cms_GA
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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag ▼ | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5856 | 5856 | GOODWILL HEALTH AND REHAB | 115486 | 4373 HOUSTON AVE. | MACON | GA | 31206 | 2015-10-15 | 151 | D | 1 | 0 | 7J0Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to honor resident choices related to use of personal wheelchair and personal choice of diet for one (1) resident (#30) of the forty-seven (47) sampled. Findings include: Interview with resident #30 on 6/26/2015 at 2:30 p.m. revealed that her personal wheelchair had been removed from her use. Resident #30 stated the facility took it away and they brought in a different one, but it was too big for the transport van. The resident stated that the wheels on the facility's wheelchair were too wide for the ramp used for transport. The resident stated that she had not asked anyone about the old chair. Interview on 6/26/15 at 6:00 p.m. with the Administrator revealed the wheelchair had been placed in storage and another wheelchair was given to the resident for use. The administrator stated that the personal wheelchair of resident #30 was too small to fit her. Resident #30 also states that she has [MEDICAL CONDITION] and is supposed to be on a low salt diet but the diet she gets tastes like it has salt. Record review of the physician orders [REDACTED]. | 2018-05-01 |
| 7882 | 7882 | EAST LAKE ARBOR | 115482 | 304 FIFTH AVENUE | DECATUR | GA | 30030 | 2012-06-21 | 151 | D | 0 | 1 | 2XUF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident, family, and staff interview the facility failed to provide supervision for smoking for one (1) resident Z from a sample of thirty five (35) residents Findings include: Review of the medical record revealed that resident Z was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was assessed as totally dependent for Activities of Daily Living (ADLs) and had limited function to both upper and lower extremities. The resident was assessed with [REDACTED]. Interview on 06-18-12 at 2:10 PM with resident Z revealed that he/she was not allowed to smoke every day because the facility informed him/her that he/she could only smoke if a family member would come to the facility to assist him/her. The resident acknowledged that he/she would like to go out side during smoke breaks. Continued interview revealed that the resident had burned his/her clothing in the past and needs assistance to smoke because of the inability to use his/her hands to hold the cigarette. The resident indicated that that the Administrator told him/her that the facility did not have anybody to assist the resident one on one. Observations on 06/19/12 at 10:30 a.m. and on 06/20/12 at 10:30 a.m., during smoke break, revealed two (2) smoking areas, one (1) at the end of the thee hundred (300) Hall and the other off the two hundred (200) Hall. Continued observations revealed more than one (1) staff member outside with the smoking residents at each of the two (2) smoking locations. Interview with the Director of Nursing (DON) on 06/20/12 at 8:25 a.m. revealed that the resident had burned his/her clothing about two years ago because he/she drops the cigarettes as is unable to hold the cigarettes in his/her hands. Continued interview revealed that that the family was notified of the resident burning himself and since the facility does not ha… | 2016-10-01 |
| 10414 | 10414 | CEDAR SPRINGS HEALTH AND REHAB | 115381 | 148 CASON ROAD | CEDARTOWN | GA | 30125 | 2009-02-11 | 151 | E | 1 | 1 | Y88V11 | Based on record review and resident and staff interviews, the facility failed to ensure that right to vote for three (3)residents ("B", "C" and "D") of four (4) residents in group interview. Findings include: During group interview conducted on 2/10/09 at 11:00a.m., three (3) residents "B', "C", and "D"complained that the facility did not assist them in voting in the presidential election in November, 2008. The residents indicated that they would have voted if given the opportunity. Resident "B" revealed that the social worker promised that she would assist him/her in completing an absentee ballot but the social worker never followed through. Review of the Facility Admission Packet revealed that under paragraph R., Voter Registration Information, the facility would assist residents to register to vote and obtain absentee ballots. Review of the State of Georgia Application for Voter Registration included instructions that revealed a copy of proper identification should be included with the application. Further review revealed that The postage is prepaid on the application and includes a pocket envelope that allows the application to be sealed with adhesive. Interview with the Administrator on 2/9/09 at 11:45am revealed that the Social Service Director registered several residents to vote but had not returned the registrations to the Elections Board in the appropriate time allocated. The Social Service Director also assisted some residents to vote but returned these ballots to the Elections Board unsealed, without the same signature as the registration, and without proper proof of identification. Further interview with the Administrator on 2/10/09 at 2pm revealed that the right to vote was covered during the admission process by the Social Services Director. Interview with the Activity Director on 2/10/09 at 8:45am revealed the residents are informed of their right to vote and if they are not registered to vote then registration or change of address form are obtained for them. The residents are assisted in completi… | 2014-07-01 |
| 5208 | 5208 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2015-11-03 | 153 | C | 1 | 0 | SXJL11 | > Based on review of the Policy for Release of Medical Information and staff interviews, the facility failed to allow the Legal Representative access to the medical record for one (1) resident (A). This failure had the potential to affect all residents in the facility. The census was one hundred sixty four (164) residents. Findings include: Intake Details dated 10/5/15 revealed the sister of Resident A requested a copy of the medical records for her brother. The Administrator charged a fee for making the copies. The sister was denied access when she ask is she could come to the facility and view the records. Review of the Park Place Nursing Facility Policy for Release of Medical Information provided on (MONTH) 2, (YEAR), documented: 4) The Administrator will contact and give the patient or family responsible party the count of pages and cost to produce requested medical information. 5) If patient or family responsible party agrees to cost, then the records will be produced within 10 days. 6) If patient or family responsible party agrees to cost, then records will be produced within ten (10) days. An interview with the Administrator on (MONTH) 2, (YEAR) at 3:20 p.m. revealed that the facility releases medical records to the resident or responsible party upon agreement to the cost of the copies. The Administrator confirmed that the resident ' s daughter requested to view the medical records and he denied access due to inability to monitor use of the records, such as taking pictures of part of the records. An interview with medical records staff member on (MONTH) 2, (YEAR) at 4:04 p.m. revealed that the process for obtaining medical records is to direct the resident, if no longer residing in the facility, to the Administrator. MR staff member informed that the medical record is not copied until the resident or responsible party agrees to the cost of the copies. She stated that the medical record is not provided for resident/ responsible party for view. Review of the Grievance Log, dated (MONTH) 20, (YEAR) revealed o… | 2018-11-01 |
| 10064 | 10064 | LIFE CARE CENTER | 115654 | 176 LINCOLN AVE | FITZGERALD | GA | 31750 | 2010-06-10 | 153 | D | 0 | 1 | 7UBW11 | Based on resident interview, it was determined that the facility failed to ensure the right of one resident ("A") to review his/her medical record of six residents in the Group Interview. Findings include: During the Group Interview (meeting) on 6/9/10 at 11:00 a.m., resident "A" stated that approximately three months ago he/she had requested to review his/her medical record. Resident "A" stated that the licensed nurse at that time stated that the Director of Nursing (DON) would have to be notified. Resident "A" stated that, several days later, staff reported that the resident's physician would have to be notified prior to the resident having access to his/her medical record. Resident "A" stated during the meeting that he/she had not been given his/her medical record for review, and had not requested access to it since that time. During an interview on 6/10/10 at 11:30 a.m., the DON stated that she had not been made aware of the resident's request to review his/her medical record. | 2015-03-01 |
| 10259 | 10259 | OCONEE HEALTH AND REHABILITATION | 115357 | 107 RIDGEVIEW DR | OCONEE | GA | 31067 | 2011-06-13 | 153 | D | 1 | 0 | 87J011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, family interview, and staff interview, the facility failed to permit a family member of one (1) resident ("A"), in a survey sample of six (6) residents, to have access to the resident's medical records, after the resident orally consented to the records release. Findings include: Record review for Resident "A" revealed an Interdisciplinary Progress Note of 04/22/2011 which documented that the resident had been admitted to the facility on that date. The resident's Minimum Data Set assessment dated [DATE] assessed the resident as alert and oriented. An Interdisciplinary Progress Notes entry of 05/25/2011 documented that the resident had been discharged from the facility on that date with a family member. An Interdisciplinary Progress Notes entry of 05/27/2011 documented that the facility's administrator had spoken with the family member by telephone regarding obtaining the resident's medical records, but further documented that the medical records were not given to the family member. During an interview with the Director of Nursing and Social Worker conducted on 06/13/2011 at 12:30 p.m., these staff members acknowledged that the family member was not allowed to see the medical records of Resident "A". During a telephone interview with the family member of Resident "A" conducted on 06/15/2011 at 3:00 p.m., the family member stated that on 05/25/2011, she had a telephone conversation with the facility's Social Worker to inform her that the family member was discharging the resident to the family member's home on that date. The family member stated that during this telephone call, she had requested a copy of the resident's medical records, especially the resident's medications, so she would be aware of the medication therapy the resident was to receive. However, the family member stated that the Social Worker refused to release the medical records, so the family member came to the facility to see the med… | 2014-10-01 |
| 10290 | 10290 | PEACHBELT HEALTH & REHAB CTR | 115552 | 801 ELBERTA RD | WARNER ROBINS | GA | 31093 | 2011-05-17 | 153 | D | 1 | 0 | QQYF11 | Based on facility document review and staff interview, the facility failed to provide access to the clinical record after a written request had been made by the legal representative of one (1) resident ("B") from a survey sample of five (5) residents. Findings include: During interview with Administrative Staff "AA" conducted on 05/17/2011 at 1:30 p.m., upon inquiry related to the status of a records request that had been made by the legal representative of Resident "A", this staff member stated that she was not aware of the status of the record request, as she had forwarded the record request to the facility's Corporate office, per protocol. She further stated that she would inquire as to whether the records that had been requested in a letter, dated March 18, 2011 to the facility from the legal representative, had been provided. Upon inquiry with the facility's Corporate office, Staff "AA" received a facsimile dated May 17, 2011 from the facility's Legal Counsel which documented that the record would be sent out immediately and apologized for the delay in sending the requested medical records out to the legal representative. During additional interview with Staff "AA" conducted on May 17, 2011 at approximately 3:35 p.m., this staff member acknowledged that there had been a delay of approximately forty (40) days, excluding weekends and holidays, since the legal representative had submitted the written request to the facility. | 2014-09-01 |
| 2137 | 2137 | LAKE CITY NURSING AND REHABILITATION CENTER LLC | 115535 | 2055 REX ROAD | LAKE CITY | GA | 30260 | 2017-06-02 | 155 | J | 0 | 1 | D1CD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident records, review of an undated policy titled, Advance Directives, and staff interviews, the facility failed to ensure residents, family and health care agent choices related to advance directives were clear and accurately reflected in the resident's medical records. The failure to provide staff with clear and accurate information related to the Advance Directive chosen by a resident had the potential to prevent a resident to expire as chosen without the interventions of life sustaining measures against their wishes. Conflicting and inaccurate information in a resident's health care record related to resident choice to be a Full Code had the potential to cause life sustaining measures not to be provided for a resident who had made that choice. This affected three of 30 stage 2 Residents (R), #217, R#290 and R#195. This failure put residents in the facility at risk for serious injury or death without an attempt of life sustaining measures as chosen by the resident to return circulatory system function and respiratory function to a viable state to sustain life. The facility's Administrator and Director of Nurses were informed of the immediate jeopardy on [DATE] at 9:30 a.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. A Credible Allegation of Compliance was received on (MONTH) 2, (YEAR). Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on (MONTH) 1, (YEAR). The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of advanced directive procedures to ensure the accuracy of advanced directives on the chart. This oversight process included the analysis of facility staffs' conformance with the facility's Poli… | 2020-09-01 |
| 3956 | 3956 | SENIOR CARE CENTER - BRUNSWICK | 115721 | 2611 WILDWOOD DRIVE | BRUNSWICK | GA | 31520 | 2017-04-07 | 155 | E | 0 | 1 | OPLQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff and resident interviews, review of the facility's policy titled, Advanced Directives Code Status - DNR Full Code Policy the facility failed to ensure that the code status was correctly reflected for eight residents. Specifically, staff interviews and clinical record documentation indicated a Do Not Resuscitate (DNR) status for one resident (R#298) who wished to be a Full Code (and desired to receive Cardiopulmonary Resuscitation (CPR) in the event the resident was found not breathing and/or found without a pulse. In addition to this, the clinical record documentation, for seven residents (R#71, R#146, R#45, R#90, R#155, R#158, R#170), indicated a Full Code status when the residents had indicated they wished to be DNR (DNR indicating that the residents did not want to have CPR performed if they were found not breathing and/or found without a pulse). The sample size was 40 residents. Findings include: The facility's policy titled, Advanced Directives Code Status-DNR-Full Code Policy most recently revised in (MONTH) (YEAR), documents, in pertinent part, It is the policy of {the facility} that the resident or legal guardian/representative has the right to formulate an Advanced Directive which specifies measures to be taken in the event of an emergency and If the resident has Advance Directives, a copy is requested and placed in the clinical record as a permanent part of the chart this policy further documents, If the resident does not have Advance Directives, the Admission Coordinator or designee indicates on the Signature Acknowledgement form and provides additional information to the resident if needed and On admission if the resident signs the DNR, the Admission Coordinator or designee hand delivers the DNR to the nurse assigned to the resident. The nurse IMMEDIATELY faxes the Do Not Resuscitate (DNR) to the attending physician. Additionally further review revealed, Once the signed DNR is faxed back to th… | 2020-09-01 |
