Failure to Use Correct ABN Form for Medicare Part A Discontinuation
Penalty
Summary
The facility failed to properly notify residents of changes in Medicare Part A coverage by not using the correct Advance Beneficiary Notice of Non-Coverage (ABN) form and by omitting required information. Facility policy, last revised on 11/05/24, stated that residents are to be informed in advance when changes occur to their bills and that CMS form 10055 would be provided prior to discharge from Medicare Part A. Record review showed that one resident admitted to Medicare Part A with COPD, acute respiratory failure, muscle weakness, and Type II diabetes was discharged from Medicare Part A on 05/07/25; another resident admitted for skilled nursing and/or rehabilitation care was discharged from Medicare Part A on 07/13/25; and a third resident admitted with COPD, tremors, and stroke was discharged from Medicare Part A on 08/28/25. Instead of using the required CMS-10055 ABN form, the facility used an outdated ABN form titled CMS-R-131 for all three residents. The outdated form did not include the date that Medicare Part A coverage would be ending for these residents, and review of the medical records confirmed that the current CMS-10055 ABN form was not present for any of them. During interviews, the Social Service Director stated she was unaware she was using the incorrect CMS form to notify residents about the discontinuance of Medicare Part A benefits and that CMS-10055 should have been used, and the Administrator stated he was unaware the correct ABN form was not being utilized.
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