Failure to Notify Responsible Party of Medicaid Approval and Share of Cost
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
The facility failed to issue timely refunds to two residents or their estate after discharge and death, respectively. One resident with multiple sclerosis and osteoporosis was discharged to another setting, but a refund of private pay funds was not issued until more than 90 days later, exceeding both regulatory and facility policy timeframes. Another resident with dementia died in the facility, and a substantial refund owed to the estate was also delayed beyond 90 days, with the responsible party reporting repeated, unanswered contacts to corporate staff. The receptionist, who handled petty cash and communicated with the off‑site business office, and the administrator both confirmed that the refunds were not processed within the required time limits.
A resident was not given the required Quality Improvement Organization (QIO) contact information on their Notice of Medicare Non-Coverage, preventing access to the appeal process for ending skilled services. Staff interviews confirmed the omission of the QIO name and phone number on the notice.
The facility did not provide complete Notice of Medicare Non-Coverage (NOMNC) forms for three residents, as the forms lacked specific information about which services would be discontinued. This omission was confirmed by the Social Service Designee.
A resident with multiple chronic conditions was not given a complete Notice of Medicare Non-Coverage when skilled services ended. The notice lacked details about the specific services being discontinued and did not include required appeal contact information or a phone number, as confirmed by facility leadership.
The facility did not fully complete required ABN forms for two residents, omitting key information such as the start date for potential financial liability and estimated service costs, as confirmed by a social worker and in contrast to facility policy.
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Failure to Timely Issue Resident Refunds After Discharge and Death
Penalty
Summary
The facility failed to ensure residents received refunds due within the regulatory timeframe of 30 days, and also failed to meet its own 90‑day refund policy. One resident with multiple sclerosis and osteoporosis was admitted and later discharged to an assisted living facility, with nursing documentation confirming the discharge. An invoice showed that this resident’s refund check for $1,565 was not issued until more than 90 days after discharge, exceeding both the facility’s policy and regulatory requirements. Another resident with dementia was admitted and later expired in the facility, with nursing notes documenting the death and notification of the physician, family, and hospice. An invoice indicated that a refund check for $6,440 to this resident’s estate was issued more than 90 days after the resident’s death. The responsible party reported not having received the refund despite multiple contacts with corporate staff. The receptionist, who managed petty cash and communicated with the corporate office, believed refunds should be issued within 90 days and acknowledged that the time elapsed for this refund exceeded that period. The administrator confirmed that refunds are processed by the corporate office, not on-site, and acknowledged that both residents’ refunds were issued later than 90 days after discharge or death and beyond the 30‑day regulatory requirement.
Failure to Provide QIO Information on Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide required information regarding the Quality Improvement Organization (QIO) on the Notice of Medicare Non-Coverage letter given to a resident whose skilled services and therapies were ending. Review of the resident's medical record showed that the notice, signed by the resident or their representative, did not include the QIO's name or phone number, which is necessary for the resident to request a timely appeal of the termination of services. This omission was confirmed during interviews with both the Social Service Coordinator and the Director of Nursing, who acknowledged that the notice lacked the required appeal information.
Incomplete NOMNC Forms Lacking Required Service Details
Penalty
Summary
The facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) forms for three residents contained all required information, specifically omitting details about which services would be discontinued. For each resident reviewed, the NOMNC forms either left blank or did not specify the services that were ending, despite being signed or acknowledged by the resident or their representative. This deficiency was confirmed by the Social Service Designee, who verified that the forms lacked the necessary specific information regarding discontinued services.
Incomplete Medicare Non-Coverage Notice Provided to Resident
Penalty
Summary
The facility failed to provide a complete and accurate Notice of Medicare Non-Coverage (NOMNC) to a resident whose skilled services under Medicare A were ending. The resident, who had a history of heart disease, falls, and chronic obstructive pulmonary disease, remained in the facility after Medicare A services were discontinued. Review of the NOMNC signed by the resident showed that it did not specify the type of services being discontinued, nor did it include information on who to contact for an appeal or provide a phone number. This deficiency was confirmed during an interview with the President of Operations, who acknowledged the notice was incomplete.
Incomplete Advance Beneficiary Notices Provided to Residents
Penalty
Summary
The facility failed to provide complete and accurate information on the Skilled Nursing Facility Advance Beneficiary Notice (ABN) forms for two residents. For one resident with multiple diagnoses including dementia, chronic kidney disease, and pressure ulcer, the ABN form was missing the required 'beginning on' date, which is necessary to inform the resident when they may become financially responsible for services. This omission was confirmed by the social worker during an interview. For another resident with diagnoses such as hypertension, COPD, vascular dementia, and dysphagia, the ABN form was also missing the 'beginning on' date and did not include the estimated cost per day or per service. The social worker confirmed these omissions during an interview. Review of the facility's policy indicated that the ABN should be fully completed to inform Medicare beneficiaries of their potential liability, but this was not followed in these cases.
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