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 discharge planning and Medicare exhaustion notice for a resident. The resident’s record had no documentation of discharge planning, and facility leaders stated the resident was billed at the self-pay rate after Medicare days were exhausted without receiving a letter or other notice. The DON said she was not involved in the admission care plan process, and the Administrator stated the facility does not give residents documentation when Medicare days end and does not have a discharge policy.
Failure to document NOMNC delivery to a resident representative. For one resident sampled for beneficiary notification, Social Services completed the NOMNC verbally by phone, but the form had only one facility signature and there was no record that the notice was mailed to the representative. The DOSS confirmed the lack of documentation and stated the facility does not use certified mail.
The facility failed to provide SNF ABNs to two residents when Medicare Part A coverage ended, and their representatives were not given written notice of possible financial liability for non-covered skilled services. One resident had Alzheimer’s disease and was unable to make decisions, and the representative reported receiving bills without prior written notice. The BOM acknowledged the notices were not provided, and the ADM stated she was not clear on ABN policy and regulations.
A resident with a Medicare Part A episode was not provided the SNF-ABN and NOMNC, and the resident was too confused to sign the forms. Staff reported the resident had no DPOA, the brother signed admission paperwork, and an admin staff member stated the paperwork needs to be signed for the NOMNC and SNF-ABN.
A resident's MPOA did not receive timely NOMNC notice of the end of Medicare-covered skilled services. Facility policy required notice at least 2 days before the last covered day, but the phone notification was made after coverage had already ended, and the Social Services Designee confirmed the MPOA was not notified in advance.
The facility failed to provide a timely NOMNC to a resident with intact cognition. Record review showed Medicare Part A coverage ended before the NOMNC was signed, and the administrator confirmed there was no evidence the notice was given at least two calendar days before coverage ended. The resident stated she did not recall the form being reviewed with her, though she was okay with therapy ending.
Failure to Provide Medicare Exhaustion Notice and Discharge Planning
Penalty
Summary
The facility failed to provide discharge planning and a letter stating when Medicare days would be exhausted for one resident who was sampled for discharge rights. The resident’s face sheet showed an initial admission to the facility, and review of the electronic medical record, including progress notes from 2/2026 through 3/2026, found no documentation of discharge planning. During interview, the Social Services Director stated she began working at the facility in March 2026, after the resident’s admission, and described that discharge planning was discussed at an initial care plan meeting and at weekly Medicare meetings, though she had only attended one or two of those meetings. The Business Office Manager stated the resident’s 100th Medicare day was on 3/18/2026, that discharge paperwork was given on 3/24/2026, and that the resident was billed at the self-pay rate from 3/19/2026 through 3/25/2026. She confirmed the resident was not aware her Medicare days were exhausted during that time. The DON stated she was new to the facility and was not involved in the 72-hour admission care plan meeting, and the Administrator stated the facility does not give residents any documentation or letter when Medicare days are exhausted and does not have a discharge policy.
Failure to Document NOMNC Delivery to Representative
Penalty
Summary
The facility failed to provide documentation that the Notice of Medicare Non-Coverage (NOMNC) was delivered to a resident representative for one of two residents sampled for beneficiary notification. For Resident #101, the NOMNC dated 11/26/25 indicated that Social Services called the resident representative on 11/24/25, but the form was signed by only one facility representative. During interview, the Director of Social Services confirmed that the NOMNC was completed verbally over the phone with only one staff signature, and stated that best practice is to have two signatures. She also stated she could not provide documentation that the NOMNC was mailed to the resident representative because the facility does not use certified mail and there was no documentation in the medical record showing that mailing occurred.
Failure to Provide SNF ABN for Medicare Coverage Changes
Penalty
Summary
The facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) for two sampled residents, Resident 86 and Resident 92, and therefore did not give written notice of Medicare coverage ending or potential financial liability for services not covered. During a concurrent interview and record review, the Business Office Manager stated that Resident 86’s last covered day for Medicare Part A was 4/16/2026 and Resident 92’s was 6/11/2026, and acknowledged that SNF ABNs were not provided in writing to either resident or their representatives. The Business Office Manager stated she was responsible for notifying residents or their representatives of changes in Medicare coverage and possible share of cost, and stated that failure to do so could leave them facing financial difficulties without being informed of changes in benefits or allowed to appeal those decisions. Resident 86’s record showed admission on 2/6/2026 with diagnoses including Alzheimer’s Disease, generalized muscle weakness, and abnormalities of gait and mobility. The MDS indicated the resident was unable to make decisions for self. During interview, Resident 86’s representative stated they were not given any written notification of changes in Medicare coverage and were receiving bills from the facility. The Administrator stated she was not clear on Advanced Beneficiary Notice policies and regulations and acknowledged that if residents were not told their Medicare coverage was ending, they may be unaware of their potential financial responsibilities and share of costs. The facility policy stated that when Medicare may not pay for otherwise covered skilled services, the resident or representative is to be notified in writing of why the services may not be covered and of potential liability for payment.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (CMS-10055) and the Notification of Medicare Non-Coverage (CMS-10123) to Resident 18 or the resident’s representative. The resident’s EMR documented a Medicare Part A episode beginning 02/17/2026 and ending on 03/09/2026. On 06/22/2026, Administrative Staff B reported that Resident 18 was unable to sign the SNF-ABN and NOMNC because the resident was very confused. Administrative Staff B also reported that the resident did not have a DPOA and that the resident’s brother signed all admission paperwork. During an interview on 06/23/2026, Administrative Staff A stated that the paperwork needs to be signed for the NOMNC and SNF.
Late Notice of Medicare Non-Coverage to MPOA
Penalty
Summary
The facility failed to provide adequate notice of the last covered Medicare A days to Resident #127's Medical Power of Attorney (MPOA). The facility policy stated that the Notice of Medicare Non-Coverage (NOMNC) would be provided at least 2 days in advance of the last covered day to allow time to appeal if the beneficiary chose. For Resident #127, the NOMNC stated that Medicare coverage of current skilled services would end on 03/04/26, but the telephone notification to the MPOA was not made until 03/06/26 at 10:00 AM. During an interview, the Social Services Designee confirmed that the MPOA was not notified at least 2 days in advance of the end of Medicare-covered skilled services.
Late NOMNC Delivery
Penalty
Summary
The facility failed to ensure the required Notice of Medicare Non-Coverage (NOMNC) was provided timely to one resident, R27, who had intact cognition on the quarterly MDS. Review of the resident’s SNF Beneficiary Protection Notification Review forms showed Medicare Part A coverage ending on 2/15/26 and again on 5/23/26, with NOMNC forms dated 6/15/26 and signed by the resident on that same date. During interview, R27 stated she did not recall anyone reviewing the form with her but said she was okay with her therapy services ending. The administrator later reviewed the record and confirmed there was no evidence the notice had been given at least two calendar days before the end of Medicare Part A coverage as required by the facility’s NOMNC policy.
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