Failure to Provide Accessible Ombudsman Information
Summary
The facility failed to protect resident rights by not providing accessible information regarding the State Long Term Care Ombudsman program and the State Survey Agency. The facility's policy mandates that residents receive a list of pertinent state regulatory and informational agencies, including the ombudsman program and the State Survey Agency. However, an observation on 5/7/24 revealed that the ombudsman poster was hung on a wall in the day room, but it was not visible to residents sitting in wheelchairs. Additionally, during a group interview, residents expressed that they did not know what an ombudsman was, where the information was posted, or how to reach the ombudsman. Twelve residents also did not know how to formally file a complaint with the state survey agency. During an interview on 5/9/24, the Administrator confirmed that the ombudsman contact information was posted in the day room but admitted to not knowing how residents had been educated on reaching the ombudsman representative or the state survey agency. The facility census at the time was 66, indicating a significant number of residents potentially affected by this deficiency.
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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