Failure to Provide and Document NOMNC and Appeal Rights for Medicare Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident and/or the resident’s responsible party, as required by facility policy and federal guidance. The resident was originally admitted with multiple diagnoses including a periprosthetic fracture around an internal prosthetic left knee joint, type 2 diabetes mellitus, history of falling, difficulty in walking, and urinary retention. A History and Physical documented that the resident had capacity to understand and make decisions, and a Minimum Data Set showed moderate cognitive impairment and a need for substantial/maximal assistance with toileting, bathing, and lower-body dressing. A physician’s order documented a planned discharge home with home health services. The facility received a NOMNC dated 12/22/2025 stating that Medicare coverage for the resident’s skilled nursing stay would end on 12/24/2025, with discharge scheduled for 12/25/2025. The NOMNC included instructions and a contact number for requesting an immediate appeal, and required that the beneficiary or representative sign and date the form to demonstrate receipt and understanding of appeal rights. However, the NOMNC form for this resident was marked “Temporarily incapacitated” in the signature section, and there was no signature from the resident or responsible party. The resident’s responsible party later reported not receiving any information on how to appeal and described the discharge as unorganized and unsafe, stating that the resident was discharged home with an IV port and that no discharge instructions were given to anyone. An administrative progress note by the Admissions Coordinator documented a phone conversation with the responsible party explaining that insurance had issued a last covered day and a discharge date, outlining options such as discharge home, caregiver resources, and the right to appeal if the resident was felt not ready for a lower level of care. The note stated that the responsible party said she would appeal and that a copy of the NOMNC and the appeal number were left at the resident’s bedside. In a subsequent interview, the Admissions Coordinator acknowledged that the facility failed to obtain a signature from the resident or responsible party confirming receipt of the NOMNC. The Admissions Director confirmed that residents or responsible parties are required to sign the NOMNC to acknowledge receipt and that the notice contains the information and phone number needed to file an appeal, and also stated unfamiliarity with the policy requirement for 30 days’ written notice for involuntary transfer or discharge, despite the facility’s Resident Rights policy referencing such notice.
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