| 4168 | 4168 | BROWN HEALTH AND REHABILITATION | 115090 | 545 COOK STREET | ROYSTON | GA | 30662 | 2015-10-16 | 155 | D | 0 | 1 | JNZX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of federal regulations, and staff and corporate consultant interview, the facility failed to have a clear record of Do Not Resuscitate (DNR)status for one (1) resident (# 51) from a sample of twenty-eight. The facility failed to maintain a written policy to implement Do Not Resuscitate (DNR) advanced directives. The facility census was one hundred twenty-two (122). Findings include: Review of the clinical record for resident #51 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the face sheet indicated the age of the resident was eighty-eight. Review of the document entitled Advanced Directive and Other ACP Documents Face Sheet in the front of the chart in a clear plastic sleeve, revealed the line specifying DO NOT RESUSCITATE ORDER was highlighted in yellow and checked. The first line of the document reads as follows: If checked, the following advance directives or DNR orders have been executed and are complete. The form lists residents name, physician and room number. The second document in the sleeve, not visible without removing it, was a document entitled ADVANCED DIRECTIVES CHECKLIST. The resident's personal representative had checked the line indicating an advanced directive had not been executed but would like to obtain additional information. The area indicating information was provided was blank. The document was signed by the personal representative on 11/25/14. Continued review of the clinical record revealed the care plan of resident #51 dated 11/15/14, included Advance Directive- request DNR Status, with an intervention to adhere to no Cardiopulmonary Resuscitation request. Interview conducted on 10/15/15 at 3:37 PM with AA confirmed there was a DNR on the chart and resident #51 was care planned to be a DNR but the DNR document is not clear because there is no signature on the only visible form, but DNR is checked indicating the order is complete. AA revealed… | 2020-02-01 |
| 4248 | 4248 | BONTERRA TRANSITIONAL CARE & REHABILITATION | 115555 | 2801 FELTON DRIVE | EAST POINT | GA | 30344 | 2016-04-14 | 155 | D | 0 | 1 | BE2O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy and procedure review, review of the Hospice Provider agreement and staff interviews, the facility failed to ensure the Do Not Resuscitate (DNR) status for one (1) resident (R#22) of the forty (40) sampled residents. Findings include: Review of the facility's policy titled Do Not Resuscitate (DNR) documented: A written physician's orders [REDACTED]. If there was no written DNR order, respond to a medical emergency with CPR and implement a full code. All DNR orders require two physician signatures for residents that do not sign the DNR form. Review of Agreement to Provide Services to Hospice Residents by the hospice provider revealed that hospice will furnish the facility with a copy of the patient's self-determination documents, the hospice patient's plan of care and communicate which services will be furnished by the facility for each hospice patient. At the time of admission, hospice shall provide the following: relevant documents relating to aggressiveness of care. The hospice shall provide a copy of any revisions, modifications and updates to the facility. Review of the clinical record for R#22 revealed [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] noted the resident did not have a condition that may result in a life expectancy of less than six months, and was receiving hospice care. Review of the care plans revealed one developed for admission to hospice services for end-stage Alzheimer's. Review of a Hospice Election and Informed Consent dated [DATE] noted a terminal [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the facility's Advance Directive Acknowledgment form for resident R#22 dated [DATE] revealed that an advanced directive had not been executed at that time. Review of the Hospice DNR Request/Refusal form noted that the section to elect to be a DNR was checked, but the line for the resident's name was blank. Further review of this form revealed that the res… | 2020-01-01 |
| 4795 | 4795 | ALTAMAHA HEALTHCARE CENTER | 115577 | 1311 WEST CHERRY STREET | JESUP | GA | 31545 | 2016-06-09 | 155 | D | 0 | 1 | JE9L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to correctly apply the Advance Directive choice for one (1) resident (#77) from a sample of twenty-eight (28) residents. Findings include: Review of resident #77's medical record noted that the resident was admitted to the facility on [DATE] under Hospice services with [DIAGNOSES REDACTED]. Further review noted an Advanced Directive document that marked the resident to be a FULL CODE. Review of resident #77 's Care Plan, initiated on 4/8/2016 documented that the resident had requested a Do Not Resuscitate (DNR) status with goals established to honor the resident 's request for DNR status and maintain dignity. Interventions in the Care Plan included: notify the physician, the family and the clergy as necessary, maintain a copy of advance directives on the chart, to flag chart DNR status, and to provide comfort, support, and daily nutrition and hydration. In addition, a Hospice Physician Plan of Care dated 5/18/2016 through 8/15/2016 included hospice nursing visits weekly and monthly Spiritual Care through Hospice. Hospice Nurses notes indicate that resident is at peace with decisions. An interview with Social Service Director on 06/09/2016 at 9:25 a.m., he/she stated that Resident #77's medical record was found to be in error, and that the resident was a Full Code and not a DNR and that the Care Plan was not correct. | 2019-06-01 |
| 5084 | 5084 | NORTHEAST ATLANTA HEALTH AND REHABILITATION CENTER | 115504 | 1500 S JOHNSON FERRY ROAD | ATLANTA | GA | 30319 | 2016-01-21 | 155 | J | 1 | 0 | KRH911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of policy and procedure, review of Emergency Medical System (EMS) records and video surveillance review, it was determined the facility failed to honor the explicit Advance Directive wishes of one (1) of twenty-five (25) sampled residents (Resident #1). Resident #1 had an Advanced Directive which specified he desired to be provided Cardio [MEDICAL CONDITION] Resuscitation (CPR) if cardiac or respiratory arrest occurred. However, on [DATE], LPN MM and LPN LL failed to initiate CPR for Resident #1 when he was found unresponsive at 5:28 a.m. 911 Emergency was not called until 6:25 a.m. LPN LL began chest compressions at 6:34 a.m. EMS arrived at 6:38 a.m. and determined Resident #1 had no pulse and was not breathing. Resident #1 did not respond to the resuscitation efforts of the paramedics and was pronounced dead at 7:00 a.m. (Refer F223, F281, F282) The facility's failure to ensure residents' Advance Directives were honored has caused, or had the likelihood to cause, serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 8:45 a.m. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. Findings include: Review of the facility policy for Advance Directives (OP2 0303.00 Release Date: (MONTH) 2005 Chapter: Resident Rights) documented: The resident has a right to accept or refuse medical or surgical treatment and to formulate an advance directive in accordance with state and federal law. The facility uses… | 2019-01-01 |
| 6095 | 6095 | EASTVIEW NURSING CENTER | 115656 | 3020 JEFFERSONVILLE ROAD | MACON | GA | 31217 | 2014-08-21 | 155 | D | 0 | 1 | E48V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to present a pre-existing medical order for Do Not Resuscitate (DNR) to emergency transport staff and/or hospital staff for one resident (#88), a closed record, of three (3) residents with advanced directives from a sample of twenty eight (28) residents. Findings include: Review of the clinical record for Resident #88 revealed that the resident was admitted on [DATE] for respite care and had [DIAGNOSES REDACTED]. Review of the resident's advanced directive, dated [DATE] and signed by a family member, revealed a Do Not Resuscitate (DNR) order that no medical treatment would be started or continued if the resident's heart stopped beating or he/she stopped breathing. Further review of the advanced directive revealed that the DNR information was to be given to paramedics, doctors, nurses or other health personnel as necessary to implement the resident's directives. Review of the [DATE] at 8:30 a.m. nurse's note revealed that the resident was found in bed breathing very fast and unresponsive to verbal and tactile stimuli. The resident's family member was at his/her bedside. The resident's pulse was fast at 125 beats per minute (BPM), his/her respirations were 32 (normal range was between 16 and 20), his/her temperature was high at 102.6 degrees Fahrenheit (F) and the resident's oxygen saturation level was low at 78 per cent (%). Further review of the nurse's note revealed that the attending physician was notified and ordered staff to transfer the resident to the hospital. The resident was transported to the hospital by emergency medical personnel with the family member at the resident's side. Review of the hospital Emergency Provider Report dated [DATE] revealed that the resident presented to the emergency room with septic shock and pneumonia and was in guarded condition. Further review of the report revealed that the family member had told the emergency room ph… | 2018-04-01 |
| 6893 | 6893 | JEFFERSONVILLE HEALTH & REHAB | 115413 | 113 SPRING VALLEY DRIVE | JEFFERSONVILLE | GA | 31044 | 2014-09-02 | 155 | D | 1 | 0 | 53TE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and health record review the facility failed to honor one resident (A) of twelve (12) sampled residents choice to refuse [MEDICAL CONDITION] medications that were ordered by the physician. The findings include: Interview with Resident A on 8/16/14 at 3:00 p.m. revealed that the facility staff would not listen to the residents. Review of the health record for Resident A indicated that he was admitted into the facility in June of 2014. Review of the Physician order [REDACTED]. Review of the physician progress notes [REDACTED]. Review of the Minimum Data Set (MDS) for Resident A that was dated 6-22-14 indicated a Brief Interview for Mental Status (BIMS) score of fifteen (15). Review of the Physician order [REDACTED]. Review of the Physician order [REDACTED]. Review of the Medication Administration Records for June, July, and August revealed that Resident #3 had refused the [MEDICATION NAME] sixteen (16) times in June, seventeen (17) times in July and twelve (12) times in August. Record review of the Medication Administration Records for June, July and August revealed that Resident A refused the [MEDICATION NAME] ER seventeen (17) times in June, fifteen (15) times in July and nine (9) times in August. Review of the Medication Administration Records and Nurse ' s Notes for Resident A revealed that on 06/11/2014 Resident A refused the [MEDICATION NAME] and [MEDICATION NAME] and said that he didn't need them. 6/17/2014 Resident A refused the [MEDICATION NAME] and [MEDICATION NAME] he said that he was not going to take those crazy meds, I've told them and told them. 6/23/2014 Resident A refused the [MEDICATION NAME] and [MEDICATION NAME] and stated I've told you that I'm not crazy. Get it stopped. 7/03/2014 Resident A refused the [MEDICATION NAME] and [MEDICATION NAME]. 8/12/2014 Resident A refused [MEDICAL CONDITION] medication he stated I am not crazy, I don't need psych meds. Despite nurse's notes that documented R… | 2017-09-01 |
| 7774 | 7774 | LIFE CARE CTR OF LAWRENCEVILLE | 115659 | 210 COLLINS INDUSTRIAL WAY | LAWRENCEVILLE | GA | 30045 | 2013-03-21 | 155 | D | 0 | 1 | 42UW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview and staff interview the facility failed to allow two (2) residents, #49 and J, from a sample of thirty-five (35) residents to formulate advance directives that contained no conflicting information regarding their wishes. Findings include: 1. Record review revealed the resident #49 had a fluorescent green-colored Full Code sticker on the Condition Alert page divider in the resident's clinical record. Further record review of the resident's clinical record revealed a facility Do Not Resuscitate Order form dated [DATE] which was signed by the resident's attending physician and her responsible party. Further record review revealed a Hospice Do Not Resuscitate Order form which was dated [DATE] and signed by the resident's attending physician and her responsible party. An interview on [DATE] at 3:05 p.m. with the 1st shift charge nurse (Licensed Practical Nurse AA) and the 2nd shift charge nurse (Licensed Practical Nurse BB) revealed that if the resident were to suffer cardiac or respiratory arrest they would perform Cardio-Pulmonary Resuscitation (CPR) on the resident based on the Full Code sticker located in the front of her clinical record. When employees AA and BB were shown the facility and hospice DNR forms both agreed that the resident should not have CPR performed in the event of a cardio-pulmonary crisis. The facility's Director of Nursing (DON) confirmed in an interview on [DATE] at 3:25 p.m. that the resident's clinical record contained conflicting information regarding the resident's advance directives. 2. Record review for resident J revealed a Full Code sticker on the front of the Condition Alert tab in the clinical record. Further record review revealed that the resident's clinical record contained a Georgia Advance Directive for Health Care document signed by the resident on [DATE] and witnessed by two individuals. This document designated the resident as desiring her natural death to occur i… | 2016-12-01 |
| 10305 | 10305 | RIDGEWOOD MANOR HEALTH AND REHABILITATION | 115341 | 1110 BURLEYSON DRIVE | DALTON | GA | 30720 | 2011-04-26 | 155 | D | 1 | 0 | 8IM012 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and facility policy review, the facility failed to ensure timely implementation of the advance directive, regarding the Do-Not-Resuscitate (DNR) status, for one (1) resident (#1) in a survey sample of five (5) residents. Findings include: Record review for Resident #1 revealed a Patient Information Summary sheet which documented that the resident was admitted to the facility on [DATE]. Further record review revealed no evidence to indicate that the resident's responsible party was either the Durable Power of Attorney for Healthcare or Guardian. Review of the resident's Do Not Resuscitate Order For Patient Without Decision Making Capacity form revealed that the form documented the resident was to be of Do-Not-Resuscitate status. This form was signed and dated both by a physician and the resident's responsible party on 06/10/2011, but was not signed by the concurring physician until 06/13/2011, three (3) days after the resident's admission to the facility. The facility's Best Practice for DNR Orders policy related to the DNR process specified that for a resident who did not have capacity or a Durable Power of Attorney for Healthcare, there had to be two (2) physician signatures for the document to be legal, and that the facility's Social Service Department was responsible for obtaining the required information and signatures within twenty-four (24) hours of admission. During an interview with the Director of Nursing (DON) conducted at 9:10 a.m. on 06/14/2011, the DON acknowledged that the Social Service Director was responsible for obtaining the required physician's signatures within twenty-four (24) hours of admission to the facility. During an interview with the Social Service Director conducted on 06/14/2011 at 1:40 p.m., this staff member acknowledged that the second physician's signature was not obtained until 06/13/2011, and that the resident was considered to be a full-code until the seco… | 2014-08-01 |
| 327 | 327 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2017-07-20 | 156 | E | 0 | 1 | TDOI11 | Based on record review, and staff interviews, the facility failed to provide complete Advance Beneficiary Notices and Notices of Medicare Non-Coverage letters when changes in services were introduced which affected liability for two of three residents reviewed (R#4 and R#37). Three residents were reviewed for Liability Notices and Beneficiary Appeal Rights. Findings include: 1. Review of the Notice of Medicare Non-Coverage form issued to Resident (R) R#4 on 2/1/17, revealed the resident's services Will end on 2/4/17. Review of the form revealed the type of current services ending section, Insert type was blank. Further review revealed, per the form, Medicare probably will not pay for after the effective date indicated on the form, was blank. Review of the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) issued to R#4 on 2/1/17, revealed the form was not completed revealing the resident/responsible party could not make an informed choice about the services they wished to receive by not knowing what they might have to pay for. The section about cost of the items/services for which Medicare would probably no longer pay for was blank. The section about secondary insurance, and contact information for the Medicare Contractor were also blank. Further review of the SNFABN revealed it contained a section in which the resident/responsible party was to mark whether they wanted to receive the items/services that might no longer be covered, or instead, declined these items/services. Per the form, the resident/responsible party was to Choose one option, check one box, and date and sign this notice. Review of the form revealed it was not signed/dated by the resident/responsible party, but instead, stated that Verbal understanding provided by telephone by a family member. Neither option on the form was marked, and there was no indication as to whether the resident/responsible party wanted non-covered services to continue or end. 2. Review of the SNFABN issued to R#37 on 3/7/17 revealed the form was not completed rev… | 2020-09-01 |
