Failure to Protect Residents from Uninformed Medicare Advantage Disenrollment
Summary
The facility failed to develop and implement operational policies and procedures to protect residents from being disenrolled from their Medicare Advantage Plans without their informed consent. The facility did not follow CMS guidance, which requires that residents or their representatives be fully informed of the risks and impacts of disenrollment and that their cognitive function be assessed to ensure they understand the information. This deficiency affected nine residents, who were either moderately cognitively impaired or had their responsible parties sign disenrollment forms without proper documentation of their request or understanding of the change. For example, Resident 9, who was moderately cognitively impaired, was disenrolled from his Medicare Advantage Plan without documented evidence of his request or understanding of the change. Similarly, Resident 10, also moderately cognitively impaired, was disenrolled without proper documentation or assessment of his cognitive function. In another case, Resident 11, who was cognitively intact, had his responsible party sign the disenrollment form without evidence that the resident or the responsible party initiated the request or understood the implications. Interviews with residents and their responsible parties revealed that the facility staff initiated conversations about changing Medicare plans, often presenting it as necessary for continued services. The facility did not adequately explain the risks or potential changes in coverage, benefits, and copays. The Director of Nursing confirmed that the facility lacked a policy on disenrollment and relied on CMS guidance, which was not properly followed, leading to the deficiency.
Penalty
Resources
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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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