Failure to Provide Required Admission Documentation and Disclosures
Penalty
Summary
The facility failed to establish and implement an admissions policy for one resident, as evidenced by the lack of a written admission agreement, consent to treat, resident rights notification, Medicare/Medicaid information, and disclosure of services and charges at the time of admission. The resident, a 71-year-old male with multiple complex medical conditions including a recent intracerebral hemorrhage, anxiety disorder, colostomy, urinary retention with catheter, and gastrostomy, was admitted from the hospital for a planned stay. Despite these needs, neither the resident nor his representative received any of the required admission documentation or information upon arrival. Interviews and record reviews revealed that the resident's representative was not provided with an admission packet, was not informed of the resident's rights, and did not receive any required disclosures or facility protocols. The representative reported that all communication regarding the admission occurred between the facility and the hospital, with no direct engagement or paperwork provided to the family. The facility attempted to obtain verbal consents and later requested the resident's social security information for billing, but the representative refused due to concerns about the admission and subsequent transfer to the emergency room. The Business Office Manager (BOM) confirmed responsibility for admission documentation and acknowledged that none of the required forms or consents were completed for this resident. The BOM stated that admission documentation typically begins on the day of admission and can be completed electronically, but in this case, there was no evidence that the resident or representative was notified or provided with the necessary documents. The facility's admission packet, which includes multiple forms and disclosures required by state and federal regulations, was not given to the resident or representative at the time of admission.