Failure to Properly Execute Arbitration Agreements
Penalty
Summary
The facility failed to ensure that arbitration agreements were properly explained to residents or their representatives in a manner they could understand, as required by federal regulations. Specifically, the facility did not obtain signatures from residents or their representatives acknowledging their understanding and agreement to the arbitration terms. This deficiency was identified during a survey where three residents were reviewed for arbitration agreements. Resident #87, who was admitted to the facility with intact cognition, did not have a signature on the arbitration agreement, although an electronic signature by a staff representative was present. During an interview, the resident stated that he was unable to recall any discussion about the arbitration agreement due to being heavily medicated upon admission. Similarly, Resident #306 and his wife both confirmed that no one explained the arbitration agreement to them, and the resident did not sign the document or receive a copy of it. Resident #307's records also lacked the necessary signatures from either the resident or their representative. Interviews with facility staff revealed confusion and miscommunication regarding the process of obtaining and documenting consent for arbitration agreements. The Admissions Director and the Concierge provided conflicting information about the list of residents who had signed the agreements, and the Concierge admitted to using a tablet to document refusals without obtaining actual signatures from residents or their representatives.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #87 discharged on 4.5.25 and is no longer residing in the facility. On 4.9.25 the arbitration agreement was reviewed and completed for resident #306 with resident signature confirming understanding. On 4.9.25 the arbitration agreement was reviewed and completed for resident #307 with resident signature confirming understanding. Resident #307 discharged on 4.14.25 and is no longer residing in the facility. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 4.9.25 the Vice President of Business Development completed a quality review of current residents to ensure arbitration agreement reviewed with resident/responsible party and documentation of comprehension of agreement in place; any concerns identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On 4.4.25 the Vice President of Business Development completed education with current admissions staff on the components of F847 arbitration agreement with emphasis on arbitration agreement reviewed/signed with resident/responsible party and documentation of comprehension of agreement. Newly hired admissions staff will be educated on the components of F847 arbitration agreement with emphasis on arbitration agreement reviewed/signed with resident/responsible party and documentation of comprehension of agreement in place by the Assistant Director of Nursing/designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Administrator/Designee to conduct random audits of 5 newly admitted residents 2 times a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with F847 arbitration agreement with emphasis on arbitration agreement reviewed/signed with resident/responsible party and documentation of comprehension of agreement in place. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.