| 748 | 748 | WILLOWWOOD HEALTHCARE AND REHABILITATION | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2016-10-14 | 156 | D | 0 | 1 | NZ7H11 | Based on interview and review of Advance Beneficiary Notices provided to residents and/or their responsible party revealed the facility failed to provide the appropriate Notice of Medicare Non-Coverage (NOMNC) to 3 of 4 sampled residents (R) (R73, R74 and R77) who received skilled services. The notices that Medicare Part A services would be ending did not provide the residents the information that they could appeal the notice or request an expedited review of their case. Findings include: 1. R73 was issued an Advance Beneficiary Notice of Non-Coverage (ABN) form CMS (Centers for Medicare and Medicaid Services)-R-131. Review of the form revealed it was signed on 6/30/16 by the spouse of R73. The notice stated Occupational Therapy (OT) and Physical Therapy (PT) Medicare Part A would be discontinued on 7/12/16. The form did not include information on how to appeal the facility's decision or to request an expedited review. The form utilized was a single-page form. A photocopy of the addressed and stamped envelope was included with the ABN form. Review of the issued CMS-R-131 revealed it was incomplete. Item C Identification Number was left blank. The section at the top of the page labeled NOTE read If Medicare doesn't pay for D. below, you may have to pay. Medicare does not pay for everything, even some care that your or your health care provider have good reason to think you need. We expect Medicare may not pay for the D.__________ below. This blank was not completed with the service that was ending. 2. The CMS-R-131 was provided to a family member of R77. The family member of R77 signed the form on 5/13/16 with the last billable day for Medicare Part A, PT and ST (speech therapy) services, documented as 5/20/16. The form did not include information on how to appeal or request expedited review of the facility's decision. Review of the issued CMS-R-131 revealed it was incomplete. Item C Identification Number was left blank. The section at the top of the page labeled NOTE read If Medicare doesn't pay for D. below, you… | 2020-09-01 |
| 856 | 856 | CALHOUN HEALTH CARE CENTER | 115340 | 1387 HIGHWAY 41 NORTH | CALHOUN | GA | 30701 | 2017-08-31 | 156 | D | 0 | 1 | KULD11 | Based on observation, staff interview, clinical record review and review of the facility's policy titled, Advance Beneficiary Notices dated (MONTH) (YEAR) revealed two of three residents (R#12 and R#17) notices were incorrectly issued denying the resident the ability to request an appeal or expedited appeal review. The sample was 27. Findings include: 1. R#12 was on a Medicare Part A stay when the facility issued the form Centers for Medicare and Medicaid Services (CMS) R-131. The form CMS-R-131 was used to indicate Part B therapy services were ending. R#12 was issued the notice indicating her physical therapy (PT) and occupational therapy (OT) were ending on 8/16/17. R#12 had reached the max (maximum) rehab potential met for the time frame. The notice was issued on 8/16/17 and signed on 8/16/17 by the responsible party. The form CMS R-131 did not provide the information and number needed to appeal to the Quality Improvement Organization (QIO) or request an expedited appeal review of the facility's decision. 2. R#17 was issued a Notice of Medicare Non-Coverage (NOMNC) form CMS- on 4/21/17. The NOMNC indicated PT/OT would end on 4/21/17. The form was signed by the responsible party on 4/21/17. The NOMNC should have been issued and signed 4/19/17. A Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) was issued to R#17 as well and did not indicate when it was given, the estimated cost of continued therapy and the information and number of the QIO was not given to request a demand bill. The SNFABN form was signed on 4/21/17 by the responsible party. Interview with the social worker on 8/30/17 at 10:12 a.m., revealed she had only been in the position about two months. She had issued the notice to R#12 and was unaware there was a separate form to notify Medicare Part A recipients. R#17 was issued a notice by the former social worker. Review of the facility's policy titled, Advance Beneficiary Notice dated (MONTH) (YEAR), revealed .4. A Notice of Medicare Non-Coverage (NOMNC) shall be issued to the resident/r… | 2020-09-01 |
| 1161 | 1161 | SOUTHLAND HEALTHCARE AND REHAB CENTER | 115376 | 606 SIMMONS ST | DUBLIN | GA | 31040 | 2016-12-16 | 156 | D | 0 | 1 | E1K811 | Based on record review and staff interview, the facility failed to provide one (1) of three (3) residents (R) 122 with the Notice of Medicare Non-Coverage Form (CMS- ) and the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (CMS- ) in a timely manner prior to the residents' discharge from Medicare Part A services. The sample size was thirty six (36). Findings include: Review of the Notice of Medicare Non-Coverage Form and the SNFABN for( R)122 this form could not be located by the facility. Further review revealed that the Social Service Director could not locate the notice. Interview on 12/13/2016 at 12:54 p.m. with the Social Services Director (SSD) revealed she could not locate the Notice of Medicare Non-Coverage Form and the SNFABN could not be located for R122. | 2020-09-01 |
| 1258 | 1258 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2016-10-20 | 156 | D | 0 | 1 | 8P5Z11 | Based on record review and staff interview, the facility failed to provide one (1) of three (3) residents (R) 7 with the Notice of Medicare Non-Coverage Form (CMS- ) and the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (CMS- ) in a timely manner prior to the residents' discharge from Medicare Part A services. The sample size was twenty-nine (29). Findings include: Review of the Notice of Medicare Non-Coverage Form and the SNFABN for R7 revealed that skilled services for the resident ended 07/28/2016. However, staff failed to mail the forms to the resident's responsible party until 07/29/2016. Further review revealed that the Social Service Director failed to notify the responsible party via telephone until 07/29/2016. Interview on 10/20/2016 at 12:54 p.m. with the Social Services Director (SSD) and the Financial Counselor confirmed that the Notice of Medicare Non-Coverage Form and the SNFABN was not sent to the to the responsible party of R7 until the day after the resident was discharged from Medicare Part A services. | 2020-09-01 |
| 1726 | 1726 | AZALEA TRACE NURSING CENTER | 115478 | 910 TALBOTTON RD | COLUMBUS | GA | 31904 | 2017-11-16 | 156 | B | 0 | 1 | NUQ511 | Based on record review, resident interview, and staff interview the facility failed to ensure that resident's rights were reviewed with residents throughout the duration of their stay at the facility. The facility census was 100 with a sample size of 32. Findings include: Review of resident council minutes for (YEAR) revealed that there was no indication that resident rights were being discussed with residents during council meetings. Interview on 11/16/17 at 9:27 a.m. with the Resident council president who reported that resident rights are not discussed and she is not aware of where the rights are posted. Interview on 11/16/17 at 9:40 a.m. with Resident (R) #2 who reported that staff do not talk about resident's rights on a regular basis. R#2 reported that no one has asked her if she wants to attend a resident council meeting. R#2 further stated that she is aware a little of her rights but it has been a while since they were discussed. R#2 reported being a resident at this facility for more than two (2) years. Interview on 11/16/17 at 9:44 a.m. with R#34 who reported that resident rights were discussed at admission but has not been discussed since. R#34 reported being a resident in the facility for about a year. Interview on 11/16/17 at 9:50 a.m. with the Admissions Director who confirmed that resident's rights are not discussed during resident council meetings but going forward she would discuss resident rights with residents. Admissions Director reported that she basically followed the template of the previous Admission Director regarding resident council meetings and notes. Admissions Director reported that now that she is aware that resident rights need to be discussed she will do so. Interview on 11/16/17 at 1:43 p.m. with R#89 who was unable to identify a time in which resident rights are discussed other than at admission. Interview on 11/16/17 at 5 p.m. with the Administrator who reported that he does not think it is correct that resident rights are not discussed. It was reported that previous Activity d… | 2020-09-01 |
| 1837 | 1837 | MCRAE MANOR NURSING HOME | 115494 | 160 SOUTH FIRST AVENUE | MC RAE | GA | 31055 | 2017-07-13 | 156 | C | 0 | 1 | M4JV11 | Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), to allow the beneficiary to make an informed decision related to continuance of Medicare skilled services and the financial responsibility for those services if Medicare does not reimburse. This notice was not provided for three of three residents(R) #9, #10, and #15) reviewed from a resident sample size was 27. Findings include: A review of the Liability Notices for R#9, R#10, and R#15 was conducted and revealed that they were discharged from skilled Medicare services and remained in the facility. Further review revealed the only notice provided to the residents was the Notice of Medicare Non-Coverage. There was no evidence that the facility had issued an SNFABN (Centers of Medicare/Medicaid Services - CMS form ) notice to the residents, providing the opportunity to continue with skilled services, at their cost, if Medicare did not reimburse. Interview on 7/12/17 at 10:25 a.m. with the Administrator revealed that she was the one that completes the Notice of Medicare Non-Coverage forms. The Administrator revealed that she has never completed the second form, CMS- , and was not familiar with the form. When asked if she discussed with the resident their options of remaining in the facility and receive therapy services or remain in the facility and not receive therapy services the Administrator revealed that she does not discuss those options with the residents. | 2020-09-01 |
| 1870 | 1870 | PRESBYTERIAN HOME, QUITMAN, IN | 115498 | 1901 WEST SCREVEN STREET | QUITMAN | GA | 31643 | 2017-05-04 | 156 | D | 0 | 1 | ROL411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure each Medicare resident whose Medicare therapy services were terminated received a notice within 2 days prior to those services ending for 2 of 3 residents (R#40 and R#44) who were reviewed for Liability Notices and Beneficiary Appeal rights. Findings include: 1. Review of the medical record for R#40 revealed she was admitted to the facility on [DATE]. R#40 had Medicare benefits and was discontinued from therapy services on 12/15/16 because she refused to participate for 3 sessions (based on hand written notes on the SNFABN (Skilled Nursing Facility Advance Beneficiary Notice) CMS (Center for Medicare and Medicaid Services) form . The facility provided R#40 with the SNFABN CMS form upon discontinuation of services on 12/19/16. Services were discontinued on 12/20/16 which was less than 2 days after the notice was given. 2. Review of the medical record for R#44 revealed she was admitted to the facility on [DATE]. R#44 had Medicare benefits that were discontinued on 12/3/16. The facility provided her with the SNFABN CMS form on 12/3/16, the same day services were terminated. The facility did not give the resident a two-day notice that benefits were ending. During an interview on 5/3/17 at 11:01 a.m. the administrative assistant said she was responsible for generating and delivering the liability notices. She said, per their procedure, the residents were to have a 72 hour notice their services were terminating. She said R#40 did not receive a 48-hour notice because she had refused therapy for three days. She said R#44 was admitted to hospice on 2/3/16 so they terminated her services that day. The administrative assistant stated she was unaware the facility was required to give at least a two-day notice to all residents who were discharged from Medicare services. The administrator was asked to provide a policy related to liability notices; no policy was provided as of the sur… | 2020-09-01 |
| 2125 | 2125 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2017-03-02 | 156 | D | 0 | 1 | 13ES11 | Based on record review and staff interview, the facility failed to issue an Advance Beneficiary Notice of Noncoverage (ABN) to one of three residents (R) reviewed (R#9), to allow them to make an informed decision about whether to continue to receive skilled services, and accept financial responsibility for those services if Medicare did not pay. The sample size was 24 residents. Findings include: Review of the facility's Notices of Exclusions from Medicare Benefits Policy noted: Policy: Notice(s) of non-coverage of items of services must be completed and given to a Medicare beneficiary, or to her or his authorized representative, before extended care services(s) or item(s) are furnished, reduced, or terminated when the SNF (Skilled Nursing Facility) believes that Medicare will not pay or will not continue to pay for extended care services that the SNF furnishes. Triggering Event/Scenario: End of Part-A covered Level of Care with benefit days available. Notice(s) Required: CMS (Centers for Medicare and Medicaid Services)- (same as the NOMNC). Triggering Event/Scenario: End of Part-A covered Level of care with benefit days available and the SNF believes that Medicare will not continue to pay for extended care services that a physician ordered. Notice(s) Required: SNF ABN (Form No. CMS- ) Review of a Notice of Discontinue from Rehabilitation Services form revealed that R#9 had a payor source of Medicare Part A, and was anticipated that her Speech Therapy (ST) would be discontinued on 11/11/16. Review of a Notice of Medicare Non-Coverage (NOMNC) form revealed that: The Effective Date Coverage of Your Current Skilled Services Will End: 11/11/16. Further review of the Additional Information section of this form revealed that: .we believe that skilled services are not covered under Medicare after 11/11/16 (Speech Therapy), and the form was signed by the resident's responsible party on 11/10/16. During interview with the Admissions Director on 2/28/17 at 10:21 a.m., she stated that R #9 remained in the facility after com… | 2020-09-01 |
| 2204 | 2204 | ARROWHEAD HEALTH AND REHAB | 115539 | 239 ARROWHEAD BOULEVARD | JONESBORO | GA | 30236 | 2017-06-15 | 156 | D | 0 | 1 | 4B7G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy for Medicare Claims Processing Manuel Chapter 30 - Financial Liability Protections, the facility failed to ensure one of three residents reviewed for receipt of liability notice for Medicare non-coverage of skilled services (Resident (R)#78). Findings include: A review of information in the Medicare Claims Processing Manuel Chapter 30, with a revision date of 1/27/17, .260.3.8 NOMNC Delivery to Representatives . The NOMNC may be delivered to a beneficiary's appointed or authorized representative . However, if the beneficiary is temporarily incapacitated a person (typically, a family member or close relative) whom the provider has determined could reasonable represent the beneficiary . in these instances of delivering a notice to an unnamed representative, the provider should annotate the NOMNC with the name of the staff person initiating the contact, the name of the person contacted and the date, time, and method (in person or telephone) of the contact. Per clinical record review, R#78 was admitted to the facility on [DATE]. The physician ordered R#78 be evaluated for skilled services on 5/4/16. On 7/19/16, the speech therapy notes indicated R#78 was to be discharged from skilled services. A review was conducted of the liability notice (Notice of Medicare Non-Coverage) for R#78. The Notice of Medicare Non-Coverage (NOMNC) for R#78, identified R#78 was discharged from skilled services with an effective dated of 7/19/16. There was no documented evidence a liability notice was provided to R#78 or to the resident's representative prior to the end of skilled services. This notice would have provided information, to the resident and/or the resident's representative, on the potential liability for non-covered services and the resident's right to appeal the facility's decision to end skilled services. There were no Progress Notes located in the electrical medical records, that… | 2020-09-01 |
