|§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.
Based on clinical record review and staff interview, it was determined that the facility failed to provide required notification to a resident whose payment coverage changed for two of three residents reviewed (Residents 186 and 81).
A review of the form "Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123," (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. Confirm the telephone contact by written notice mailed on that same date.
Issuing the Notice to Medicare Provider Non-coverage (NOMNC), form CMS-10123, to a beneficiary only conveys notice to the beneficiary of his or her right to an expedited review of a service termination and does not fulfill the facility's obligation to advise the beneficiary of potential liability for payment. A facility must still issue the SNFABN to address liability for payment.
A review of the "Form Instructions Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055" revealed that the SNF enters a good faith estimate of the cost of the corresponding care that may not be covered by Medicare. The beneficiary selects an option box to indicate a desire to continue to receive the care or not to continue to receive the care and if there is a desire to have the bill submitted to Medicare for consideration. The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice.
The SNF must issue this notice when there is a termination of all Medicare Part A services for coverage reasons. If after issuing the NOMNC, the SNF expects the beneficiary to remain in the facility in a non-covered stay, the SNFABN must be issued to inform the beneficiary of potential liability for the non-covered stay.
Clinical record review for Resident 186 revealed a Change in Status Notification form dated March 2, 2021, that indicated her payment source changed from Humana to private pay. The form indicated that her last covered day of the former payer was March 4, 2021, and the first date of the new status was March 5, 2021. A CMS-10123 (NOMNC) indicated that the effective date coverage would end was March 4, 2021.
The facility did not provide Resident 186 an Advanced Beneficiary Notice (SNFABN) that would provide a good faith estimate of the cost of the care that may not be covered so that she could decide if she wished to continue receiving care not paid for by Medicare and assume financial responsibility.
Interview with the Nursing Home Administrator and the Director of Nursing on October 14, 2021, at 2:30 PM revealed no evidence that the facility provided Resident 186 a SNFABN regarding potential (custodial care) costs that she would be responsible for after the last date of her Humana coverage.
Clinical record review for Resident 81 revealed that her payment coverage changed on April 15, 2021, when Medicare payment for services stopped.
Review of a CMS-10123 form indicated that Resident 81's niece was informed via telephone that the effective date Resident 81's coverage would end was April 14, 2021. This notice did not contain a dated signature; however, was stamped that "GREEN validation card used in lieu of signature." A handwritten note, "no date noted," filled the space for the representative's signature date. Review of the certified mail receipt to Resident 81's responsible party did not include any postmark seal or date; nor a date when the representative signed for the receipt of the mail. Review of a SNFABN form also indicated that Resident 81's niece was informed via telephone that the effective date Resident 81's coverage would end was April 14, 2021, and included the estimated daily room rates. This notice did not include a response from Resident 81's niece to select an option box to indicate a desire to continue to receive the care or discontinue the care; and if there was a desire to have the bill submitted to Medicare for consideration. Resident 81's niece did not sign the signature box to acknowledge that she read and understood the notice. This notice did not contain a dated signature; however, was stamped that "GREEN validation card used in lieu of signature." A handwritten note, "no date noted," filled the space for the representative's signature date.
Interview with the Nursing Home Administrator on October 15, 2021, at 12:40 PM, confirmed the above findings.
28 Pa. Code 201.18(b)(2)(e)(1) Management
28 Pa. Code 201.29(a) Resident rights
| ||Plan of Correction - To be completed: 12/07/2021|
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.
1. Resident 186 has discharged from the facility. Resident 186 received all required notices based on her non-Medicare insurance coverage. Resident 81 RP received verbal notification as well as certified notice of change in payor. Resident 81 RP acknowledged with RP signature that notification was received and documentation of verbal conversation with RP indicates timely notice provided.
2. Facility verified all residents and/or RP of resident, in the last quarter (July-September 2021), received notification of room rates upon admission as well as notification of payor change.
3. Facility will continue to provide room rate notification upon admission to facility to resident or resident RP. Facility will provide room rate notification to resident and/or resident RP upon payor change within facility in conjunction with payor notification guidelines. Education provided to RNAC office and social workers in regard to payor change notifications. Education provided to RNAC office in regard to notification processes required in cases where certified mailings are returned to facility incomplete. RNAC will attempt to notify resident RP x 2 via phone in cases of incomplete paperwork.
4. ANHA or designee will conduct audits to ensure room rate notification are provided upon admission as well as proper notification processes upon payor change times weekly x 3 months. Results will be reported at QAPI.