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F0582
B

Failure to Provide Required Cost Estimates on SNF ABN Forms

Berlin, New Hampshire Survey Completed on 06-19-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide written notification to residents and/or their representatives regarding the specific items and services offered by the facility, the charges for those services, and the amount of potential liability for services not covered by Medicare. For two residents who were discharged from Medicare services but remained in the facility, the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) forms did not include the required estimated costs for ongoing care and services. Instead, the forms stated 'No cost estimate available' for the per day/item or service, which did not meet the requirement for a good faith cost estimate as outlined in the SNF ABN form instructions. Interview with a staff member from Social Services confirmed that it was their practice to write 'No cost estimate available' rather than providing an estimated cost. Review of the official SNF ABN form instructions indicated that while it is permissible to state that no cost estimate is available in rare circumstances, this should not be a routine or frequent practice. The deficiency was identified through record review and staff interview, and it affected two residents who remained in the facility after their Medicare coverage ended.

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