| 2233 | 2233 | CROSSVIEW CARE CENTER | 115541 | 402 E. BAY ST | PINEVIEW | GA | 31071 | 2017-02-24 | 156 | E | 0 | 1 | 0NL311 | Based on record review and staff interview, the facility failed to provide the Notice of Medicare Non-Coverage (Form CMS- ) in a timely manner, prior to three residents (#72, #53, and #6) being discharged from Medicare Part B services and failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (Form CMS- ) prior to one resident (#53) being discharged from Medicare Part A services from a total sample of three residents. Findings include: 1. The facility issued an Advance Beneficiary Notice of Noncoverage (ABN) (Form CMS-R-131), dated 6/10/16, for Medicare Part B services that would end on 6/14/16 for Resident (R) #72. However, the facility did not issue the required Notice of Medicare Non-Coverage (Form CMS- ). 2. The facility issued an ABN, Form CMS-R-131, signed by R#53 on 6/6/16, for Medicare Part B services that would end that same day. There was no evidence of the notice being issued prior to services ending on 6/6/16. In addition, the required Form CMS- was not issued. A review of Form CMS- , dated 8/26/16, revealed that R#53's responsible party was notified in advance, via telephone on 8/22/16, of Medicare Part A services that would end on 8/26/16. However, there was no evidence that the facility also issued the required Form CMS- . The facility issued an ABN, Form CMS-R-131, signed by R#53, on 9/28/16, for Medicare Part B services that would end on 10/4/16. However, there was no evidence that the required Form CMS- was also issued. 3. The facility issued an ABN, Form CMS-R-131, signed by the R#6's responsible party on 5/27/16, for Medicare Part B services that would end on 5/31/16. However, there was no evidence that the required Form CMS- was also issued. The facility also issued an ABN, Form CMS-R-131, signed by R#6's responsible party on 6/27/16, for Medicare Part B services that would end on 6/27/16. However, there was no evidence that the required Form CMS- was also issued. During interviews on 2/24/17 at 11 a.m. and 12:40 p.m., the Social Service Director stated that she us… | 2020-09-01 |
| 2527 | 2527 | CAMELLIA GARDENS OF LIFE CARE | 115570 | 804 SOUTH BROAD STREET BOX 1959 | THOMASVILLE | GA | 31792 | 2017-01-12 | 156 | D | 0 | 1 | FCJY11 | Based on record review and staff interview, the facility failed to provide two (2) of three (3) residents (#24 and #33) with the Notice of Medicare Non-Coverage Form (CMS- ) and the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (CMS- ) in a timely manner prior to the residents ' discharge from Medicare Part A services. There were three (3) residents that were reviewed that had been discharged from Medicare Part A services from the facility. Findings include: 1. Review of the Notice of Medicare Non-Coverage Form and the SNFABN for resident # 24 revealed that services ended on 7/30/2016. The notice was not mailed out to the resident until 1/12/2017. There was no signature by the resident or responsible party. A note stated that there was a telephone conversation between staff and resident ' s spouse in which, staff explained the letter to resident ' s spouse and that the letter would be signed and mailed back to the facility. 2. Review of the Notice of Medicare Non-Coverage Form and the SNFABN for resident # 33 revealed that services ended on 9/17/2016. The notice was not discussed or mailed to resident until 1/12/17. Review of the paperwork revealed that there was a telephone message left for the beneficiary ' s representative on 1/12/17 and there was only the signature of the staff. Interview on 1/12/2016 at 1:59 p.m. with staff CC which stated that she was responsible for notifying residents when they were being discharged from Medicare Part A services. Staff also stated that a discharge meeting is held within 72 hours of being placed on Medicare Part A services. Staff reported that she tries to set up an additional meeting with residents and rehabilitation staff to discuss resident ' s discharging and progress, but that meeting may or may not take place. Staff reported that she does usually send out the ABN notices within the 48 hour timeframe, but she did not do it for these two residents and she did not know why she didn ' t. | 2020-09-01 |
| 2649 | 2649 | GORDON HEALTH AND REHABILITATION | 115584 | 1280 MAULDIN ROAD NE | CALHOUN | GA | 30703 | 2016-12-15 | 156 | D | 0 | 1 | YZ5011 | Based on staff interview and record review the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) for one (1) Resident (#23) of three (3) residents reviewed who were discharged from Medicare Part A services. The facility also failed to provide a copy of the Skilled Nursing Facility Advanced Beneficiary Notice to the resident (#23) who continued to reside in the facility under Part B services. The sample was twenty-six (26). Findings include: Review of the records for Resident (R#23) revealed the resident was admitted to the facility for skilled services on 10/24/16. Review of the skilled services review note dated 11/22/16 revealed R#23 was discharged from physical therapy (PT) and occupational therapy (OT) services with effect from 11/22/16. Review of the physician ' s progress note dated 11/22/16 revealed the physician documented the resident's last day of therapy would be 11/22/16 and that the resident would transition to LTC effective from 11/23/16. Further review of the records for R#23 revealed that it did not contain a copy of the Notice of Medicare Non-Coverage (NOMNC), nor a copy of the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN). Interview on 12/12/16 at 1:15 p.m. with the Financial Comptroller (FC), revealed that the facility expected R#23 to be discharged from skilled services after 11/22/16 based on a recommendation from therapy, and also expected the resident to remain in the facility on custodial care with effect from 11/23/16. The resident resumed skilled services, effective from 12/1/16, after a cast was removed from her arm. The financial comptroller confirmed that neither a copy of the Notice of Medicare Non-Coverage (NOMNC), nor a copy of a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) was on file to indicate it was provided to the resident or family at the time of discharge from services on 11/22/16, and that she did not know why this was not done, except that it might have been an oversight. The FC further stated she had checked with the … | 2020-09-01 |
| 2729 | 2729 | BAYVIEW NURSING HOME | 115593 | 12884 CLEVELAND STREET WEST | NAHUNTA | GA | 31553 | 2016-09-09 | 156 | D | 0 | 1 | GXK411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to provide the Notice of Medicare Non-Coverage (Form CMS- -NOMNC) for two (2) residents (# 80, and #74) who were discharged to home from Medicare Part A Skilled Services from a sample of twenty-seven (27). Findings include: 1. Record review revealed that Resident #80 was admitted to the facility on [DATE]. A Rehab Discharge Notification facility form dated 6/13/16 is on file to indicate resident # 80 end of skilled services. Further investigation revealed that resident #80 did not receive a Notice of Medicare Non-Coverage (Form CMS- -NOMNC), which would indicate the effective date the coverage of Skilled Services would end on 6/15/16 prior to being discharge home on 6/16/16. 2. Record review revealed that Resident #74 was admitted to the facility on [DATE]. A Rehab Discharge Notification facility form dated 4/21/16 is on file to indicate resident #74 end of skilled services. Further investigation revealed that resident #74 did not receive a Notice of Medicare Non-Coverage (Form CMS- -NOMNC) which indicated the effective date the coverage of Skilled Services would end on 4/27/16 prior to being discharge home on 4/23/16. During an interview with the Financial Coordinator on 9/8/16 at 3:50 p.m. revealed that resident #80 and resident #74 did not receive the Notice of Medicare Non-Coverage prior to being discharge to home. Financial Controller revealed that no residents who were discharged to home from Medicare Part A skilled services had received the CMS- form because she had been told the form were not needed for resident returning home and was not aware the form was required. | 2020-09-01 |
| 2743 | 2743 | EATONTON HEALTH AND REHABILITATION | 115595 | 125 SPARTA HIGHWAY 16 EAST | EATONTON | GA | 31024 | 2017-06-19 | 156 | D | 0 | 1 | SEI911 | Based on record review, resident and staff interview, the facility failed to provide the telephone number for the State Survey Agency (SSA) so that a complaint concerning any suspected violation of state or federal nursing facility regulations could be reported. In addition, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for three of three residents (R) reviewed (R #3, #5, #28), who were discharged off skilled services and remained in the facility. The facility census was 72 residents and the sample size was 28 residents. Findings include: 1. Review of the notices provided to R #3, #5, and #28 after they were discharged off skilled therapy revealed that the Notice of Medicare Non-Coverage (NOMNC) was the only notice given. This was verified during interview with the Financial Controller on 6/16/17 at 5:20 p.m., who stated that all three residents remained in the facility and had not used up their 100 days of Medicare eligibility. She further stated that she had unofficial guidance in her office that outlined what notices were required in specific situations. Review of this guidance titled Denial Notices-Summary noted that for a resident whose Part A stay was ending, had days remaining in the benefit period, and the resident remained in the Center, that both the NOMNC and the SNFABN should be issued. This was verified during further interview with the Financial Controller, who stated that she should have issued the SNFABN for these three residents, and that it was an oversight on her part not to do so. 2. Interview with R Z on 6/16/17 at 1:30 p.m. revealed that the residents who attended the Resident Council meetings were not informed by staff of how to notify the State Survey Agency (SSA) of any complaints that they may have regarding their care. Continued review revealed that she was not aware of the poster on the wall near the dining room which documented the address and telephone number of the SS[NAME] After receiving permission from R Z to review the Resident Cou… | 2020-09-01 |
| 2854 | 2854 | CANTON NURSING CENTER | 115606 | 321 HOSPITAL ROAD | CANTON | GA | 30114 | 2017-11-09 | 156 | E | 0 | 1 | K12W11 | Based on record review and staff interview, the facility failed to provide the Advance Beneficiary Notice of Noncoverage (ABN) to seven of seven Residents (R) reviewed (#4, #18, #49, #156, #95, #137, #87), who were discharged off Medicare Part A services, and who remained in the facility. The sample size was 37 residents. Findings include: Review of R #4's Notice of Medicare Non-Coverage (NOMNC) (Form CMS- ) revealed that she was discharged off Medicare Part A skilled services on 9/14/17. During interview with the Assistant Director of Nursing (ADON) on 11/8/17 at 12:54 p.m., she verified that R #4 remained in the facility after skilled services ended, the resident did not use up her 100 days of Medicare eligibility, and that the NOMNC was the only notice given to her family. She further stated that she had never issued an ABN before. During interview with the ADON on 11/9/17 at 8:42 a.m., she stated that she went back six months, and there were six additional residents discharged off Part A services, who remained in the facility, and who had not used up their 100 days of eligibility. Review of these residents' NOMNCs revealed the following: R #18's skilled services ended on 8/1/17. R #49's skilled services ended on 8/8/17. R #156's skilled services ended on 8/8/17. R #95's skilled services ended on 8/29/17. R #137's skilled services ended on 10/2/17. R #87's skilled services ended on 11/2/17. During further interview with the ADON at this time, she verified that none of these residents or responsible parties had been provided the ABN notice. | 2020-09-01 |
| 3042 | 3042 | EASTMAN HEALTHCARE & REHAB | 115622 | 556 CHESTER HIGHWAY | EASTMAN | GA | 31023 | 2017-08-24 | 156 | D | 0 | 1 | 1QQN11 | Based on interview and review of the facility's Advance Beneficiary Notice provided to residents and/or their responsible party revealed the facility failed to provide the appropriate Notice of Medicare Non-Coverage (NOMNC) to three of three sampled residents (R) (R#2, R#11 and R#22) who received skilled therapy services. The notice Medicare Part A services would be ending did not provide the residents the required information they needed to appeal the notice or request an expedited review of their case. Findings include: 1. R#2 was issued an Advance Beneficiary Notice of Non-Coverage (ABN) CMS (Centers for Medicare and Medicaid Services)-R-131 form. Review of the form revealed the resident signed on 6/1/17. The notice stated Occupational Therapy (OT), Speech Therapy (ST) and Physical Therapy (PT) Medicare Part A services would be discontinued. It did not state the date services would end. The form did not include information on how to appeal the facility's decision or to request an expedited review. The form utilized was a single-page form. 2. The CMS-R-131 form provided to R#11 revealed no date specified for the discontinuance of PT/OT/ST services. The reason services were ending was listed as see CMS (Centers for Medicare and Medicaid). The form did not include the last covered date of service. The form was signed by the resident on 3/7/17. The form did not include information on how to appeal or request expedited review. 3. The CMS-R-131 form provided to R#22 revealed no date specified for the discontinuance of PT/OT/ST services. The last covered day was not indicated for the therapy services. The form was signed by the resident with an x on 5/24/17. The form did not provide information on how to appeal or request an expedited review. Interview with the Social Worker (SW) on 8/24/17 at 3:14 p.m., revealed she was told to use Form CMS-R-131 by the skilled nursing facility (SNF) company. She indicated she was new to nursing homes and did not know there were required forms or required specific information used t… | 2020-09-01 |
| 3382 | 3382 | SOUTHERN PINES | 115657 | 801 ELBERTA ROAD | WARNER ROBINS | GA | 31093 | 2017-08-24 | 156 | D | 1 | 1 | RY0S11 | > Based on record review and staff interview, the facility failed to provide one (1) resident (R#31) of three (3) residents with the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) CMS form that was discharged from Medicare Part A coverage. Findings include: Review of the Notice of Medicare Non-Coverage form for R#31 revealed the services ended on 6/8/17. Review of the therapy notes revealed R#31 remained in the facility and continued to receive skilled services. R#31 was discharged from skilled services on 8/14/17 the 87th day of the 100 days coverage period. During an interview with the Social Worker on 8/23/17 at 2:31 p.m. she revealed that she is responsible for issuing the Notice of Medicare Non-Coverage forms to the residents or responsible party. She also revealed she issued the Notice of Medicare Non-Coverage form to R#31 on 6/5/17 since services would end on 6/8/17. She also revealed that R#31 remained in the facility and continued to receive skilled services; however she did not know to issue the SNFABN form. During an interview with the Business Office Manager on 8/23/17 at 4:00 p.m. she revealed R#31 was discharged from skilled services on th 87th day of the 100 days of coverage. The Business Office Manager also revealed she did not know to provide SNFABN to residents or their responsible party. | 2020-09-01 |
| 3551 | 3551 | CARLYLE PLACE | 115680 | 5300 ZEBULON ROAD | MACON | GA | 31210 | 2017-08-13 | 156 | D | 1 | 1 | KPDP11 | > Based on record review and staff interview, the facility failed to issue the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to one of three residents (R) reviewed (R #49), who was discharged off Medicare Part A services and remained in the skilled nursing facility. The facility census was 31, and the sample size was 21 residents. Findings include: Review of R #49's Notice of Medicare Non-Coverage (NOMNC) form noted that her skilled services ended on 5/20/17. During interview with the Administrator on 8/12/17 at 12:21 p.m., she stated that R #49 remained in the skilled nursing facility after coming off Part A services. During an interview with the Minimum Data Set (MDS) Coordinator on 8/12/17 at 12:39 p.m., she stated that she had never issued a notice other than a NOMNC when a resident's skilled services ended. During an interview with the community's Executive Director on 8/12/17 at 3:34 p.m., he stated that even though the facility did not issue the SNFABN when residents came off skilled services, the residents received the services that they needed. | 2020-09-01 |
