Failure to Provide Medicare Beneficiary Notices
Summary
The facility failed to provide appropriate liability and appeal notices to Medicare beneficiaries, as required by Medicare guidelines. This deficiency was identified during a recertification survey, where it was found that two residents, who were receiving Medicare Part A Skilled Services, were not given the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN- form CMS-10055) upon the termination of their Medicare benefits. The facility's policy mandates the issuance of this notice to inform residents of potential liability for services not covered by Medicare, but there was no documented evidence that the notice was provided to the affected residents. Interviews conducted during the survey revealed that the Minimum Data Set Coordinator, who is responsible for informing residents about their Medicare coverage, was unaware of the requirement to issue the SNF ABN. The Director of Nursing Services stated that they were not involved in the beneficiary notification process, which is handled by the Minimum Data Set Coordinator. This lack of awareness and communication within the facility led to the failure to provide the necessary notices to the residents, resulting in a deficiency under the regulation 10 NYCRR 415.3(h)(2)(i).
Plan Of Correction
Plan of Correction: Approved January 3, 2025 Immediate Corrective Action: - The Facility Administrator on 12/09/2024 issued the Minimum Data Set Coordinator a memorandum regarding Medicaid/Medicare Coverage/Liability Notice and updated protocols for ensuring residents are aware of their rights. - An Adhoc meeting was held by the DON on 12/09/2024 with the MDS coordinator and Compliance Officer to review and discuss the notification process and policy. No amendments were made to the policy. Resident #24 and Resident #36 were individually notified at the conclusion of the meeting regarding the ineffective notification and the facility’s commitment to minimizing these deficiencies. Identification of Others Potentially Affected: - The facility respectfully submits all residents were potentially affected by this practice. A list of other residents that remained in the facility and were discharged from a MCR Part A stay were reviewed and will be given the SNFABN as appropriate. Systemic Changes to Prevent Recurrence: - The Compliance officer and DON formulated and reinstated the protocol and procedure for Medicaid/Medicare Coverage/Liability Notification on 12.10.2024. - The MDS coordinator and RN Managers were re-in-serviced on 12.12.2024 by DON for the protocols and procedures regarding NOTIFYING RESIDENTS OF MEDICAID/MEDICARE COVERAGE OR LIABILITY. Quality Assurance Monitoring: - The Minimum Data Set Coordinator will perform weekly audits for residents for the next 2 months, then monthly thereafter to maintain compliance. Any discrepancies identified during the audit will be reported and documented to the DON. The qualitative summary and analytics will be presented quarterly at the QAPI team meetings. - Audit tool has been created and implemented for ongoing monitoring. Responsible Party: Minimum Data Set Coordinator
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Provide SNF-ABN for Medicare Non-Covered Services: The facility failed to provide a SNF-ABN to a resident when Medicare Part A coverage ended and the payor source changed to private pay. Records showed the resident had diagnoses including an artificial hip joint, cellulitis, and dysphagia, and staff documented only a NOMNC review with the resident’s wife; the chart did not show that the resident or family received the SNF-ABN for services no longer covered under Medicare Part A.
A resident with Medicare Part A skilled services remaining was given a NOMNC, but the facility did not provide the required SNF-ABN showing the estimated cost if the resident chose to continue services privately. The DON said she believed the SNF-ABN was unnecessary because the resident had Medicaid pending and only issued the NOMNC.
Failure to Provide Notice of Medicare Non-Coverage: A resident did not have clear documentation that she received notice of Medicare non-coverage before services were denied. The resident’s denial forms contained signatures that did not appear consistent with each other or with the admission financial form, and the progress notes did not show the forms were received. When interviewed, the resident did not recall signing any papers about Medicare denial or the right to appeal.
Failure to Provide Timely Medicare Non-Coverage Notices: The facility did not ensure two residents received proper written notice of Medicare non-coverage through SNFABN/NOMNC. One resident’s form only documented a voicemail to the RP, with no signature, no clear contact documentation, and no proof the notice was mailed. Another resident did not receive a SNFABN even though Medicare Part A skilled services were ending and therapy continued beyond the family’s stated preference.
A resident who was Medicaid-eligible did not have written admission notices in the chart showing which items and services were covered under the State Medicaid plan and which services could be charged out of pocket, including the charge amounts. Although the facility’s admission packet included a Consent to Treat, admission agreement, and Explanation of Charges, the resident’s record lacked signed or dated copies, and the Administrator and DON acknowledged the missing documentation.
A facility failed to provide the required SNFABN to two residents whose Medicare Part A coverage ended but who stayed in the facility on private pay. Although NOMNCs were signed and indicated coverage would end, the records lacked evidence that the residents or their representatives were given the ABN explaining potential costs and options. Interviews showed confusion between SS and the HUC about who was responsible for completing the forms, and both confirmed the forms were not completed for these residents.
Failure to Provide SNF-ABN for Medicare Non-Covered Services
Penalty
Summary
The facility failed to provide a Skilled Nursing Advanced Beneficiary Notice of Non-coverage (SNF-ABN) with the estimated amount of nursing services that would be charged for one of three sampled residents, Resident R120. Review of the admission record showed the resident was originally admitted on [DATE]. His MDS dated 6/18/26 listed diagnoses including an artificial hip joint, cellulitis, and dysphagia. The census document showed he was admitted under Medicare Part A on 3/27/26 and changed to private pay on 4/19/26. A social services note dated 4/17/26 documented that Resident R120 was given a NOMNC form and that it was verbally reviewed with his wife, since he was unable to sign. The note stated that both the resident and his family acknowledged and agreed with the NOMNC and did not intend to appeal. However, review of the social services notes and clinical nurse notes did not show that Resident R120 or his wife were provided with a SNF-ABN form for services no longer covered under Medicare Part A. During interview on 8/5/26 at 10:19 a.m., the Regional Director of Clinical Services confirmed that the facility failed to provide the SNF-ABN form to inform the resident or his family of items and services no longer deemed eligible under Medicare Part A.
