Failure to Provide Estimated Costs on CMS-10055 Forms
Penalty
Summary
The facility failed to provide residents with an estimated cost of skilled services on the CMS-10055 form when Medicare coverage was ending. For three residents reviewed, the section of the form requiring an estimated cost was left incomplete, with the word 'Pending' written instead of an actual amount. This omission occurred despite the requirement to inform residents of their potential financial liability for services not covered by Medicare or Medicaid. Interviews with the MDS Coordinator revealed that the facility relied on a contracted billing service and did not have direct access to the pricing information needed to complete the forms. The MDS Coordinator did not attempt to obtain the necessary cost estimates from the billing service or corporate headquarters. The DON acknowledged that the lack of estimated costs prevented residents and their representatives from making fully informed decisions about whether to continue skilled services that might not be covered.