| 4309 | 4309 | ZEBULON PARK HEALTH AND REHABILITATION | 115295 | 343 PLANTATION WAY | MACON | GA | 31210 | 2016-06-17 | 156 | D | 0 | 1 | XJQ911 | Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), to allow the beneficiary to make an informed decision related to continuance of Medicare skilled services and the financial responsibility for those services if Medicare does not reimburse. This notice was not provided for three (3) of three (3) residents (#97, #110, and #224). From a sample size of thirty-three (33). The reviewed were the resident's discharged from skilled Medicare services and remained in the facility. Findings include: A review of the Liability Notices for residents #97, #110, and #224 was conducted and revealed that they were discharged from skilled Medicare services and remained in the facility. Further review revealed the only notice provided to the residents was the Notice of Medicare Non-Coverage. There was no evidence that the facility had issued an SNFABN (Centers of Medicare/Medicaid Services - CMS form ) notice to the residents, providing the opportunity to continue with skilled services, at their cost, if Medicare did not reimburse. Interview on 06/17/16 at 9:20 a. m. with the Case Manager (CM)/Discharge Planner revealed that he/she was not familiar with the CMS form . Continued interview revealed that he/she provided residents with a verbal notice of their right to appeal. The CM confirmed that no training on providing CMS form had been provided by previous CM. The CM confirmed that the three (3) residents reviewed were only provided the non-coverage form and were not provided the SNFABN form. The CM confirmed that there is no facility policy on providing the CMS form . | 2019-11-01 |
| 4700 | 4700 | SAVANNAH BEACH HEALTH AND REHAB | 115633 | 26 VAN HORNE STREET | TYBEE ISLAND | GA | 31328 | 2016-04-21 | 156 | E | 0 | 1 | 6PXD11 | Based on record review and staff interview, the facility failed to provide three (3) of three (3) residents (#24, #26 and #50) with the Notice of Medicare Non-Coverage Form (CMS- ) and the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (CMS- ) in a timely manner prior to the residents' discharge from Medicare Part A services. There were twenty-four (24) residents who had been discharged from Medicare Part A services in the last six (6) months. Findings include: 1. Review of the Notice of Medicare Non-Coverage Form and the SNFABN for resident #24 revealed that Speech Therapy services ended 3/29/2016. Although the Notice of Medicare Non-Coverage form and the SNFABN were signed by the resident, staff failed to date the forms to show that the resident was provided the forms for review prior to discharge from Speech Therapy services on 3/29/16. Further review of the SNFABN revealed that there was no indication that staff had obtained the residents decision to continue Speech therapy services after 3/29/16. 2. Review of the Notice of Medicare Non-Coverage Form and the SNFABN for resident #26 revealed that skilled services ended 11/07/2015. However, staff failed to mail the forms to the resident's responsible party until three (3) days later on 11/10/2015. Further review of the SNFABN revealed that there was no indication that staff had obtained the responsible party's decision to continue the skilled services after 11/7/15. 3. Review of the Notice of Medicare Non-Coverage Form and the SNFABN for resident #50 revealed that skilled services for the resident ended 1/26/16. However, staff failed to mail the forms to the resident's responsible party until the day the resident was discharged from skilled services on 1/26/2016. Further review of the SNFABN revealed that there was no indication that staff had obtained the responsible party's decision to continue skilled services after 1/26/16. Interview on 4/21/2016 at 3:04 p.m. with the Social Services Director (SSD) revealed that the SSD mailed the Notice of Me… | 2019-08-01 |
| 4783 | 4783 | PROVIDENCE HEALTHCARE | 115484 | 1011 SOUTH GREEN STREET | THOMASTON | GA | 30286 | 2015-07-17 | 156 | D | 0 | 1 | GXFP11 | Based on facility policy review and staff interview, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to allow the beneficiary to make an informed decision related to continuance of Medicare services if Medicare does not reimburse. This notice was not provided for three (3) of three (3) residents reviewed ( #9, #55, and #113), who were discharged from skilled Medicare services and who remained in the facility, from a survey sample of thirty (30) residents. Findings include: An interview conducted on 7/17/15 at 8.56 a.m. with the Administrator revealed SNFABNs had not been performed due to the Social Services Director (SSD) not being aware she was responsible for obtaining the notices. The Administrator confirmed the ABNs were not obtained. An interview conducted on 7/17/15 at 9.04 a.m. with the SSD revealed she had never been informed of the responsibility of obtaining SNFABNs. An interview conducted on 7/17/15 at 9.10 a.m. with the Bookkeeper revealed she was informed by her supervisor (the regional director) that SSD is responsible for SNFABNs because it is company policy. Review of the facility's policy entitled Notices of Exclusions from Medicare Benefits - Under Triggering Event/Scenario - End of Part - A Covered Level of Care, revealed that this was to be completed by Social Services. | 2019-06-01 |
| 4799 | 4799 | HEALTHCARE AT COLLEGE PARK, LLC | 115579 | 1765 TEMPLE AVENUE | COLLEGE PARK | GA | 30337 | 2015-08-20 | 156 | B | 0 | 1 | R61O11 | Based on Record Reviews, and Staff Interviews, the facility failed to ensure three (3) residents (#41, #89, and #91) received and signed Advance Beneficiary Notice out of twenty-one (21) sampled residents. Findings Include: During review of the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), revealed resident #41, with date of notice 3/19/15, resident #89, with date of notice 4/13/15, and Resident #91, with date of notice 5/28/15, were not signed and dated by the resident and/or the authorized representative. Further review of the (SNFABN) revealed no documented evidence that the resident and/or representative received and/or was notified of any end of service/options notices. During an interview with the Business Office Manager BB on 8/19/15 at 4:00 p.m., revealed that the (SNFABN) were mailed out, but she did not obtain any signatures from the residents/authorized representatives, or ensured the notices were received, or returned back to her from the Resident/Authorized Representative. | 2019-06-01 |
| 5016 | 5016 | PINEHILL NURSING CENTER | 115564 | 712 PATTERSON STREET | BYROMVILLE | GA | 31007 | 2015-07-23 | 156 | D | 0 | 1 | Z5Z011 | Based on resident interview, record review and staff interview, the facility failed to review resident rights topics and maintain an attendance log during resident council monthly meeting for fifty-five (55) of fifty-five (55) residents. Findings Include: A review of the (YEAR) Resident Council monthly meeting minutes revealed that the minutes recorded during resident council meeting did not have any recorded Resident Rights topic or the attendance of participating residents. The Resident Council meetings minutes indicated that only two staff and the Resident Council president were in attendance each month. An interview on 07/22/15 at 2:12 p.m. with Resident L revealed that staff did not provide any resident right topics during Resident Council monthly meetings and that several residents attended the meetings. An interview on 07/22/15 at 2:33 p.m. with the Activity Director revealed that he/she was unaware of resident rights review as being part of Resident Council monthly meetings or to obtain an attendance log of participating residents. | 2019-02-01 |
| 5025 | 5025 | ROSEMONT AT STONE MOUNTAIN | 115565 | 5160 SPRING VIEW AVENUE | STONE MOUNTAIN | GA | 30083 | 2015-10-09 | 156 | C | 0 | 1 | KX8511 | Based on record review and interviews, the facility failed to provide all required liability and appeal notices for seven (7) of seven (7) residents (#59, #173, #24, #4, #27, #9, and #45) for residents that had been discharged from Medicare Part A Skilled Services. Census for the facility was one hundred thirty (130). Findings include: Review of Resident's #59, #173, #24, #4, #27, #9, and #45 Notice of Medicare Provider Non-Coverage form (Liability notices), revealed that none of the forms had been signed by the resident or residents responsible party. Interview with the Medicare Nurse on 10/08/2015 at 4:45 p.m. revealed that she only talked to resident's responsible parties on the phone regarding the Notice of Medicare Provider Non-Coverage form (CMS ) and she had no knowledge if the liability notices were ever signed or sent back to the facility. Interview with the Administrator on 10/08/2015 at 4:55 p.m. revealed the Administrator confirmed that the Notice of Medicare Provider Non-Coverage form the facility mailed to the resident's, and/or their responsible party, was not sent out. Continued interview with the Administrator revealed that the Medicare Nurse had not been trained regarding form CMS /SNF ABN and added that she was unaware of anything about the form or what it was used for. | 2019-02-01 |
| 5060 | 5060 | WASHINGTON CO EXTENDED CARE FA | 115702 | 610 SPARTA ROAD | SANDERSVILLE | GA | 31082 | 2015-06-25 | 156 | C | 0 | 1 | CRFH11 | Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), to allow the beneficiary to make an informed decision related to continuance of Medicare skilled services and the financial responsibility for those services if Medicare does not reimburse. This notice was not provided for three (3) of three (3) residents (#8, #20, and #53) reviewed who were discharged from skilled Medicare services and remained in the facility. Findings include: A review of the Liability Notices for residents #8, #20, and #53 were conducted and revealed that they were discharged from skilled Medicare services and remained in the facility. Further review revealed that the only notice that was provided was the Notice of Medicare Non-Coverage. There was no evidence that the facility had issued an SNFABN notice to these residents, providing the opportunity to continue with skilled services, at their cost, if Medicare did not reimburse. Interview on 06/24/15 at 4:55 p.m. with the Social Worker (SW) revealed that she was familiar with the CMS form but does not have the resident or the responsible party complete that form. Continued interview revealed that therapy was assisting with the form if the resident wanted to continue with therapy service while residing in the facility. The SW confirmed that the three (3) residents reviewed were only provided the non-coverage form and were not provided the SNFABN form. Interview on 06/25/15 at 2:35 p.m. with the Director of Therapy Services revealed that the therapy department only assists with SNFANB when the resident would like to continue therapy services and remain at the facility. She revealed that if therapy assists with completing the SNFABN she would hand it directly back to the Social Worker or the Minimum Data Set (MDS) Coordinator. Continued interview revealed that she understood that resident's that exhausted their skilled therapy days and remained in the facility should have a SNFABN form completed. | 2019-02-01 |
| 5167 | 5167 | PRUITTHEALTH - EASTSIDE | 115391 | 2795 FINNEY CIRCLE | MACON | GA | 31217 | 2015-04-10 | 156 | B | 0 | 1 | 1NOO11 | Based on observation, record review, and staff interview, the facility failed to post the information on how to contact the State survey and certification agency for three (3) of five (5) days of the survey. The facility census was seventy-six (76) residents. Findings include: During an interview with Licensed Practical Nurse BB on 04/08/15 at 7:20 a.m. related to her awareness of who to contact for any abuse concerns, she stated that she was not aware of where the phone number was to contact the Stage agency. During a walk-through of the hallways and common areas of the facility at this time revealed that no printed information on how to contact the State was located. During interview with the Minimum Data Set Coordinator on 04/08/15 at 10:45 a.m., she stated that the number to contact the State was on a bulletin board in the hallway off the main entrance, but verified that the poster was no longer there. During interview with the Director of Nurses (DON) on 04/08/15 at 11:15 a.m., she verified that the State information was not posted, and stated that it must have been taken down to paint the walls about three weeks earlier. During further interview and observation at 11:19 a.m., the DON stated that she found a bulletin board with the State and Ombudsman information inside a closet, and that she would have someone hang it back up. Review of the facility's Abuse Prevention policy revealed that all required posters and materials will be appropriately displayed. | 2018-12-01 |
| 5242 | 5242 | EAST LAKE ARBOR | 115482 | 304 FIFTH AVENUE | DECATUR | GA | 30030 | 2015-05-21 | 156 | B | 0 | 1 | 466Q11 | Based on record review and staff interview, the facility failed to provide the required Liability and Appeal notices for one (1) of three (3) residents who were discharged from Medicare Part A Services. Findings include: During an interview with the Social Services Director (SSD), on 05/21/15 at 11:35 a.m. the SSD revealed that resident #50 was discharged from skilled services on 05/19/15 and that he remained in the facility afterwards. Review of Notice of Medicare Non-Coverage notice dated 05/13/15 revealed that resident #50 signed the CMS Form but was not provided the CMS Form providing the resident with an informed choice regarding whether or not to continue with services and the potential costs. The SSD acknowledged that she did not have resident #50 sign the Advanced Beneficiary Notice (ABN) because she had never seen the notice before and was unaware that she was required to provide the notice to residents being discharged from Medicare Part A who were to remain in the facility. | 2018-11-01 |
| 5256 | 5256 | FRIENDSHIP HEALTH AND REHAB | 115559 | 161 FRIENDSHIP ROAD | CLEVELAND | GA | 30528 | 2015-03-12 | 156 | E | 0 | 1 | 9J7411 | Based on record review and staff interview, the facility failed to ensure that Liability and Appeal Notices for three (3) of three (3) resident's reviewed (#35, #45, and #49), were given timely following discharged from Medicare Part A Skilled services. Findings include: Record review for resident #35 revealed the resident received Medicare services from 10/25/14 until 11/14/14. There was no evidence that any Liability notice was given to the resident that Medicare covered days were ending. Record review for resident #49 revealed that resident received Medicare services from 11/16/13 until 2/23/14. Notification that Medicare covered services were ending was issued on 2/13/14. Record review for resident # 45 revealed the resident received Medicare services from 12/1/14 until 12/18/14. There was no evidence that any Liability Notice was given to resident that Medicare covered services were ending. Interview with the Financial Services Coordinator AA on 3/12/15 at 10:37 AM revealed that the former office manager had resigned and she was not able to provide Liability notices for these resident. | 2018-11-01 |
| 5470 | 5470 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2015-03-26 | 156 | D | 0 | 1 | ZJXE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interviews the facility failed to ensure that the facility policy was followed and that staff had a clear understanding of the Advanced Directive status for one (1) resident #52 of twenty four (24) sampled residents. Findings include: Record review the Face Sheet for resident #24 revealed the the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of the Advance Directive Checklist dated [DATE] and signed by the resident's representative revealed the resident had executed an advance directive which would be supplied to the facility in addition to a No Cardiopulmonary Resuscitation (DNR) signed on the same day by the resident's representative. Review of the Physician order dated [DATE] revealed an order for [REDACTED].>Record review of the Nurses Notes dated [DATE] at 3:15 a.m. revealed the resident was found not breathing, unresponsive and without a pulse during rounds by Licensed Practical Nurse (LPN) CC. Cardiopulmonary Resuscitation (CPR) was started on the resident and 911 was called. After the Emergency Personal was onsite, it was discovered the resident had a DNR status and CPR was stopped and the resident was pronounced at this time by the on call Registered Nurse (RN). An interview on [DATE] at 3:27 p.m. with LPN CC revealed that she would have to check the chart to determine DNR status but she would error on the side of caution and being CPR. An interview on [DATE] at 3:29 p.m. with LPN BB revealed that she would check the chart under the Advanced Directive tab to determine the Code Status of a resident and that there is a list of DNR status resident on each Medication Administration Record [REDACTED]. An interview and review of the MAR indicated [REDACTED]. LPN CC revealed at this time that he/she did not know who was responsible for updating the list. An interview and review of the facility policy for Do Not Resuscitate Policy: Georgia updated on ,[DA… | 2018-09-01 |