Failure to Provide SNF-ABN for Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) to 1 of 3 sampled residents, R1, when Medicare Part A skilled services had days remaining. R1's CMS-10123 Notice of Medicare Non-Coverage (NOMNC) showed that services ended on 7/17/26, but R1 was not given the CMS-10055 SNF-ABN identifying the estimated cost of services if she chose to continue skilled services on her own. During an interview on 8/4/26 at 10:30 a.m., the DON stated she had taken over providing beneficiary notices after a recent staffing change and believed the CMS-10055 was not needed because R1 had Medicaid pending, so only the CMS-10123 notice was provided. The facility's 5/12/26 ABN policy stated the ABN informs the beneficiary of potential non-coverage and the shift of financial liability if Medicare denies the claim.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to ensure a resident received notice of Medicare non-coverage for services covered under Medicare before those services were denied. For one resident, the admission record showed an admission date of 8/21/25 and discharge date of 9/10/25, and the financial questionnaire from admission contained the resident’s signature. The resident’s Medicare denial form (CMS-10123) dated 9/5/25 and managed care denial form (U Care) dated 9/7/25 also contained signatures, but the signatures on the forms did not appear similar to each other, and the signature on the U Care form did not appear similar to the financial questionnaire signature. The resident’s progress notes did not show that the Medicare or U Care denial forms were received, and during an interview on 7/31/26, the resident stated she did not recall signing any papers about Medicare denial and the right to appeal. The resident reported she had been at the facility for 21 days and was home and doing well.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to ensure timely written notification of Medicare non-coverage for two residents reviewed for beneficiary notification. For one resident, the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage indicated that skilled services covered by Medicare Part A were expected to end and that the resident would convert to Medicaid, but the signature line only noted that a voicemail was left with the responsible party. The form did not contain the resident’s or authorized representative’s signature, and there was no documentation identifying who was contacted, documenting telephone contact attempts, or showing that the written notice was mailed when contact could not be verified. The resident remained at the facility. For another resident, the Business Office Manager did not provide a SNFABN for Medicare Part A skilled services that were scheduled to end, and the resident later discharged from the facility. During interview, the Business Office Manager stated that a call had been placed to the responsible party for the first resident and a message was left, but no follow-up occurred and no return call was received. The Business Office Manager also stated that the second resident’s family had said on admission they did not want the resident to stay beyond 20 days and believed this was a family-initiated discharge, so a SNFABN was not required, even though the resident stayed past 20 days and received therapy services.
Missing Admission Notice and Charge Disclosure Documentation
Penalty
Summary
The facility failed to ensure that one Medicaid-eligible resident was informed in writing, at the time of admission or when the resident became eligible for Medicaid, of the items and services included under the State Medicaid plan that could not be charged to the resident and the items and services offered by the facility that could be charged, including the amount of those charges. The deficiency was identified during record review and interview for Resident #12, who was the only Medicaid-eligible resident reviewed. Review of the facility’s admission packet showed a Consent to Treat signature page, an admission Agreement stating that the resident had received an explanation of charges, and an Explanation of Charges document listing items and services covered in the daily room rate and those that could result in out-of-pocket charges. However, Resident #12’s medical record did not contain a signed or dated consent for treatment, admission agreement, or explanation of charges. During interviews, the Administrator stated leadership was unable to locate the admission paperwork, the DON acknowledged the missing documentation, and the past Administrator could not explain why the resident did not have the admission notices in the chart.
Missing SNFABN When Medicare Part A Ended
Penalty
Summary
The facility failed to ensure that residents whose Medicare Part A services were ending, but who remained in the facility, received the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) before services terminated. Two residents, R4 and R31, were identified as affected. R31 was admitted on Medicare Part A coverage, which ended on 5/11/26, and remained in the facility on private pay the next day. Although R31 had a signed Notice of Medicare Non-coverage (NOMNC) dated 5/7/26 stating Medicare coverage would end on 5/11/26, the electronic medical record did not show that a SNFABN was provided to R31 or the representative to advise of the potential cost of staying in the facility after Medicare Part A ended and to offer the choice of receiving the services, asking Medicare to be billed, or declining the services. R4 started Medicare Part A coverage on 5/4/26 and it ended on 6/27/26; R4 remained in the facility on private pay the next day. R4’s NOMNC, signed 6/24/26, stated Medicare coverage would end on 6/27/26 and noted verbal consent from the responsible party, with the form signed by the facility social services employee. However, the record lacked evidence that a SNFABN was provided to R4 or the representative. During interviews, the social services employee stated she had not been completing the forms and was not trained on them, while the health unit secretary stated she had not completed the NOMNC or ABN forms since April 2026 and confirmed R4 and R31 did not receive them. The administrator stated the NOMNC and ABN forms should be completed in a timely manner, and the facility policy stated that if the beneficiary continues to stay in the care center, the facility would provide the NOMNC and SNF ABN demand bill portion.
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