F0627

D

Failure to Involve Designated Representative in NOMNC and Discharge Preparation

Dallas, Texas Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide and document sufficient preparation and orientation for a safe and orderly discharge, and failure to ensure that a resident’s designated representative was notified and involved when a Notice of Medicare Non-Coverage (NOMNC) was issued and signed. The resident was an older male admitted for rehabilitation with diagnoses including prostate cancer and a cognitive communication deficit. His admission MDS showed a BIMS score of 14, indicating intact cognition, and documented that he was usually understood, usually understood others, and had adequate vision, though he required supervision or touch assistance with most ADLs. The care plan did not address any need for a representative’s involvement in decision-making, despite the electronic health record listing a family member as the resident’s responsible party and the admission agreement being signed by that family member as the designated representative.

The Administrator met with the resident in his office, with the receptionist present, and presented the NOMNC, documenting that the last covered day and discharge date were explained and that the resident was asked about home health and discharge location. The NOMNC form showed that the Administrator notified the resident of the notice and that the resident signed it, with information that he could appeal if he disagreed. However, the Administrator did not notify or involve the resident’s designated responsible party at the time the NOMNC was issued or signed, even though the responsible party had signed all prior admission documents on the resident’s behalf. The Administrator later stated he considered the resident to be his own responsible party and believed the resident comprehended the NOMNC and appeal process, despite acknowledging he did not know why the resident was not listed as his own responsible party in the EHR or why he had not signed his own admission documents.

The resident’s responsible party reported that she had been handling all of the resident’s business with the facility because he was heavily medicated, not coherent enough, and unable to read well, and that she had signed all prior documents. She stated she was not notified of the discharge notice, was not provided the NOMNC to sign, and only learned of it when the resident called and said he had to sign papers and was being “kicked out.” The resident stated he was partially blind in one eye from a cataract, was not comfortable reading, and allowed his family to handle his business. He reported that the Administrator stopped him on his way to the dining area, took him into the office, told him he had to sign some paperwork, and that he did not understand what he was signing but signed because he was told he had to. The receptionist confirmed she had been instructed by the former BOM at admission to have the family sign the admission agreement on the resident’s behalf because the resident probably would not understand what he was signing. The facility’s transfer and discharge policy required that transfer/discharge notices be provided to the resident and the resident’s representative in a language and manner they can understand, and CMS NOMNC instructions require that if an enrollee cannot comprehend the notice, it must be delivered to and signed by a representative. These requirements were not followed in this case.