| 5512 | 5512 | PLACE AT MARTINEZ, THE | 115308 | 409 PLEASANT HOME ROAD | AUGUSTA | GA | 30907 | 2015-02-06 | 156 | B | 0 | 1 | UZN611 | Based on record review and staff interview, the facility failed to ensure that two (2) of three (3) Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) for residents #54 and #104 were properly completed, and failed to provide one (1) resident (#54) with the SNFABN when they were discharged off Medicare Part A services and remained in the facility. A total of three (3) residents were reviewed for the issuance of the proper liability and appeal notices. The sample size was thirty-six (36) residents. Findings include: 1. Review of the Notice of Medicare Provider Non-Coverage (Generic Notice) for resident #104 revealed that he was discharged from Physical Therapy (PT) and Occupational Therapy (OT) on 11/03/14, and the resident remained in the facility. Review of both this Notice and the SNFABN revealed that the forms were not signed by the responsible party (RP) until 11/04/14. In addition, the section on the SNFABN for the RP to indicate whether or not they wanted the resident to continue to receive skilled services was left blank, so that there was no indication that they knew of and understood their right to do so. 2. Review of the Medicare Notices for resident #44 revealed that she was discharged from PT on 01/01/15, and the Generic Notice and SNFABN were signed by the RP on 01/08/15, seven days after skilled services ended. Further review of the Notices revealed that resident #54 was discharged from OT on 01/12/15. Review of the SNFABN's revealed that the section for the RP to indicate that they were aware of their right to continue the skilled services was blank. Further review of the Notices revealed that the resident was discharged from Speech Therapy (ST) on 01/19/15 and remained in the facility, and the only Notice issued was the Generic Notice. Review of this Generic Notice revealed that it was signed by the RP on 01/22/15, three days after the skilled services ended. During interview with the Social Services Director (SSD) on 02/04/15 at 2:25 p.m., she stated that she recently received training… | 2018-08-01 |
| 5544 | 5544 | GREEN ACRES HEALTH AND REHABILITATION | 115578 | 313 ALLEN MEMORIAL DRIVE,SW | MILLEDGEVILLE | GA | 31061 | 2014-11-13 | 156 | D | 0 | 1 | 9P1Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) for four (4) of six (6) residents reviewed (# 35, #108, #113 and #118) who were discharged from Medicare Part A Skilled Services and remained in the facility. Findings include: 1. Record review for Resident #35 revealed a Notice of Medicare Non-Coverage (Form CMS -NOMNC) dated [DATE], which indicated the effective date the coverage of Skilled Services would end was [DATE]. However, further record review revealed that even though Resident #35 remained in the facility after being discharged from Skilled Services on ,[DATE]//2014 and did not use up the 100 days of Medicare eligibility, there was no evidence to indicate that the resident/representative received a Skilled Nursing Facility Advance Beneficiary Notice or Denial Letter, CMS - , as required. 2. Record review for Resident #118 revealed a Notice of Medicare Non-Coverage form dated [DATE], which indicated the effective date the coverage of Skilled Services would end was [DATE]. However, further record review revealed that even though Resident #118 remained in the facility until his/her discharge from the facility on [DATE] and did not use up the 100 days of Medicare eligibility, there was no evidence to indicate that the resident/representative received a Skilled Nursing Facility Advance Beneficiary Notice or Denial Letter, as required. 3. Record review for Resident #113 revealed a Notice of Medicare Non-Coverage form dated [DATE], which indicated the effective date the coverage of Skilled Services would end was [DATE]. However, further record review revealed that even though Resident #113 remained in the facility after being discharged from Skilled Services on [DATE] and did not use up the 100 days of Medicare eligibility, there was no evidence to indicate that the resident/representative received a Skilled Nursing Facility Ad… | 2018-08-01 |
| 5547 | 5547 | GRACE HEALTHCARE OF TUCKER | 115596 | 2165 IDLEWOOD ROAD | TUCKER | GA | 30084 | 2014-11-20 | 156 | D | 0 | 1 | ELBQ11 | Based on record review and staff interview, the facility failed to provide all required liability and appeal notices for three (3) residents (#90, #94, and #104) of four (4) residents reviewed who were discharged from Medicare Part A Skilled Services. Findings include: 1. Record review for Resident #104 revealed a Notice of Medicare Non-Coverage (Form CMS ), signed by the resident and dated 11/02/2014, which indicated that the effective date the coverage of Skilled Services (Physical Therapy) would end was 11/05/2014. However, further record review revealed that even though Resident #104 remained in the facility after being discharged from Skilled Services on 11/05/2014 and did not use all 100 days of Medicare eligibility, there was no evidence to indicate that the resident/representative received a Skilled Nursing Facility Advance Beneficiary Notice or Denial Letter, as required. During an interview with the Minimum Data Set (MDS) Coordinator HH conducted on 11/18/2014 at 8:45 a.m., MDS Coordinator HH acknowledged that Resident #104 Skilled Services were discontinued 11/05/2014, and that the resident remained in the facility. MDS Coordinator HH further stated that she had called Resident #104's Responsible Party (RP) a few days before the resident was to be discharged from Skilled Therapy Services and was told by the RP that the RP wanted to appeal the facility's decision to terminate services. MDS Coordinatory HH stated she verbally informed Resident #104's RP that the resident would be liable to pay for therapy if therapy continued and Medicare upheld the facility's decision to terminate the service, but further stated that she did not know that the facility had to put this information in writing by issuing a Skilled Nursing Facility Advanced Beneficiary Notice. An Expedited Appeal Request dated 11/10/2014 and addressed to Resident #104 documented a written notice of denial to the Resident #104 regarding a request by the Qualified Independent Contractor (QIC) for reconsideration of termination of Skilled Servi… | 2018-08-01 |
| 5597 | 5597 | SIGNATURE HEALTHCARE OF SAVANNAH | 115120 | 815 EAST 63 STREET | SAVANNAH | GA | 31405 | 2014-10-30 | 156 | B | 0 | 1 | EV9H11 | Based on record review and staff interview, the facility failed to provide the Notice of Medicare Non-Coverage for three (3) of three (3) residents reviewed (#10, #38, #85) that were discharged from skilled services and went home, and failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) for three (3) of three (3) residents reviewed (#9, #47, #96) who were discharged from skilled services and remained in the facility. The sample size was twenty-eight (28) residents. Findings include: Interview with the Minimum Data Set (MDS) Coordinator CC on 10/28/14 at 3:00 p.m. and 3:22 p.m., she revealed that if a resident went home after coming off skilled services, that the facility did not provide any Medicare notice at all. Upon further interview, she stated that if a resident was discharged off skilled services and remained in the facility, they were provided with the Notice of Medicare Non-Coverage only. MDS Coordinator CC further revealed that no Medicare notices were provided for residents #10, #38, and #85, because the residents went home after termination of skilled services. Upon further interview, she verified that residents #9, #47, and #96 remained in the facility after completing skilled services, and that the only notice they were provided was the Notice of Medicare Non-Coverage. She verified that none of these residents had used up their one hundred (100) days of benefit eligibility. MDS Coordinator CC further revealed that she did not know that she was supposed to issue the SNFABN for residents who remained in the facility after completing skilled services, and that all residents completing skilled services were to receive the Notice of Medicare Non-Coverage. | 2018-07-01 |
| 5841 | 5841 | GOODWILL HEALTH AND REHAB | 115486 | 4373 HOUSTON AVE. | MACON | GA | 31206 | 2012-09-27 | 156 | B | 0 | 1 | WXQ711 | Based on record review and staff interview, the facility failed to provide documentation that the required Medicare liability and appeal rights notices were provided for one (1) of three (3) residents reviewed (#63), who was discharged from Part A services. Findings include: Review of facility records revealed no evidence that the required Medicare liability notice was provided to resident #63 prior to being discharged from Medicare Part A services. During interview with Social Services Director DD on 09/27/12 at 8:30 a.m., she stated a former Social Services employee had been responsible for completing resident #63's liability and appeal rights notices, and that she could not find any documentation that this had been done. | 2018-05-01 |
| 6057 | 6057 | PRUITTHEALTH - PEAKE | 115394 | 6190 PEAKE ROAD | MACON | GA | 31220 | 2014-04-18 | 156 | E | 0 | 1 | 130111 | Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), to allow the beneficiary to make an informed decision related to continuance of Medicare skilled services and the financial responsibility for those services if Medicare does not reimburse. This notice was not provided for six (6) of six (6) residents reviewed (#52; #96; #107; #122; #153; #187), who were discharged from skilled Medicare services and who remained in the facility from a sample size of forty-four (44) residents. Findings include: Review of the Notices provided for residents #52; #96; #107; #122, #153, #187, who were discharged from skilled Medicare services and remained in the facility, revealed that the only notice that was provided was the Notice of Medicare Non-Coverage. There was no evidence that the facility had issued an SNFABN notice to these residents, providing the opportunity to continue with skilled services, at their cost, if Medicare did not reimburse Interview on 04/17/14 at 1:45 p.m. with the Financial Controller revealed that she was not aware that the SNFABN had to be provided for residents discharged from skilled services and who remained in the facility. She verified that none of these residents had used up their 100 days of eligibility to receive Medicare services. | 2018-04-01 |
| 6117 | 6117 | MANOR CARE REHABILITATION CENTER - DECATUR | 115246 | 2722 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2014-05-22 | 156 | D | 0 | 1 | HIJL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews the facility failed to ensure that one (1) resident (A) was aware of the resident rights and failed to ensure periodic reviews of resident rights from a sample of twenty nine (29) residents. Findings include: Interview on 5/21/14 at 10:19 a.m. with resident A revealed that he was not aware that he had rights in the facility, including the process for lodging a complaint with the state office and who the Ombudsman representative was or how to contact. Continued interview revealed that the facility did not provide information related to resident rights since their admission to the facility. Review of Minimum Data Set (MDS) assessment dated [DATE] for resident A revealed the resident was assessed with [REDACTED]. Interview on 5/22/14 at 8:40 a.m. with the Social Services Director and the Activity Director revealed that they were both unclear as to whose responsibility it was to conduct periodic reviews of resident's rights. Continued interview revealed that they agreed that resident rights reviews could be presented during a resident council meeting, but that to their knowledge this had not taken place. Further interview revealed that residents are provided resident rights information upon admission but they are not aware of any times residents received reviews or allowed a forum to discuss their rights. Interview on 5/22/14 at 12:09 p.m. with the Administrator and Director of Nursing revealed that random residents are given a questionnaire as part of the facility's Quality Assurance program but could not provide evidence that residents received periodic updates of their resident rights. | 2018-03-01 |
| 6371 | 6371 | UNIVERSITY NURSING & REHAB CTR | 115467 | 180 EPPS BRIDGE RD | ATHENS | GA | 30606 | 2014-10-02 | 156 | D | 0 | 1 | CZVT11 | Based on record review and staff interview, the facility failed to provide the required liability and appeal notices for one (1) resident (#112) of three (3) residents reviewed who was discharged from Medicare Part A services. Findings include: During interview with the Social Services Director on 09/30/14 at 11:54 a.m., she stated that resident #112 was discharged from skilled services on 05/23/14, and that he remained in the facility afterwards. Continued interview, revealed that she was not able to find any liability or appeal rights notices that were provided for resident #112. At 1:25 p.m., the SSD stated that when a resident was discharged from Medicare Part A services and stayed in the facility, that she normally gave them the Generic Notice and the Advanced Beneficiary Notice (ABN), and did not know why there were no notices for resident #112. | 2018-01-01 |
| 6557 | 6557 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2013-06-27 | 156 | B | 0 | 1 | DT4T11 | Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), and failed to document that the resident was being discharged from skilled therapy on the Notice of Medicare Non-Coverage form (Generic Notice) for one (1) resident (#86) from a total of four (4) residents that were reviewed. Findings include: Review of the Generic Notice for resident #86 revealed that the resident would no longer be covered for skilled nursing services effective 5/30/13; however, no evidence that the SNFABN was provided to the resident and/or legal representative. Interview with the Admissions Director on 6/26/13 at 8:30 a.m., revealed that resident #86 remained in the facility after being discharged from skilled nursing services on 5/30/13; even though, she had had not used up hundred (100) days of Medicare of eligibility. Continued interview revealed that she issues the SNFABN for all residents coming off Medicare services, but this particular case got overlooked. | 2017-11-01 |
| 6681 | 6681 | AMARA HEALTHCARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2013-01-10 | 156 | D | 0 | 1 | 6UUW11 | Based on record review and staff interview, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) prior to termination of Medicare-A covered skilled services, and failed to ensure the responsible party (RP) received the denial notice for one (1) of one (1) residents reviewed (#7). Findings include: During interview with Minimum Data Set (MDS ) Coordinator HH on 01/09/13 at 2:20 p.m., she stated she was able to locate only one resident (#7) since the facility's last standard survey who had been discharged from Medicare Part A services, without having used up their 100 days of eligibility, or been discharged to the hospital. Upon further interview, she stated that resident #7 had remained in the facility after termination of skilled therapy. Review of the denial letter entitled SNF Determination On Continued Stay revealed that resident #7 was discharged from skilled services on 12/23/11. Further review revealed that the form had not been signed by the RP, and a handwritten notation at the bottom of the form noted the facility was not able to reach the RP by phone on 12/20/11, and the denial letter was mailed to them on that date. There was no documentation that the letter had been received by the RP. During interview with MDS Coordinator HH, she stated that there was no proof that the denial letter was ever received by the RP, and did not know why it was not sent by certified mail, as they had done in the past. During interview with MDS Coordinator HH on 01/10/13 at 11:05 a.m., she stated that she did not know why the NOMNC (used to inform the beneficiary of their right to an expedited review of a service termination by a Quality Improvement Organization), was not issued for resident #7. | 2017-10-01 |
