Failure to Inform Resident of Insurance Coverage
Summary
The facility staff failed to inform a resident about her medical coverage during her stay, resulting in a deficiency. The resident, who had diagnoses of depression and anxiety disorder, was admitted to the facility with intact cognitive skills and the capacity to make decisions. However, the facility did not inform her that she lacked secondary insurance coverage, which would cover costs not paid by her primary insurance. This oversight led to the resident receiving a medical bill for the uncovered amount. The facility's electronic medical records lacked documentation indicating that the resident was informed about her lack of secondary coverage. Interviews with the Business Office Manager (BOM) and the Director of Nursing (DON) revealed that the facility's protocol required staff to verify and inform residents about their insurance coverage upon admission and assist them in applying for secondary coverage if needed. However, the BOM admitted that there was no conversation or documentation regarding the resident's lack of secondary coverage, and the DON confirmed that it was the staff's responsibility to assist residents with applying for Medicare services. The resident expressed that she was unaware of her lack of secondary coverage and would have chosen not to stay at the facility had she been informed. She expected the facility staff to inform her of her medical benefits and assist with any issues, but this did not occur. The BOM and DON acknowledged the importance of informing residents about their insurance status to prevent issues with continuous care and financial responsibility for uncovered portions of care.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with complex medical and behavioral health needs was not provided with information or assistance to apply for long-term Medicaid benefits after her skilled care Medicaid coverage ended. Despite facility policy requiring such assistance, staff confirmed that the resident was not offered help with the Medicaid application process.
Failure to Assist Resident with Medicaid Application After Change in Payor Status
Penalty
Summary
The facility failed to provide a resident with information and assistance regarding how to apply for Medicaid benefits when her skilled care Medicaid coverage ended. The resident, who had multiple complex medical diagnoses including chronic respiratory failure, severe malnutrition, COPD, substance use disorders, and mental health conditions, was admitted to the facility and later received a notice from the Medicaid provider stating she no longer required daily nursing care and could be cared for at a lower level. Despite this change in payor status, the facility did not offer or assist the resident in applying for long-term Medicaid services, as confirmed by interviews with the Business Office Manager and the resident herself. A review of the facility's policy indicated that residents who continue to need LTC services should be provided with the necessary assistance to apply for Medicaid coverage. However, documentation and staff interviews revealed that this assistance was not provided to the resident in question. The facility's failure to act was further highlighted by the lack of explanation from staff as to why the application process was not initiated, despite the resident's ongoing need for care and the facility's stated policy.
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