Failure to Provide Required SNF ABN and Cost Information When Medicare Coverage Ended
Penalty
Summary
The deficiency involves the facility’s failure to provide the required Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-coverage (ABN) Form CMS-10055 to a Medicare Part A beneficiary when his covered stay ended and he remained in the facility. The resident census was 61, with 15 residents sampled and three reviewed for beneficiary notifications. For one resident, documentation showed that his Medicare Part A last covered day was 01/28/26, after which he remained in the facility for long-term care on a private pay basis. Facility records, including the medical record and business office documentation, did not contain evidence that the SNF ABN Form CMS-10055 was provided. A social service note dated 01/30/26 stated that the social worker provided the SNF ABN and that the resident would remain private pay for approximately 30–60 days until an apartment was available, and that a private pay quote was given to the resident’s representative. Another social service note, created on 02/09/26 with an effective date of 01/30/26, documented that the resident requested staff review the SNF ABN with his representative, who was not present and whose arrival time was unknown. Email communication from the facility to the resident’s representative on 01/27/26 indicated there was a form the resident would need to sign that reviewed his appeal rights and his right to appeal if he believed Medicare should cover the long-term care stay, and that the appeal could take up to four months while therapy continued, with room, board, and therapy to be billed if the appeal was unfavorable. However, this email chain did not mention the SNF ABN or provide an estimated cost to continue therapy services. During an interview on 02/10/26, the social worker stated the ABN should be provided prior to discharge and reported that she had provided the form, but that the resident did not sign or return it because he wanted to review it with his representative. She confirmed she was unable to show that the resident was provided with the ABN Form CMS-10055 because she did not have a copy. The facility’s policy dated 12/01/17 required appropriate notification of discharge from Medicare services, including appeal rights, when Medicare coverage ends, but the appropriate notification of discharge from Medicare services was not provided in this case.
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