| 6697 | 6697 | MITCHELL COUNTY NURSING HOMES | 115266 | 37 SOUTH ELLIS STREET | CAMILLA | GA | 31730 | 2013-08-29 | 156 | D | 0 | 1 | FG5W11 | Based on record review and staff interview, the facility failed to provide the required liability and appeal notice for residents discharged from Medicare Part A services for one (1) resident (#83) from a sample of thirty four (34) residents. Findings include: UNIT 1: Review of facility records revealed no evidence that the required Medicare liability and appeal notice was provided to resident #83 prior to being discharged from Medicare Part A services. Interview on 8/28/13 at 8:20 a.m. with the Director of Nurses (DON) revealed that the resident did not receive a letter of appeal because he/she used all of the one-hundred (100) days allotted. Continued interview revealed that the DON did not think we had to issue those letters unless there was a requested demand bill. | 2017-10-01 |
| 6734 | 6734 | HARBORVIEW HEALTH SYSTEMS JESUP | 115414 | 1090 W ORANGE ST | JESUP | GA | 31545 | 2017-08-17 | 156 | E | 0 | 1 | 73MR11 | Based on staff interview and record review, the facility to provide accurate information on the Notice of Medicare Non-Coverage (Form CMS- ) for five residents (#3, #5, #2, #108 and #94) and failed to provide the skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (Form CMS- ) for two residents (#108 and #94) being discharged from medicare part A services from a total sample of six residents. Findings include: During an interview on 8/17/17 at 9:40 a.m., the Minimum Data Set (MDS) coordinator stated that Resident (R) #3, R#5 and R#2 were receiving skilled services while on Medicare Part A. 1. The facility issued the Notice of Medicare Non-Coverage (Form CMS- ), signed by R#3 on 5/11/17, for skilled services ending on 5/17/17. However, the form incorrectly documented that the skilled services that were ending were Medicare Part B services. 2. The facility issued the Notice of Medicare Non-Coverage (Form CMS- ), signed by R#5 on 5/6/17, for skilled services ending on 5/8/17. However, the form incorrectly documented that the skilled services that were ending were Medicare Part B services. 3. The facility issued the Notice of Medicare Non-Coverage (Form CMS- ), signed by R#2 on 4/3/17, for skilled services ending on 4/5/17. However, the form incorrectly documented that the skilled services that were ending were Medicare Part B services. During an interview on 8/17/17 at 11 a.m., the Social Service Director stated that R#108 and R#94 received skilled services while under Medicare Part A services. 4. The facility issued the Notice of Medicare Non-Coverage (Form CMS- ), signed by R#108 on 7/24/17, for skilled services ending on 7/26/17. However, the form incorrectly documented that the skilled services that were ending were Medicare Part B services. In addition, the facility issued Form CMS-R-131, instead of the required skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (Form CMS- ). 5. The facility issued the Notice of Medicare Non-Coverage (Form CMS- ), signed by R#94 on 8/4/17 for skilled services… | 2017-10-01 |
| 6879 | 6879 | SPARTA HEALTH AND REHABILITATION | 115382 | 11744 HIGHWAY 22 E | SPARTA | GA | 31087 | 2013-03-28 | 156 | C | 0 | 1 | 06L711 | Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (CMS form ) for three of three residents reviewed (#38, #40, and #77) who were discharged from Medicare Part A services and remained in the facility. The facility also failed to ensure that the Notice of Medicare Non-Coverage (CMS form ) was received by the responsible party (RP) for one resident (#38), and that the CMS form was provided prior to termination of services for one resident (#40). Findings include: During interview on 3/27/13 at 8:00 a.m., the facility's Financial Controller stated that the CMS form Notice of Medicare Non-Coverage was the only notice that she was aware of that had been provided for a resident or RP when a resident was discharged from Medicare Part A services but, the Social Services Director (SSD) was responsible for issuing those notices. The Financial Controller verified that residents #38, #40, and #77 had not used up their 100 days of Part A eligibility, and that all three remained in the facility after termination of skilled services. Review of resident #38's Notice of Medicare Non-Coverage form (CMS form ) revealed that there was no evidence that the resident's responsible party had received the notice. Review of resident #40's Notice of Medicare Non-Coverage form (CMS form ) revealed that his/her skilled services ended on 12/23/12 but, the form was not signed by the resident until 12/26/12. During an interview on 03/27/13 at 12:50 p.m., the SSD stated that he mailed the CMS form to the RP when a resident was discharged from skilled services. He said that was the only form he provided even if the resident stayed in the facility. The SSD stated that he had mailed the CMS form to resident #38's RP, and tried to reach them by telephone to determine if they wanted to appeal the decision to terminate the skilled services but, he did not document that information. The SSD verified that resident #40 did not sign the Notice of Medicare Non-Coverage… | 2017-09-01 |
| 7077 | 7077 | PRUITTHEALTH - VIRGINIA PARK | 115531 | 1000 BRIARCLIFF ROAD NE | ATLANTA | GA | 30306 | 2014-10-10 | 156 | E | 0 | 1 | 840K11 | Based on record review and staff interview, the facility failed to provide all required liability and appeal notices for five (5) of seven (7) residents reviewed (#63; #71; #88; #110; #162) who were discharged from Medicare Part A skilled services. Findings include: 1. Record review for Resident #63 revealed a Notice of Medicare Non-Coverage (Form CMS -NOMNC), signed for the resident by a resident representative and dated 06/22/2014, which indicated the effective date the coverage of Skilled Services (Physical Therapy) would end was 06/25/2014. However, further record review revealed that even though Resident #63 remained in the facility after being discharged from Skilled Services on 06/25/2014 and did not use all 100 days of Medicare eligibility, there was no evidence to indicate that the resident/representative received a Skilled Nursing Facility Advance Beneficiary Notice or Denial Letter, as required. 2. Record review for Resident #71 revealed a Notice of Medicare Non-Coverage form, signed for the resident by a resident representative and dated 05/20/2014, which indicated the effective date the coverage of Skilled Services (Physical Therapy, Occupational Therapy, and Speech Therapy) would end was 05/22/2014. However, further record review revealed that even though Resident #71 remained in the facility after being discharged from Skilled Services on 05/22/2014 and did not use all 100 days of Medicare eligibility, there was no evidence to indicate that the resident/representative received a Skilled Nursing Facility Advance Beneficiary Notice or Denial Letter, as required. 3. Record review for Resident #88 revealed a Notice of Medicare Non-Coverage, signed for the resident by a resident representative and dated 09/12/2014, which indicated the effective date the coverage of Skilled Services would end was 09/15/2014. However, further record review revealed that even though Resident #88 remained in the facility after being discharged from Skilled Services on 09/15/2014 and did not use all 100 days of Medicare elig… | 2017-08-01 |
| 7238 | 7238 | EARLY MEMORIAL NURSING HOME | 115271 | 11740 COLUMBIA ROAD | BLAKELY | GA | 39823 | 2012-07-26 | 156 | C | 0 | 1 | 01VM11 | Based on review of the liability notices issued to residents, who had been discharged from Medicare Part A services, it was determined that the facility failed to issue a Notice of Provider Non-Coverage (CMS form ) to notify residents of their right to an expedited review by the Quality Improvement Organization (QIO) and failed to document a reason for discharge on the Skilled Nursing Facility Advance Beneficiary Notice (CMS form ) for three residents (#99, #28 and #76) in a sample of three residents. Findings include: 1. Resident #99 was issued a CMS form on 6/27/12. However, that notice did not describe the Medicare Services that had been provided, an estimated cost for the continuation of those services and the date of expected discharge from Medicare Part A services. There was only documentation of the cost for room and board and a total cost for PT, OT, ST. There was no evidence that a CMS form had been issued to the resident of his/her right to an expedited review by the QIO. 2. Resident #28 was issued a CMS form on 7/16/12. However, that notice did not describe the Medicare services that had been provided, an estimated cost for the continuation of those services and the date of the expected discharge from Medicare Part A services. There was only documentation of the cost of room and board and a cost amount for PT and OT. There was no evidence that a CMS form had been issued to the resident of his/her right to an expedited review by the QIO. 3. Resident #76 was issued a CMS form on 7/02/12. However, that notice did not describe the Medicare services that had been provided, an estimated cost for the continuation of those services and the date of the expected discharge from Medicare Part A services. There was only documentation of the cost of room and board. There was no evidence that a CMS form had been issued to the resident of his/her right to an expedited review by the QIO. | 2017-06-01 |
| 7510 | 7510 | SOCIAL CIRCLE NSG & REHAB CTR | 115532 | 671 NORTH CHEROKEE ROAD | SOCIAL CIRCLE | GA | 30025 | 2012-11-15 | 156 | D | 0 | 1 | MP7M11 | Based on record review and staff interview, the facility failed to ensure that the responsible party was notified in a timely manner when one (1) resident (#18) was discharged off Medicare Part A services. A total of three (3) residents discharged from skilled services were reviewed. Findings include: Review of resident #18's Notice of Medicare Non-Coverage (Generic Notice) noted that the Skilled Nursing services were ending on 07/20/12. A Certified Mail Receipt noted the Generic Notice and Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) were mailed to the responsible party on 07/20/12, and the Date of Delivery receipt noted that the responsible party received the forms on 07/26/12. During interview with the Social Services Director (SSD) on 11/14/12 at 2:20 p.m., she verified that the Notices were not mailed to the responsible party until the day the resident's services ended, and that the responsible party did not receive them until six days later. Upon further interview the SSD added that the responsible party was not called during this time to notify them the Notices had been mailed, and/or to explain the purpose for the Notices. | 2017-03-01 |
| 7534 | 7534 | MAGNOLIA MANOR OF MARION COUNTY | 115599 | 349 GENEVA ROAD | BUENA VISTA | GA | 31803 | 2012-10-12 | 156 | D | 0 | 1 | MRPO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to accurately inform one resident (#63) of a change in payor source from a total sample of 29 residents. Findings include: Resident #63 was admitted to the facility on [DATE]. The resident received skilled physical therapy services from 5/3 through 6/21/12 and skilled occupational therapy services from 5/7 through 6/22/12. A review of the discharge therapy notes revealed that the resident was discharged from skilled physical therapy on 6/21/12 and skilled occupational therapy on 6/22/12 due to payor source request. The facility issued the resident an Advanced Beneficiary Notice, to notify him/her of the discontinuation of therapy services. However, the the facility issued the notice on 7/02/12, after the therapy services had already been discontinued. Staff inaccurately wrote in the notice that the skilled therapy services were to be discontinued on 7/05/12. See F406 for additional information regarding resident #63. | 2017-03-01 |
| 7761 | 7761 | CHRISTIAN CITY REHABILITATION CENTER | 115573 | 7300 LESTER ROAD | UNION CITY | GA | 30291 | 2012-05-23 | 156 | C | 0 | 1 | CK2111 | Based on observations and staff interview, the facility failed to post the telephone number for contacting the state agency with concerns and grievances. The facility's census was 188. Findings include: Observations of the common area on the first floor and resident care areas on the second through fifth floors on 5/20/12 at 1:03pm, 5/21/12 at 1:25pm, 5/22/12 at 12:53pm, and 5/23/12 at 9:41am revealed there was no information posted regarding contacting the state abuse hotline to report grievances. Interview with the Director of Nursing on 5/23/12 at 9:41 a.m. revealed she did not know where the poster for reporting abuse was displayed. Interview with the administrator and observations of the lobby area of the first floor and patient care areas on the second through fifth floors with him, beginning at 9:45 a.m. on 5/23/12, revealed the abuse hotline poster was not displayed in these areas. He revealed the poster should be displayed on the Information Center bulletin board in the first floor lobby. | 2016-12-01 |
| 7831 | 7831 | SCEPTER REHABILITATION AND HEALTHCARE CENTER, LLC | 115643 | 3000 LENORA CHURCH DRIVE | SNELLVILLE | GA | 30078 | 2012-06-21 | 156 | E | 0 | 1 | U3SV11 | Based on record review and staff interview the facility failed to send the required notice to three (3) residents (#186, #116, and #4) of thirty-five (35) sampled residents informing them of their right to request a claim be submitted to Medicare for review related to the termination of skilled Medicare services. Findings include: Residents # 186, #116 and #4 were admitted to the facility receiving Skilled Medicare Services. Each remained in the facility after skilled services were discontinued. Review of the advance notices each received informing them of their appeal rights revealed they only received notification of their right to an expedited review by an independent review board. There was no documentation they had received notice of their right to file an appeal to Medicare. Business Office staff member HH was interviewed on 6/21/12 at 3:30 p.m. and stated residents being discharged from skilled services are presently only being informed of their right to an expedited review. | 2016-11-01 |
| 7924 | 7924 | CALHOUN NURSING HOME | 115264 | 265 TURNER STREET | EDISON | GA | 39846 | 2012-10-04 | 156 | D | 0 | 1 | RQB211 | Based on a review of Medicare part A liability notices, it was determined that the facility failed to issue a Notice to Medicare Provider Non-Coverage (CMS ) form to convey the right to an expedited review of a service termination to two residents (#35 and #8) from a sample of three residents reviewed for medicare liability notices, from a total sample of 30 residents. Findings include: 1. The Business Office Manager issued a notice on 7/05/12 of Medicare part A discharge on 7/08/12 for resident #35. Although the facility had issued a Skilled Nursing Facility Advance Beneficiary Notice (CMS- ), facility staff failed to issue the CMS- form, the notice of a right to an expedited review of the termination of services. 2. The Business Office Manager issued a notice on 8/16/12 of Medicare part A discharge on 8/20/12 for resident #8. Although the facility had issued a Skilled Nursing Facility Advance Beneficiary Notice (CMS- ), facility staff failed to issue the CMS - form, the notice of a right to an expedited review of the service termination. | 2016-09-01 |
| 7998 | 7998 | MONTEZUMA HEALTH CARE CENTER | 115364 | 506 SUMTER ST | MONTEZUMA | GA | 31063 | 2012-03-29 | 156 | B | 0 | 1 | NZ6611 | Based on observation and staff interview the facility failed to post the telephone number for the State Survey and Certification Office. Census = 78 Findings include: Observation of posted signs in the facility revealed that there was no posting of the State Survey and Certification phone number. Interview on 03/28/12 at 5:50 p.m. with the Administrator and Registered Nurse Consultant BB concurred that the number was not posted on any board in the facility. | 2016-07-01 |
| 8003 | 8003 | QUIET OAKS HEALTH CARE CENTER | 115396 | 125 QUIET OAKS DRIVE | CRAWFORD | GA | 30630 | 2012-05-17 | 156 | B | 0 | 1 | R15H11 | Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) for three (3) of three (3) residents (#12, #57 and #63) discharged from Medicare Part A services, and failed to ensure that the responsible party (RP) received the Notice of Medicare Provider Non-coverage (Generic Notice) when mailed for two (2) of three (3) residents (#12 and # 63). Findings include: On 05/15/12 at 3:05 p.m., the Social Service Director (SSD)/Admissions Coordinator stated that residents #12, #57, and #63 were discharged from Medicare Part A services, and that all three (3) residents remained in the facility. He further stated that the Generic Notices were mailed to the RP's, but he could not verify that they actually received the Notice as none of them were signed and returned except for resident #57. On 5/16/12 at 8:15 a.m., the SSD stated that he stopped sending out the SNFABN months ago. | 2016-07-01 |
