Failure to Provide Required Financial Liability Notice When Payer Source Changed
Summary
The facility failed to notify a resident and/or the resident’s representative of potential financial liability when the payer source changed from Medicare to private pay. The resident was admitted with chronic kidney disease stage 3, gait and mobility abnormalities, depression, and a history of transient ischemic attack, and the admission record identified the resident’s representative as the guarantor. The case manager stated the resident had full Medicare coverage for 100 days upon admission and that a Notice of Medicare Non-Coverage (NOMNC) dated 3/17/23 indicated Medicare-covered services would end on 3/20/23, with discharge scheduled for 3/21/23. However, the NOMNC was unsigned and lacked attestation. A plan of care note documented that the Kaiser case manager emailed the NOMNC to the facility case manager, stating the resident was to be discharged to a board and care, and that the facility case manager would follow up the next day. The business office manager reported that the resident’s payer changed effective 3/21/23, requiring private payment from that date until discharge due to lack of secondary insurance, and that this change was based on the unsigned NOMNC. The business office manager acknowledged that the NOMNC should have been signed by the resident and that a notice of private pay costs should have been provided, but neither occurred. The medical records assistant confirmed there was no signed NOMNC in the chart and no documentation that a private pay cost notice was issued. Review of the facility’s contract with Kaiser showed that residents may be billed for non-covered or unauthorized services only if notified beforehand and if a Financial Responsibility Form is signed, and otherwise the facility cannot charge more than the resident’s cost share. The facility’s policy on Notice of Covered and Non-Covered Services required that residents receive a notice detailing covered and non-covered services and associated charges upon admission and periodically throughout their stay, but this was not documented for this resident at the time of the payer change.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to complete NOMNC forms with the required QIO name and toll-free number for three residents, leaving generic template language and missing Medicare service details on the notices. For one resident, staff used an expired ABN instead of the correct SNFABN, and the DON/Administrator acknowledged the incorrect form was used and that the generic NOMNC template should have been completed before being given to residents.
Failure to issue NOMNC forms for two residents before Medicare skilled coverage ended. The BOM stated they were responsible for the notices and none could be found for the residents, and the Admin stated Medicare-insured residents were supposed to receive advance NOMNC notice.
Improper NOMNC Signatures and Notification: Two residents with intact cognition and capacity to make decisions were not appropriately notified of Medicare coverage changes. One resident denied seeing or signing the NOMNC, while the BOM acknowledged she signed both NOMNC forms even though she was not the resident or representative. The DON stated only the resident or representative should sign, and the facility policy required timely Medicare notices to the resident and/or representative.
A resident admitted with Medicare Part A benefits remained in the facility after Part A coverage ended, but the facility did not provide the required SNF ABN to notify the resident of potential financial liability for continued services. Staff confirmed the SNF ABN was not completed, and the Administrator acknowledged the omission.
Failure to Provide SNF-ABN for Medicare Non-Coverage: The facility did not provide SNF-ABN forms to two residents when Medicare Part-A coverage ended. One resident had hypothyroidism, MDD, dysphagia, and hyperlipidemia and remained in the facility for LTC after a NOMNC was issued; another resident had muscle weakness, arthritis, and anxiety disorder and also received a NOMNC, but the record did not show review or issuance of an SNF-ABN. The NHA confirmed the omission.
Failure to Provide NOMNCs to Two Residents Two residents whose Medicare Part A skilled services were ending while they remained in the facility did not receive the required NOMNC. The SWD stated he was unaware the notices were needed, and the SWC said her quarterly review with him focused on discharge planning and did not include when NOMNCs should be issued.
Incomplete Medicare Non-Coverage Notices and Use of an Expired ABN
Penalty
Summary
The facility failed to ensure that the CMS Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, was completed with the required Quality Improvement Organization (QIO) name and toll-free telephone number before it was issued to three residents reviewed for beneficiary notifications. For each of the three residents, the NOMNC forms retained generic template language, including the placeholder for the type of Medicare-covered services, and did not include the facility’s QIO name or toll-free contact number. The forms were signed by the residents, and the notices stated that Medicare-covered services would end after the listed date, but the required specific information was not entered on the forms. The facility also failed to provide the correct Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN), Form CMS-10055, for one resident. Instead, an expired ABN, Form CMS-R-131, was signed by that resident even though the form had been retired from use by CMS before the signature date. During interview, the Administrator acknowledged that the resident should have received the correct form and stated there was no knowledge that staff attempted to correct the error or provide the appropriate form. The Administrator also acknowledged that the facility used a generic CMS-10123 template and that it should have been completed with the correct information before residents received it.
