Failure to Provide Medically Related Social Services and Benefits Assistance
Penalty
Summary
The facility failed to provide medically related social services to assist a resident in understanding and accessing insurance and public benefits needed to continue necessary care. Federal regulations at 42 CFR 483.10(g)(4) require that residents receive notices and information regarding Medicare and Medicaid eligibility and coverage in a format and language they understand, and the facility’s Director of Social Services job description included assisting discharged residents and families with placement options. The resident, who had diagnoses including hypertension, diabetes, and a need for care after a surgical amputation, was admitted for rehabilitation and had a care plan goal for discharge home with family support and home health services. A progress note documented that the resident lost an insurance appeal, the family chose to take the resident home that day, and arrangements were made for transportation and durable medical equipment, with the facility temporarily lending a wheelchair cushion and sliding board. Subsequent documentation showed that the resident later expressed a desire to extend the rehab stay with a new prosthesis, but the social worker was not available and nursing and rehab staff did not have updated insurance information. Another note indicated that personal care and continued stay at the SNF level without insurance coverage were offered to the resident’s son, who declined. During interview, the resident’s family member stated that the facility had been informed the resident lived alone without supervision upon discharge and lacked funds to remain as a private pay resident, and further stated the resident was not offered assistance with completing Medicare/Medicaid or Social Security Disability applications. Review of the clinical record confirmed there was no documentation of referrals or assistance with such applications, and the DON acknowledged that the facility failed to provide medically related social services to this resident.
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