Failure to Inform Residents About Ombudsman Program
Summary
The facility failed to ensure that residents were informed about the State Long-Term Care Ombudsman program, which is an advocate for residents' rights in long-term care. This deficiency was identified through observations, interviews, and record reviews, revealing that five residents were not provided with accessible information about the ombudsman. The residents involved had various medical conditions, including dementia, stroke, multiple sclerosis, and Alzheimer's disease, with some having intact cognition while others had moderate cognitive impairments. During a Resident Council meeting, the residents expressed that they were unaware of what an ombudsman was, the services provided, or how to contact them. The facility's Activities Director admitted to not reviewing ombudsman information with the residents and was unaware of the ombudsman's role. The facility's Administrator stated that all staff were required to know about the ombudsman and how to direct residents to their advocate, indicating a lapse in staff training and communication regarding this requirement.
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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