Failure to Protect Residents from Exploitation During Medicare Advantage Plan Changes
Penalty
Summary
The facility failed to protect residents from exploitation by allowing an outside insurance vendor to make unauthorized changes to the Medicare Advantage plans of cognitively impaired residents. The process involved the facility's Social Service Director (SSD) introducing the insurance agent to residents and providing a list of residents deemed 'conversational' or cognitively intact, based on BIMS scores. However, the SSD was not present during the insurance presentations or when enrollment forms were signed, and could not explain why residents with BIMS scores below 12 were included. The insurance agent relied solely on the facility's assessment of residents' decisional capacity and did not verify cognitive status or legal authority to consent. Three residents were specifically identified as having their Medicare Advantage plans changed without proper consent. One resident, with severe cognitive impairment and no documented POA or family notification, was unable to recall or understand the insurance change and had a history of mental illness and behavioral symptoms. Another resident, also with moderate cognitive impairment and no POA or family notification, did not understand the insurance discussion or why they signed the paperwork. The third resident, with severe cognitive impairment and a documented POA, was not able to understand or recall the insurance change, and the POA was not contacted or present for the consent process. In all cases, the enrollment forms were signed with a typed signature, and there was no evidence that the residents or their legal representatives were properly informed or consented to the changes. The facility's own policies require the prevention of exploitation and the identification of residents at increased risk for abuse or neglect, including those with cognitive impairment. Despite this, the facility did not ensure that only residents capable of informed consent were approached by the insurance agent, nor did they notify or involve family members or legal representatives as required. The process lacked oversight, documentation, and verification, resulting in unauthorized changes to vulnerable residents' insurance coverage.