Failure to Verify Legal Authority for Medicare Advantage Enrollment
Penalty
Summary
The facility failed to ensure that there was proper documentation verifying that residents' representatives had the legal authority to make decisions regarding enrollment in a Medicare Advantage plan. This deficiency was identified for eight residents who were enrolled in a new Medicare Advantage Institutional Special Needs Plan (I-SNP) through an outside insurance vendor. The process involved the Social Service Director (SSD) introducing the insurance agent to residents and contacting representatives for those deemed non-decisional based on their Brief Interview for Mental Status (BIMS) scores. However, the SSD was not present during the enrollment discussions or when consent forms were signed, and the facility did not verify or maintain documentation confirming the legal authority of those signing on behalf of cognitively impaired residents. For several residents with moderate to severe cognitive impairment, as indicated by low BIMS scores, enrollment forms were signed by family members or significant others whose legal authority to act as Power of Attorney (POA) or health care surrogate was not established in the residents' medical records. In some cases, POA paperwork was either missing, incomplete, or executed after the enrollment forms were signed. For example, one resident's enrollment form was signed by a significant other, but the POA paperwork did not include the resident's name, and another resident's daughter signed the enrollment form before POA documentation was completed. Other cases involved siblings or children signing without any supporting legal documentation in the records. The facility did not have a policy regarding the obtaining of consents for such enrollments, and staff relied on the insurance vendor's process without ensuring compliance with CMS requirements. CMS guidance specifies that an authorized representative must have legal authority under state law and that documentation of this authority must be available upon request. The lack of verification and documentation of legal authority for those enrolling residents with cognitive impairment in the Medicare Advantage plan constituted the deficiency identified during the survey.