Failure to Notify Responsible Party of Medicaid Approval and Share of Cost
Penalty
Summary
The facility failed to notify the responsible party or Power of Attorney of a resident's Medi-Cal insurance approval in a timely manner. The resident in question was admitted with multiple diagnoses, including myalgia, unspecified dementia, unspecified psychosis, and toxic encephalopathy, and was assessed as having severely impaired cognitive skills and requiring maximal assistance with activities of daily living. According to the Social Service Director (SSD), both she and the Business Office Manager (BOM) were responsible for notifying residents or their responsible parties of Medi-Cal approval. Although the resident's Medi-Cal insurance was approved in August, the SSD did not notify the responsible party until several months later, in March, due to an outstanding share of cost balance. The BOM stated that she attempted to call the responsible party in October to inform them of the Medi-Cal approval and share of cost, but the call was not answered. Despite frequent visits and calls from the responsible party, there was no documentation or confirmation that the responsible party was notified of the insurance approval or the share of cost. The facility's policy and procedures require the Social Services Designee to provide information to residents and families regarding Medicare/Medicaid and other financial assistance programs, but this was not followed in this instance.