Failure to Develop Policies for Medicare Health Plan Changes
Summary
The facility failed to develop policies and procedures in accordance with CMS guidance to protect residents from being disenrolled from Medicare Health Plans without their request, consent, knowledge, and/or complete understanding. A review of clinical records, CMS guidance, and facility documentation, along with staff interviews, revealed that the facility did not have established policies and procedures to ensure that residents or their representatives were fully informed, both verbally and in writing, about the risks and impacts of changing their Medicare health plans. The Nursing Home Administrator confirmed that the facility may initiate discussions about making changes in Medicare Health plans for its residents but was unable to provide documentation of policies and procedures that outline the process of assisting beneficiaries with such changes and ensuring that residents possess the cognitive ability to make these changes at the given time. The CMS memo reviewed indicated that only a Medicare beneficiary, their authorized representative, or a party authorized under state law can request enrollment or disenrollment from a Medicare health or drug plan. The facility did not have documentation to support that enrollment actions were initiated by the beneficiary or their representative, nor did it have a process to ensure that residents understood the impact of changing their coverage. The lack of documentation and established procedures suggests that the facility did not comply with regulations regarding enrollment/disenrollment and resident rights, as required by CMS and state codes.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to ensure that residents were provided with and signed the necessary admission documentation, including the Consent to Treatment and Other Acknowledgements form and the Nursing Home Admission Agreement. This affected 41 residents, resulting in the facility not having consent to bill Medicare/Medicaid or to treat the residents.
Failure to Provide and Obtain Signed Admission Documentation
Penalty
Summary
The facility failed to ensure that residents admitted were provided with a description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources, as well as information concerning Medicare and Medicaid eligibility and coverage. This deficiency affected 41 residents whose records were reviewed for admission documentation. The review revealed that the Consent to Treatment and Other Acknowledgements form was not signed by the resident or their representative, nor was it witnessed by a facility representative. Additionally, the Nursing Home Admission Agreement, which describes the daily room rate, the right to an assessment of resources, and the authorization to bill Medicaid or Medicare for services rendered, was also not signed or witnessed as required. For instance, Resident #2 was admitted with diagnoses including hypertension, heart failure, and chronic kidney disease. The admission documentation for this resident lacked the necessary signatures on both the Consent to Treatment and Other Acknowledgements form and the Nursing Home Admission Agreement. Similar deficiencies were found in the records of other residents, such as Resident #3, who was admitted with hyperglycemia, diabetes, and hypertension, and Resident #5, who was admitted and readmitted with diagnoses including encephalopathy, chronic obstructive pulmonary disease, and hypertension. In each case, the required forms were not signed by the resident or their representative, nor were they witnessed by a facility representative. The issue was confirmed during an interview with Social Service Designee (SSD) #828, who acknowledged that the facility did not ensure the 41 residents had signed admission agreements. This lack of signed documentation resulted in the facility not having consent to bill Medicare/Medicaid for services rendered or a consent to treat while the residents were admitted. This deficiency represents non-compliance investigated under Complaint Number OH00151839.
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