Failure to Include Service Costs on Beneficiary Notices
Penalty
Summary
The facility failed to ensure that the estimated costs of services were included on the CMS-10055 forms for three residents reviewed for beneficiary notifications. The forms, which are intended to inform residents of their potential liability for services not covered by Medicare, were missing the section that specifies the cost of skilled services. This omission was identified during a review of the forms signed by the residents, where it was noted that the cost section was left blank. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed a lack of awareness regarding the requirement to include service costs on the CMS-10055 forms. The MDS Coordinator, who was new to filling out these forms, was unaware of the need to specify costs and did not know if there was a facility policy for completing beneficiary notices. The DON confirmed that the purpose of the form is to inform residents of their rights to appeal non-coverage and the costs of services, acknowledging that the omission of cost information could impact residents' decision-making.