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F0847
D

Failure to Ensure Residents' Capacity to Understand Arbitration Agreements

Beaver, Pennsylvania Survey Completed on 02-14-2025

Penalty

Fine: $28,71056 days payment denial
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement, as evidenced by the cases of two residents. Resident R300, who was admitted to the facility, signed a binding arbitration agreement the day after admission. However, a subsequent Minimum Data Set (MDS) assessment revealed that the resident had severe cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 3, indicating a lack of capacity to comprehend the agreement. The resident was diagnosed with Non-Alzheimer's Dementia, weight loss, and depression, which further contributed to the cognitive impairment. Similarly, Resident R428 signed a binding arbitration agreement shortly after admission. An MDS assessment conducted a few days later showed that this resident also had severe cognitive impairment, with a BIMS score of 0. The resident was diagnosed with Non-Alzheimer's Dementia, diabetes, and high blood pressure. The facility's Admission Director confirmed that the facility did not ensure these residents had the capacity to understand the terms of the binding arbitration agreements they signed.

Plan Of Correction

1. A binding arbitration agreement was sent to R428's emergency contact. A binding arbitration agreement was sent to R300's. 2. The New Admissions Director audited the last 30 days of admissions to ensure residents who admitted and signed arbitration agreements understood, per the regulation. 3. The New Admissions Director was re-inserviced by the NHA to ensure residents who admit and review the arbitration agreement are explained in a manner they can understand per the regulation. 4. The New Admissions Director will audit admissions for the next 30 days to ensure residents who admit and review the arbitration agreement are explained in a manner they can understand per the regulation. Audit findings will be shared by the QAPI committee.

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