F0582

E

Failure to Notify Residents and Families of Conversion From Medi-Cal to Private Pay

Riverside, California Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify four residents and/or their responsible parties of changes in their primary payor status from Medi-Cal IEHP to private pay, as required by resident rights and the facility’s own policy. Record review showed that each of the four residents had Medi-Cal IEHP as the primary payor prior to January 1, 2026, and that their primary payor was changed to private pay effective January 1, 2026, in the PointClickCare (PCC) census records. The facility’s policy titled “Pay Source Conversion” states that Social Services is responsible for notifying the family of non-coverage and anticipated payment, and that the resident and/or responsible party must be informed of their financial obligations when there is a conversion from one primary pay source to another.

Resident 2 was admitted with a history of transient ischemic attack and was documented as self-responsible, with an MDS indicating intact cognition. Resident 3 was admitted with dementia, also documented as self-responsible, and had an MDS indicating intact cognition. Resident 4 was admitted with dementia, had a responsible family member, and an MDS showing she was rarely/never understood with moderately impaired cognition. Resident 5 was admitted with metabolic encephalopathy and had an MDS indicating moderately impaired cognition. Despite these documented conditions and responsible party designations, interviews with Residents 2, 3, and 5 revealed that they were unaware they were currently paying privately for their stays, did not know the cost, and reported that no one had discussed these financial changes with them. Resident 4 was non-responsive at the time of attempted interview, and later her responsible party reported not receiving any notification of the payor change or information about the cost.

Interviews with staff confirmed that required notifications were not provided. The Business Office Manager (BOM) stated that her department is responsible for notifying residents and responsible parties of payor changes via a notice of insurance change letter, but reported that the Director of Finance (DOF) at the corporate office initiated the payor changes on December 31, 2025, without informing her. The Accounts Receivable Director stated that the BOM, Administrator (ADM), or Social Services Director (SSD) should inform residents about becoming private pay. The Social Service Assistant stated that the BOM is responsible for payor changes and that she had never dealt with payor changes. The ADM stated the BOM is supposed to give notice of payor status changes to residents and report such changes in stand-up meetings, but he was not aware of the corporate-initiated changes and the BOM did not report any payor changes. The DOF stated that BOM, SSD, and sometimes ADM should explain payor changes and document their actions, and later clarified that no written Medi-Cal recommendation was received and that the decision to change the four residents to private pay was made at the facility level. These actions and inactions resulted in residents and responsible parties not being notified of the change from Medi-Cal to private pay and their resulting financial obligations.