Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to inform three residents of their options and costs when Medicare Part A coverage ended, as required by federal regulations. For each of the three residents reviewed, documentation showed that the required CMS-10055 form, which explains non-coverage and provides information about appeal rights and private pay options, was not provided. The residents involved had varying degrees of cognitive impairment and were dependent on staff for activities of daily living. Their care plans included restorative programs and therapy services, and their diagnoses included conditions such as parkinsonism, chronic kidney disease, diabetes, and muscle weakness. Despite the transition from Medicare Part A to private pay status, the necessary notifications and explanations were not documented as given to the residents. Staff interviews revealed that the social worker responsible for providing these notifications was new to the position and unfamiliar with the CMS-10055 form. Upon review, the social worker could not locate the form in facility records and acknowledged that residents should be informed about their financial responsibilities and appeal rights when Medicare coverage ends. Facility policy requires completion of the form and resident signature to confirm understanding, but this process was not followed for the residents in question.