Failure to Provide Required Medicare Coverage Notices to Resident with Decision-Making Capacity
Penalty
Summary
The facility failed to provide a resident with the required Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), which are documents intended to inform Medicare beneficiaries when their covered services are ending and when they may be liable for payment for non-covered services. The resident in question was admitted with diagnoses including generalized muscle weakness, abnormal gait, and lack of coordination, and was assessed as having no cognitive impairment and the capacity to make his own decisions. Despite this, the facility provided the NOMNC and SNFABN to the resident's son, who was not involved in the resident's care and was not authorized to make healthcare decisions on his behalf. The son made the decision to forfeit the appeal process for continued Medicare coverage, resulting in the discontinuation of the resident's rehabilitative services and transition to custodial care. Interviews and record reviews confirmed that the resident was not aware of the forfeiture of his appeal rights and would have wanted to make the decision himself. The facility's own policy required that residents or their representatives be informed in advance of changes to their billing and coverage, and that they be given the opportunity to assume financial responsibility for continued skilled services. The failure to provide the required notices directly to the resident, who was capable of understanding and making decisions, resulted in the resident losing the opportunity to appeal the termination of Medicare coverage for his rehabilitative services.