Failure to Notify Resident of SSI Resource Limit Exceedance
Summary
The facility failed to notify a Medicaid recipient, Resident 10, when their personal fund account balance reached $1,800, which is within $200 of the $2,000 resource limit that could impact their Medicaid coverage. According to the facility's Resident Trust policy, revised in May 2017, the facility was required to notify the resident, their guardian or durable power of attorney, the facility social worker, and the local department of social and health services in writing when a resident's account balance approached this limit. However, the facility did not adhere to this policy, resulting in Resident 10's account balance exceeding the SSI resource limit by $696.53 as of July 23, 2024. Interviews with facility staff revealed a lack of awareness and communication regarding the Medicaid SSI resource limitations. Staff W, an Administrative Assistant, confirmed the excess balance but was unaware of the Medicaid SSI resource limitations and did not discuss trust balances with the social worker. Staff E, the Social Services Director, mentioned that it had been years since they were notified about a resident exceeding their SSI resource limits. The facility administrator, Staff A, acknowledged that Resident 10 should have been notified as per the policy but was not. This oversight placed the resident at risk for personal financial liability for their care.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia, hypothyroidism, and hyperlipidemia was discharged, but the facility’s resident fund account remained open with a balance still in it. The RBOM confirmed the account had not been closed after discharge and stated resident financial accounts should be closed within 30 days, consistent with facility policy.
A facility failed to return trust fund balances for 6 residents after discharge or death within the required 30 days. The BOM stated she was responsible for closing RFMS accounts and notifying AR, but she did not do so for these residents, and another staff member said checks were not distributed because she had only just been notified. Record review showed each resident had a remaining balance, including amounts over $7,000, and the facility policy required conveyance of funds and final accounting within 30 days.
A resident with anxiety disorder, DM2, depression, dementia, and cerebral infarction was cognitively impaired and discharged with a resident fund balance of $10,771.93. The RBO manager confirmed spend-down notifications were not sent to the resident’s POA, and only the quarterly statement was provided. Facility policy required notification when a Medicaid resident’s balance was within $200 of the state asset limit.
A resident’s trust funds were not conveyed within the required timeframe after discharge, and the resident reported not receiving a final accounting or clear explanation of the amount owed. Staff described multiple checks being issued, voided, or returned, with the resident still waiting for payment months later. The facility policy stated discharged resident trust accounts are to be closed within 15 calendar days and a check issued to the resident.
A resident’s personal funds credit balance was not timely refunded after discharge, and the final accounting was delayed while the facility waited on Medicaid reimbursement. Records showed the resident’s Social Security payment was received after discharge, the resident reported not receiving the April SSA check, and staff emails indicated the refund was being held until the bill was caught up. The Administrator confirmed the credit balance should have been sent within 30 days and not withheld pending reimbursement.
A resident’s funds were not returned to the POA within the required timeframe after discharge. The resident was admitted under Hospice private pay with an $8,500 deposit, later discharged home with outside Hospice care, and the spouse filed a complaint about the delayed reimbursement. The NHA said reimbursement requests go to corporate AP, the billing cycle can take 30 to 60 days, and a check was eventually issued and cashed after the delay; the reason for the delay was unknown, though AP and business office staffing had changed.
Failure to Close and Convey Resident Funds After Discharge
Penalty
Summary
The facility failed to convey a discharged resident’s personal funds in a timely manner. Resident #124 was admitted to the facility with diagnoses including dementia, hypothyroidism, and hyperlipidemia, and the most recent quarterly MDS indicated the resident’s cognitive status was unable to be fully assessed, the resident did not reject care or wander, and required moderate to maximal assistance with ADLs. The resident was discharged on 03/16/26, but review of the Resident Statement Landscape from the Resident Fund Management Service showed the resident’s financial management account had not been closed or frozen and still had a balance. During interviews, the RBOM confirmed the account remained open after discharge and stated that resident financial accounts should be closed within 30 days of discharge. Facility policy titled Management of Personal Funds stated the facility will reconcile and close all accounts within 30 days of discharge and send funds to an appropriate agency.
Failure to Return Resident Trust Fund Balances After Discharge or Death
Penalty
Summary
The facility failed to return resident trust fund balances for 6 residents who had been discharged or had expired, and the balances were not conveyed within 30 days. During interview, the Business Office Manager stated that she is responsible for closing residents’ RFMS accounts when a resident discharges or expires and for notifying Corporate Accounts Receivable so a check can be issued to the resident, the resident’s appointed person, or the state. She stated she did not complete this process for residents R5 through R10, and that more than 30 days had passed for each of those residents. The other staff member interviewed stated that trust fund checks are distributed when the address of the recipient is known, and that she had not distributed checks for these residents because she was only notified by the Business Office Manager on the date of interview. Record review showed that each of the 6 residents had a remaining RFMS balance after discharge or death. R5 expired with a balance of $3,432.40. R6 expired with a closing interest balance of $1,274.66. R7 expired with a closing interest balance of $969.33. R8 was discharged with a closing interest balance of $7,724.64. R9 expired with a closing interest balance of $1,538.68. R10 expired with a closing interest balance of $1,904.33. The facility policy stated that upon discharge, eviction, or death, the facility must convey the resident’s funds and a final accounting within 30 days to the resident or, in the case of death, to the individual or probate jurisdiction administering the estate.