Failure to Issue Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue Notification of Medicare Non-Coverage (NOMNC) forms at least two calendar days before Medicare skilled coverage ended for 2 of 3 sampled residents reviewed for beneficiary notices. Resident 27 was admitted to the facility and later discharged on 04/27/2026 to an adult family home, and the record showed no NOMNC form was provided before discharge. Resident 161 was admitted to the facility and later discharged on 12/02/2025 to home, and the record also showed no NOMNC form was provided before discharge. During interview, the Business Office Manager stated they were responsible for issuing the notices and that none could be found for Residents 27 and 161, and the Administrator stated Medicare-insured residents were supposed to receive NOMNC notice in advance and that the lack of notices for these residents did not meet expectations.
Improper NOMNC Signatures and Notification
Penalty
Summary
The facility failed to ensure that two sampled residents, Resident 33 and Resident 88, were appropriately notified of changes in their Medicare coverage through provision of the Notice of Medicare Non-Coverage (NOMNC) form. Resident 33 was admitted with diagnoses including HTN and DM, and the MDS indicated intact cognition, maximal assistance with ADLs, and the H&P stated the resident had the capacity to understand and make decisions. Resident 88 was admitted with diagnoses including depression and severe chronic kidney disease, and the MDS indicated intact cognition with supervision needed for ADLs; the H&P also stated the resident had the capacity to understand and make decisions. During an interview on 5/28/2026, Resident 33 denied that the signature on the NOMNC form was his and denied having seen or ever being presented with the form. In a concurrent interview and record review, the BOM stated she had signed the NOMNC forms for Residents 33 and 88, but acknowledged she should not have signed them because she was not the resident or the resident representative. The BOM stated signing the forms without the residents' consent or knowledge could cause a loss of trust and affect their rights. The DON stated the NOMNC forms should only be signed by the resident or resident representative, not the BOM. The facility policy stated it is the facility's responsibility to ensure Medicare notice forms are completed as per Medicare guidelines and given to the resident and/or representative timely.
Failure to Provide SNF ABN After Medicare Part A Coverage Ended
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to 1 of 3 sampled residents reviewed for beneficiary notification. Resident 13 was admitted in 12/2025 with Medicare Part A benefits, and the facility’s SNF Beneficiary Notification Review form showed the resident’s last covered day for Medicare Part A services was 2/18/26 while the resident remained in the facility. Despite the termination of Part A coverage and the resident’s continued stay, the resident was not given a SNF ABN to notify them of potential financial liability for services received. Staff 19 confirmed that residents whose Part A services end and who remain in the facility should receive a SNF ABN in addition to a Notice of Medicare Non-Coverage, and stated that the SNF ABN was not completed for Resident 13. Staff 1 acknowledged the facility failed to complete the required SNF ABN for Resident 13.
Failure to Provide SNF-ABN for Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF-ABN) to inform residents when items and services were no longer eligible for Medicare Part-A coverage for two sampled residents. Resident R4 was admitted to the facility and had an MDS dated 3/2/26 showing diagnoses that included hypothyroidism, major depressive disorder, dysphagia, and hyperlipidemia. A clinical social services note dated 3/16/26 indicated that R4 was issued a NOMNC with a last covered day of 3/18/26, and the resident remained in the facility for long-term care, but the record did not include evidence that an SNF-ABN was provided. Resident R57 was admitted and later readmitted to the facility, and her MDS documented diagnoses including muscle weakness, arthritis, and anxiety disorder. Her clinical record showed that she was issued a NOMNC on 5/11/26, but clinical nurse notes and social services notes did not indicate a review of the NOMNC form provided to her. Facility documentation did not include evidence that SNF-ABN forms were provided to either resident, and during an interview on 5/20/26 at 10:28 a.m., the NHA confirmed that the facility failed to provide the SNF-ABN form as required.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The provider failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) was given to two sampled residents whose Medicare-covered skilled services were ending while they still had remaining Medicare benefit days and remained in the facility. Resident 19’s CMS SNF Beneficiary Notification Review form showed a Medicare Part A skilled services episode start date of 10/28/25 and a last covered day of 12/31/25, but he was not given the NOMNC. Resident 21’s CMS SNF Beneficiary Notification Review form showed a Medicare Part A skilled services episode start date of 12/9/25 and a last covered day of 1/15/26, but she was also not given the NOMNC. During interview, the social worker designee stated he was unaware that residents 19 and 21 should have received the NOMNC, and the social worker consultant stated she met quarterly with him to review resident items but did not discuss when NOMNC forms should be provided.
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