Failure to Ensure Informed Consent for Medicare Plan Changes
Summary
The facility failed to develop and implement policies and procedures in accordance with CMS guidance to protect residents from being disenrolled from Medicare Health Plans without their informed consent. The deficiency was identified through a review of clinical records, CMS guidance, facility documentation, and interviews with staff and residents. The facility did not ensure that residents were fully informed of the risks associated with disenrolling from Medicare Advantage plans, nor did they assess the residents' cognitive competence to make such decisions. Three residents were affected by this deficiency. Resident 3, who was cognitively intact with a BIMS score of 13, was disenrolled from her Medicare Advantage plan without documented evidence of her initiating the request or understanding the implications. Similarly, Resident 4, also cognitively intact, was disenrolled from his plan without proper documentation of his or his representative's understanding of the change. Resident 5, who was not available for interview, was also disenrolled without evidence of initiating the request or understanding the change. Interviews with facility staff, including the Business Office Manager and the Nursing Home Administrator, confirmed that the facility lacked operational policies and procedures for assisting residents with changes to their Medicare health care coverage. The staff admitted to discussing insurance changes with residents during open enrollment without the residents initiating these requests, which contributed 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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