Delay of Oncology Immunotherapy Due to Mismanagement of Medicare Status and Communication Failures
Penalty
Summary
The deficiency involves the facility delaying a resident’s immunotherapy oncology treatment due to misunderstandings and actions related to Medicare Part A coverage and the resident’s payor status. The resident had a complex history of multiple squamous cell carcinomas, basal cell carcinoma, prostate cancer, autoimmune pancreatitis, and imaging showing a hypermetabolic renal mass and pulmonary nodule. Prior to admission, the resident had initiated immunotherapy (cemiplimab) with a plan for eight cycles. Following a ground-level fall and right femoral neck fracture, the resident underwent right hip hemiarthroplasty and was discharged from the hospital to the facility for subacute skilled therapy under Medicare benefits. The admission contract and facility resident rights policy stated that residents would be fully informed of their rights, services, and charges, and that the facility would assist residents in exercising their rights and ensure they were treated with dignity and respect. During the admission and screening process, facility staff did not identify that the resident was actively receiving immunotherapy and had ongoing oncology appointments. Admissions staff reported they did not see any immunotherapy when screening the resident, and social services reported they did not realize the resident was supposed to receive immunotherapy until after admission. The facility assessment referenced cancer-related care needs in general but did not identify any residents currently receiving cancer treatments. After admission, the DON/ADON contacted the oncologist’s office on multiple occasions requesting that the resident’s immunotherapy be placed on hold, initially citing insurance reasons and asking to hold treatment for a few weeks. Oncology documentation showed that the oncologist’s office attempted to return calls, explained that provider approval was needed to withhold treatment, and ultimately pushed out appointments until mid-December, with a note that the facility would call when ready to reschedule. Over the subsequent weeks, facility documentation and interviews show that the resident and family were informed or believed that immunotherapy could not be continued while the resident was on Medicare Part A skilled therapy. Progress notes from February indicated that social services told the family the resident could start immunotherapy once off skilled therapy, and that the resident’s last covered Medicare A day would be set so the resident could transition to private pay and Part B. The daughter then contacted the oncologist to resume immunotherapy, and family provided appointment dates to the facility once they were scheduled. In interviews, the daughter stated she was told immunotherapy had to stop while the resident was receiving therapy on Medicare benefits and that treatment could resume only after switching to private pay, and the resident similarly stated he was told he could not see the oncologist while on Medicare and could resume now that he was private pay. The oncologist’s nurse confirmed receiving calls from facility staff requesting that immunotherapy be put on hold and later a call from the daughter indicating the resident was no longer on Medicare benefits and wanted to restart treatment. These actions and communications resulted in delayed oncology immunotherapy services and missed scheduled appointments for the resident, contrary to the resident’s rights to be fully informed, to participate in care planning, and to receive assistance in exercising those rights.
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