Failure to Notify Resident Representative of Medicare Non-Coverage Due to Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a Notice of Medicare Non-Coverage (NOMNC) and Advanced Beneficiary Notice (ABN) were provided to the appropriate representative for a resident with known cognitive impairment. The resident in question had documented moderate to severe cognitive deficits, as evidenced by a Brief Interview for Mental Status (BIMS) score of 9 and multiple St. Louis University Mental Status Examination (SLUMS) scores indicating dementia. The resident's care plan and provider notes consistently identified cognitive impairment, confusion, and the involvement of a family member as the resident's decision-maker and power of attorney (POA). Despite this, the facility had the resident personally sign the NOMNC form when skilled services were ending, without involving the family member or POA. The business office manager stated that the facility was unaware of the POA status, as there was no documentation of a POA or guardian on file, and the resident was listed as the guarantor on hospital forms. The family member, who had previously handled all paperwork for the resident, was not notified of the coverage termination and only became aware after the resident's status changed to private pay, resulting in an outstanding bill. The facility's policy required that the NOMNC be issued to the resident or legal responsible party, but did not specify procedures for residents with cognitive deficits. The policy also indicated that staff should confirm receipt of the notice and adequately explain it, but in this case, the notice was not communicated to the family or POA, and the resident, due to cognitive impairment, was unable to understand or contest the decision. The deficiency was identified through interviews, document review, and communication with the ombudsman.