the check was printed and given at the facility level without corporate involvement. The Administrator stated that he would have expected the BOM to send any remaining resident funds to TPL or back to the state if not used for funeral expenses, indicating that the facility did not follow required procedures for final accounting and disposition of the resident’s funds within 30 days of death.
Failure to Timely Refund Deceased Resident’s Funds
Penalty
Summary
The facility failed to timely refund resident funds to a deceased resident’s representative, resulting in a deficiency related to misappropriation of resident property. The facility’s abuse policy prohibits exploitation and misappropriation of resident money and defines misappropriation as wrongful temporary or permanent use of a resident’s belongings or money without consent. The resident involved was a 96-year-old with essential hypertension, age-related cognitive decline, type 2 diabetes mellitus, and dementia, who had been admitted with these diagnoses and later died while on hospice services. The admission contract specified that any monies remaining after discharge would be returned to the resident after the facility received all payments from third-party payor sources, and that funds of a deceased resident would be released upon receipt of appropriate estate documentation. After the resident’s death, internal emails between the HR/Business Office Manager and the Corporate Bookkeeper documented that the resident’s family member was concerned about receiving a refund and that an initial refund amount of $1,940 was identified. A later statement showed a balance of $10,465, and a subsequent email from the Corporate Bookkeeper confirmed a total refund amount of $10,465 with no other anticipated charges. Interviews revealed that the refund request had to be adjusted after an additional payment was received, and that the facility fell behind on processing the revised request and required preapproval due to the higher amount. The Business Office Manager acknowledged that refunds, particularly for private pay, were not processed timely, that there was no policy on refunds, and that the refund should have been completed months earlier, while another administrator indicated that refunds typically take 30 to 45 days to be issued.
Failure to Timely Refund Resident Credit Balance After Death
Penalty
Summary
The facility failed to timely disburse a resident refund in accordance with its admission agreement, which required that any credit balance be refunded within a reasonable time not to exceed 30 days after discharge or transfer, minus any outstanding private insurance balance. The admission and financial records showed that the responsible party was clearly identified on the admission documents, face sheet, and financial records, and was authorized for healthcare decision making, care plan participation, emergency contact status, healthcare representative status, and management of the resident’s financial liabilities. The responsible party was also an authorized party on the resident’s private bank accounts used to pay the resident’s monthly private pay liability to the facility. The resident, who had diagnoses including unspecified cerebral infarction (stroke), chronic CHF, and metabolic encephalopathy, was admitted on the specified date and later died of natural causes at the facility. At the time of death, the business office and resident account records showed that $1,995.00 was owed to the responsible party to settle the account. The facility did not disburse these funds until after it received a notarized Heirship Affidavit from the local court and then further delayed issuing the refund check for 41 days after receipt of that document, resulting in the refund being paid more than five months after the resident’s death. During interview, the Administrator confirmed that, under the admission agreement, the refund should have been issued within 30 days of the resident’s death and that the agreement had not been followed by the former administration.
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