Failure to Provide Social Services Assistance for Continuity of Health Insurance Coverage
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services to assist a resident in maintaining mental and psychosocial well-being by ensuring continuity of health insurance coverage. The resident was admitted with a displaced bimalleolar fracture of the left lower leg and hypertension, and was dependent on staff for most ADLs. The resident had decision-making capacity. During an IDT meeting, the resident’s family member expressed interest in applying for Medi-Cal once Medicare coverage for skilled nursing services was ending, and the Social Services Director (SSD) stated they would refer the family member to the Business Office Manager (BOM) for assistance with the Medi-Cal application. The facility issued a Notice of Medicare Non-Coverage indicating the last day of Medicare coverage for skilled services. The SSD reported that they referred the family member to the BOM but did not follow up on the Medi-Cal application or otherwise assist the resident in applying for health insurance. The Assistant DON/Case Manager confirmed that the SSD told the family member during the IDT meeting that the BOM would assist with the Medi-Cal application. The DON reviewed the SSD’s job description, which required the SSD to provide information to residents and families about Medicare/Medi-Cal and other financial assistance programs and to refer them to appropriate social service agencies when needed, and stated the SSD did not follow this job description. The facility’s social services policy required provision of medically related social services, including informing and educating residents and families about health care options and assisting with financial matters. As a result of these failures, the resident had no health insurance after Medicare coverage ended and personally bore the cost of skilled nursing services received thereafter.
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