Failure to Notify Resident of Spend-Down Balance
Penalty
Summary
The facility failed to ensure residents were notified to spend down their resident fund balances. Record review showed Resident #56 was admitted with diagnoses of anxiety disorder, type II diabetes, depression, dementia, and cerebral infarction, and the MDS assessment identified the resident as cognitively impaired. The resident had an account balance of $10,771.93 upon discharge. During interview, the Regional Business Office Manager confirmed that spend-down notifications were not sent to the resident’s POA, and only the quarterly statement was provided. The manager also confirmed the account balance at discharge and stated that Resident Fund Management Services mailed the quarterly statements and sent a copy to the facility. Facility policy required the community to notify all Medicaid residents or responsible parties once the account balance was within $200 of the state-specific asset limit.
Failure to Timely Return Discharged Resident Funds
Penalty
Summary
The facility failed to convey a discharged resident’s funds and provide a final accounting within 30 days after discharge. The resident stated he was discharged from the facility in late November 2025 and believed he was owed money from the facility, but he had not received any funds or a clear explanation of the amount owed. He reported that when he contacted the facility, he was told a check had already been sent in April 2026, and he also stated that another facility called on his behalf and was told Social Security had sent $720 back to the facility, which he believed he should receive as well. He further stated the facility never told him the amount of the check and that he had not heard back since April 2026. The Business Office Manager stated she had just started on June 1, 2026 and was not aware the resident was waiting on a check, but she had just approved and printed a check dated July 1, 2026 for $689.08 and planned to mail it that day. The Corporate BOM stated she had learned about the resident’s funds about a month earlier and explained that one check had been sent on 5/28/26 and voided because it was never received, a second check was sent on 6/9/26 and returned because it was never received, and a new check dated 7/1/26 was being sent. The facility’s policy stated trust fund accounts are to be closed upon permanent discharge within 15 calendar days, not to exceed into the next month, and a check issued to the resident if the facility was not the rep payee.
Delayed Refund of Resident Personal Funds After Discharge
Penalty
Summary
The facility failed to timely remit and provide a final accounting of a resident’s personal funds after discharge. The resident’s Resident Fund Management Service form showed authorization for a transferring account, a $60 monthly allowance, and direct deposit of Social Security benefits, but did not identify the facility as the resident’s Social Security representative payee. The resident’s Medicaid coverage ended on 2/28/26, and the resident discharged from the facility on 3/9/26. The Healthcare and Family Services LTC Discharge/Death Results documented personal funds and other funds balances of $0.00 and a room and board balance of $2,608.40, and the document was uploaded to the record on 3/10/26. Record review and interviews showed the resident did not receive the April Social Security check after discharge and reported speaking with the Business Office Manager and Social Security without resolution. The March invoice showed a balance forward of $2,608.40, a deposit of $1,627.00 from SSA TREAS 310 XXSOC, and a patient liability charge of $1,627.00, with an ending balance due of $981.40. The April invoice later showed a $1,627.00 SSA credit and an ending credit balance of $309.80. An email from the Business Office Manager stated the April Social Security payment should be sent back because it was received after discharge and that the resident’s $60 should be sent now, with the refund for SSA to follow once the bill was caught up. The trust transaction history showed a $60 deposit and a $60 refund, and the final invoice later showed a balance forward credit of $309.80 with ending balance of $0.00. The Administrator confirmed the resident’s personal funds credit balance should have been sent within 30 days and should not have been withheld pending Medicaid reimbursement.
Delayed Return of Resident Funds After Discharge
Penalty
Summary
The facility did not ensure that resident funds were returned to the Power of Attorney, family, or estate within 30 days of discharge or death for 1 of 3 residents reviewed for conveyance of resident funds. R6 was admitted under Hospice Private Pay, and the facility received an $8,500 check at admission. R6 discharged from the facility to home under the care of an outside Hospice entity on 04/08/26. A complaint was later received from the spouse on 06/22/26 regarding delay in receiving reimbursement for the one-day admission after the deposit had been provided. During interview on 07/09/26, the NHA stated that reimbursement requests are sent to corporate accounts payable, that the billing cycle can take 30 to 60 days, and that a check was cut on 06/12/26 and cashed on 06/22/26. The NHA stated the reason for the delay was unknown, but noted changes in accounts payable personnel and the facility's business office manager during that period.
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