Failure to Maintain Accurate Medical Records for NOMNC Issuance
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident, as required by accepted professional standards. Specifically, there was a discrepancy in the documentation and issuance of the Notice of Medicare Non-Coverage (NOMNC) for the resident. The family member responsible for the resident received the NOMNC via email on 04/08/25, indicating that services would end on that date. However, the resident's electronic health record (EHR) contained a scanned copy of the NOMNC with handwritten information stating it was issued on 04/04/25, and a social services note also documented the NOMNC as being issued on 04/04/25. During interviews and record review, the Social Services Assistant confirmed that the NOMNC was actually issued on 04/08/25, not 04/04/25 as documented in both the EHR and the social services note. This inconsistency in documentation demonstrates a failure to maintain accurate medical records for the resident.