§483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.
§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
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Observations:
Based on a review of clinical records and facility provided documentation, and interview with staff, it was determined that the facility failed to provide the required advanced notice, through a Notice of Medicare Non-Coverage (CMS 10123), regarding the termination of Medicare services for one of three residents sampled (Residents R1)
Findings include:
Review of Resident's R1 clinical record it revealed admission date on February 7, 2024, for short term rehabilitation. Resident's R1 funding source was Medicare skilled A services. Conntinued review of the clinical record revealed that Resident R1 was discharge from the facility on March 15, 2024. Then, Resident R1 was readmitted from the local hospital on March 19, 2024 with Medicare Part A benefits.
On March 26, 2024, at 12:21 p.m. an interview was held with the Social Worker Director who revealed that Resident R1 was discharged as the Medicare service benefits were exhausted. It was further reported when Medicare funding exhausted therefore, Resident R1 did not receive Notice of Medicare Non-Coverage (NOMNC) cms-10123 the right to appeal a denial of Medicare services.
On March 26, 2024, at 2:11 p.m. an interview was held with Administrator, Employee E1 and Business Director, Employee E6 who reported that Resident R1 was discharge mistakenly. Resident's R1's admission date was entered currently however, facility system started calculating Medicare remaining benefit days that were used from the Resident's R1 prior admission date in 2023; therefore, it gave a report to the facility that Resident's R1 Medicare benefits were exhausted versus facility determined that a resident no longer qualifies for Medicare Part A. Employee E1 confirmed that Resident R1 should have not been discharged on March 15, 2024. And if Resident R1 was appropriately qualified to be discharged Notice of Medicare Non-Coverage (NOMNC) cms-10123 should have been issued.
28 Pa Code 201.29(a) Resident rights
| | Plan of Correction - To be completed: 04/05/2024
- Resident R1 was readmitted to the Center, benefits were verified and corrected.
- All residents currently under a Medicare Part A Stay were audited to ensure that all remaining days in their benefit period were accurate
- NHA completed in-service with BOM on ensuring that all residents available Medicare A days are inputted correctly into PCC in accordance with the benefit summary report.
- The Administrator / Designee will complete weekly audits of signed Medicare Part A remaining days 3 times per week x 4 weeks. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.
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