| 8053 | 8053 | THUNDERBOLT TRANSITIONAL CARE AND REHABILITATION | 115624 | 3223 FALLIGANT AVENUE | THUNDERBOLT | GA | 31404 | 2011-12-08 | 156 | B | 0 | 1 | VJEI11 | Based on observation and staff interview the facility failed to post contact numbers for reporting abuse to the State Agency for residents on one hall, (1) West Wing Hall, of three (3) halls in the facility. Findings include: Observation on 12/08/11 at 11:55 a.m. revealed that there was not an Abuse Hotline poster on the West Unit that explains how to report suspected abuse to the state agency. A tour of the West Wing Unit with Licensed Practical Nurse (LPN) CC at this same time revealed that there was no Abuse Hotline poster prominently displayed for residents, staff or family to utilize. The poster was prominently displayed on the East Wing Unit. | 2016-07-01 |
| 8181 | 8181 | CUMMING NURSING CENTER | 115551 | 2775 CASTLEBERRY ROAD | CUMMING | GA | 30041 | 2012-02-02 | 156 | D | 0 | 1 | T1BV11 | Based on observation, record review and staff and resident interview the facility failed to inform two (2) of thirty-four (34) sampled residents of their right to contact the state agency with concerns and grievances. Findings include: Resident F was interviewed on 2/02/12 at 11:00 a.m. as representative for the Resident Council. She stated she had attended every meeting since her admission. A review of the Resident Council Minutes for calendar year 2011 and January 2012 revealed she was a regular participant. She further stated various facility departments are invited to the meetings to discuss relevant issues and address any concerns. She also stated resident rights were not discussed with the except a voting and the ability of the council to meet without staff if the residents so desire. Resident F was not aware of contact information for the State Agency. The Administrator was interviewed on 2/02/12 at 2:00 p.m. and stated resident rights information was provided to family members during the admission process. He further stated this was a very long process and usually does not involve the resident. The facility staff did not cover resident rights at council meetings and did not currently have another means of covering this information after admission except for posters displayed near the lobby on a bulletin board. On 02/2/12 at 1:10 p.m., resident B stated that they did not know that they could contact the State agency for care complaints, and that nobody in the facility had talked to him/her about this. The facility assessed resident B's Cognitive Status Summary Score on their most recent Minimum Data Set (MDS) as 14 (a score of 13-15 is cognitively intact). | 2016-06-01 |
| 8321 | 8321 | HAZELHURST CENTER | 115626 | 180 BURKETT FERRY ROAD | HAZLEHURST | GA | 31539 | 2011-12-01 | 156 | B | 0 | 1 | 9HEV11 | Based on record review and staff interview, it was determined that the facility failed to issue the Skilled Nursing Facility Advance Beneficiary Notice (CMS form ) or Denial Letter and provide the estimated cost of continued services to three residents in order to allow them to make an informed decision about whether or not they wanted to pay for the services in a sample of three residents who have been discharged from Medicare Part A services since June, 2011. Findings include: The facility had issued notices to three residents who they believed were to be discharged from Medicare Part A services because they no longer required skilled rehabilitation and/or skilled nursing services. However, they failed to issue the required CMS form liability notice or Denial Letter and, did not provide those residents or their legal representatives the estimated cost of those services in order to make an informed decision about whether they wanted to pay for those services themselves. One resident was discharged from Medicare Part A services on 6/13/11, one on 7/27/11, and the third on 8/22/11. During an interview on 11/30/11 at 10:45 a.m., the business office manager stated that the social service staff was previously responsible for issuing notices but, did not issue any notices of liability with estimated costs to the residents that were being discharged from Medicare Part A services. She confirmed that the mandatory notices or Denial Letter and estimated costs had not been issued to the three residents in the sample. | 2016-03-01 |
| 8335 | 8335 | COOK SENIOR LIVING CENTER | 115655 | 706 NORTH PARRISH AVE . | ADEL | GA | 31620 | 2012-02-23 | 156 | B | 0 | 1 | 028H11 | Based on record review and staff interview, it was determined that the facility had failed to provide three (#33, #100, and #51) of three sampled residents, who were discharged from Medicare Part A services, with the CMS- form and the Skilled Nursing Advanced Beneficiary Notice (SNFABN) form (CMS - ) or a mandatory uniform Denial Letter to inform the resident of his/her right to an appeal and potential liability for the non-covered services and the estimated cost of those non-covered services. Findings include: On 2/23/12 at 1:12 p.m., the Minimum Data Set (MDS) coordinator stated that she had not provided the CMS- form and the SNFABN form or a mandatory uniform Denial Letter to residents who had been discontinued from Medicare Part A services for coverage reasons. She had incorrectly provided the CMS-R-131, a Medicare Part B form. Twenty-three residents had been discharged from Medicare Part A services for coverage reasons since 9/27/11. 1. Resident #33 was notified by the facility on 1/26/12 that Medicare Part A coverage for skilled services would end on 1/30/12. However, the facility failed to provide the resident with the required CMS form and the CMS- form or a uniform Denial Letter to inform the resident of his/her right to an appeal and potential liability for the non-covered services and the estimated cost of those non-covered services if the resident chose to continue to receive them. 2. Resident #100 was notified by the facility on 10/7/11 that Medicare Part A coverage for skilled services would end on 10/10/11. However, the facility failed to provide the resident with the required CMS form and the SNFABN form or uniform Denial Letter to inform the resident of his/her right to an appeal and potential liability for the non-covered services and the estimated cost of those non-covered services if the resident chose to continue to receive them. 3. Resident #51 was notified by the facility on 11/28/11 that Medicare Part A coverage for skilled services would end on 12/1/11. However, the facility failed to pro… | 2016-03-01 |
| 8346 | 8346 | OAKS HEALTH CTR AT THE MARSHES OF SKIDAWAY ISLAND | 115715 | 95 SKIDAWAY ISLAND PARK ROAD | SAVANNAH | GA | 31411 | 2012-05-10 | 156 | B | 0 | 1 | PLR011 | Based on a review of the facility's Notice of Medicare Provider Non-Coverage form (form CMS- ), it was determined that the facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (form CMS- ) or mandatory uniform Denial letter to two of three residents who were discharged from Medicare Part A services to inform them of their potential liability for payment of non-covered services in order to allow them to make an informed decision of whether or not to continue services. Findings include: 1. Resident #41 was discharged from Medicare Part A services on 2/10/12 and continued to reside in the facility. However, the facility only issued the resident a CMS- notice. 2. Resident #17 was discharged from Medicare Part A services on 2/08/12 and remained in the facility. However, the facility only issued the resident a CMS- notice on 2/04/12. The facility failed to issue a CMS- notice or a mandatory uniform Denial letter to inform them of their potential liability for payment of non-covered services in order for them to make an informed decision of whether or not they wanted to pay for the continuation of services. | 2016-03-01 |
| 8528 | 8528 | MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER | 115582 | 2255 FREDERICA ROAD | SAINT SIMONS ISLAND | GA | 31522 | 2011-10-06 | 156 | D | 0 | 1 | XPEN11 | Based on record review and staff interview, it was determined that the facility had failed to provide two (S and T) of three sampled residents, who were discharged from Medicare Part A services, with the Skilled Nursing Advanced Beneficiary Notice (SNFABN) form (CMS - ) or a mandatory uniform Denial Letter to inform the resident of his/her potential liability for the non-covered services and the estimated cost of those non-covered services. Findings include: On 10/5/11 at 3:35 p.m., the Business Office manager stated that she had not provided the SNFABN form or a Denial Letter to residents who had been terminated from Medicare Part A services for coverage reasons. According to documentation provided by the Business Office manager, 32 residents had been discharged from Medicare Part A services for coverage reasons since 6/2011. 1. Resident S was notified by the facility on 4/11/11 that Medicare Part A coverage for skilled services would end on 4/12/11. However, the facility failed to provide the resident with the required SNFABN form or a uniform Denial Letter to inform the resident of his/her potential liability for the non-covered services and the estimated cost of those non-covered services if the resident chose to continue to receive them. 2. Resident T was notified by the facility on 5/9/11 that Medicare Part A coverage for skilled services would end on 5/13/11. However, the facility failed to provide the resident with the required SNFABN form or uniform Denial Letter to inform the resident of his/her potential liability for the non-covered services and the estimated cost of those non-covered services if the resident chose to continue to receive them. | 2016-01-01 |
| 8561 | 8561 | OAKS - BETHANY SKILLED NURSING, THE | 115705 | 1305 EAST NORTH STREET | VIDALIA | GA | 30475 | 2011-03-09 | 156 | B | 0 | 1 | 78N611 | Based on a review of the facility's Skilled Nursing Facility Advance Beneficiary Notice and Notice of Medicare Provider Non-Coverage forms, it was determined that the facility failed to issue the mandatory denial notices to two residents (#21 and #25) that included their potential liability for payment of non-covered services in order to allow them to make an informed decision about whether or not they wanted to continue to receive specific items or services, knowing that they might have to pay for those items or services themselves, and failed to be sufficiently specific as to the reason why the facility expected Medicare to deny payment. Findings include: According to CMS' Liability Notices/Notice of Medicare Provider Non-coverage instructions, the Notice of Medicare Provider Non-Coverage form (CMS- ) was supposed to be issued when all covered services ended for coverage reasons. If the facility expected the beneficiary to remain in the facility in a non-covered stay, either the CMS- form or a Denial Letter was required to be issued to inform the beneficiary of the potential liability for the non-covered stay. The standards for use by Skilled Nursing Facilities (SNF) in implementing the CMS- form as described in the 70-Form CMS- Skilled Nursing Facility Advance Beneficiary Notice, instructed the SNF to give the specific reason(s) why it expected Medicare to deny payment. The reason(s) cited were to be in understandable lay language and sufficiently specific to allow the resident to understand the basis for the expectation that Medicare would deny payment. Estimated cost amounts could be provided either with the description of extended care items and services or on the estimated cost line. The facility believed that two residents' (#21 and #25) continued stay in the facility would not be paid for by Medicare Part A. However, the Skilled Nursing Facility Advance Beneficiary form (CMS- ) issued to those residents on 3/1/11 and 3/3/11 respectively, did not conform with the notice requirements to explain to the bene… | 2016-01-01 |
| 8627 | 8627 | SAVANNAH SQUARE HEALTH CENTER | 115546 | ONE SAVANNAH SQUARE DRIVE | SAVANNAH | GA | 31406 | 2011-09-22 | 156 | B | 0 | 1 | RA8R11 | Based on resident and staff interviews the facility failed to ensure that residents were informed of their right to notify the state agency of concerns related to their care for one (1) resident (A) from a sample of twenty-eight (28) residents. Findings include: Interview with resident A on 9/21/11 at 10:20 AM revealed the resident was not aware that he/she could notify the state agency about concerns related to the care he/she was receiving. Continued interview revealed that he/she would not know how to notify the State. Observation on 9/21/11 at 11:00 a.m. revealed that there was no evidence that information related to contacting the state agency was posted in the facility. Interview with the administrator on 9/21/11 at 1:38 PM revealed the information regarding contacting the state was not posted. He revealed that the information was taken down when the facility was painted, and never put back up. | 2015-12-01 |
| 8654 | 8654 | RIVERVIEW HEALTH & REHAB CTR | 115641 | 6711 LAROCHE AVENUE | SAVANNAH | GA | 31406 | 2011-09-29 | 156 | B | 0 | 1 | OEDC11 | Based on record review and staff interview, the facility failed to provide documentation that a Notice of Medicare Provider Non-Coverage (Generic Notice) was provided for one (1) of three (3) residents reviewed (#181), and failed to provide proof that the responsible party received this Notice for one (1) resident (#101). Findings include: On 9/28/11 at 1:02 p.m., Admissions Coordinator 'II' stated that the facility never provided the Notice of Medicare Provider Non-Coverage for residents discharged from Medicare if they were going home, only for the residents that remained in the facility. She stated that if the responsible party was not able to be contacted by phone, that a letter by regular mail was sent. Review of resident #101's Generic Notice revealed that Skilled Nursing Services were ending on 5/10/11. No date of notice, nor name and number for the Quality Improvement Organization was included on the form. In the Additional Information section of the form, it was noted that the responsible party (RP) was called on 5/06/11 and 5/09/11, that there was no answer, and that a letter with the Notice of Non-Coverage was sent on 5/10/11. In addition, the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) was unsigned, and an attached letter addressed to the RP dated 5/06/11 noted resident #101 no longer met skilled criteria to be covered under Medicare Part A, and to call the Admissions Coordinator if he had any questions. There was no proof that the letter was mailed or received by the RP. Additionally, Option 2 on the SNFABN was checked indicating that the resident/RP did not want to receive Skilled Nursing Services. The Admissions Coordinator stated that whenever she left a phone message for the RP, her message would say that if she didn't hear back it would indicate to her that they did not want to appeal the decision, and would mark Option 2 on the form herself. On 9/28/11 at 1:15 p.m., the Social Services Director, who was previously responsible for preparing Liability and Appeal Notices, stated s… | 2015-12-01 |
| 8686 | 8686 | AMARA HEALTH CARE & REHAB | 115150 | 2021 SCOTT ROAD | AUGUSTA | GA | 30906 | 2011-08-25 | 156 | C | 0 | 1 | HP8Y11 | Based on observation and staff interview, the facility failed to display required information effecting all residents and/or responsible parties within the facility. Findings include: Observation during the three days of the survey, 8/22/11-8/25/11 revealed the state required abuse poster was not displayed. Interview on 8/25/11 at 10:00 a.m. with the nursing home Administrator confirmed that the State Abuse Hotline poster was not displayed. | 2015-11-01 |
| 8702 | 8702 | DELMAR GARDENS OF GWINNETT | 115350 | 3100 CLUB DRIVE | LAWRENCEVILLE | GA | 30044 | 2011-12-15 | 156 | B | 0 | 1 | RY4011 | Based on observation, record review, staff and resident interviews, the facility failed to ensure the residents were aware of how to contact the State for care complaints. Four (4) of five (5) residents ('A,' 'B,' 'C,' 'E') interviewed did not know how to contact the State. The facility census was sixty-one (61) residents. Findings include: On 12/13/11 at 8:55 a.m. and 4:40 p.m., 12/14/11 at 12:00 p.m., and 12/15/11 at 9:30 a.m., residents 'A,' ' B', 'C', and 'E' stated that they did not know how to contact the State agency for complaints, and did not recall the staff discussing this during Resident Council meetings. No documentation was found in the 2011 Resident Council minutes that the staff discussed the residents' ability to complain to the State and/or where the poster was located. During observations in the facility, the State Abuse reporting poster was displayed on a table just inside the front entrance. However, the poster was not easily visible to the residents unless they went to the Administrator's office or out the front door. On 12/15/11 at 9:30 a.m., resident 'E' stated they did not recall seeing the State poster even though they had been to the Administrator's office before. On 12/13/11 at 4:15 p.m., and 12/14/11 at 2:53 p.m., the Activity Director and Social Services Director stated that this information wasn't covered in Resident Council meetings. | 2015-11-01 |
| 8860 | 8860 | WILLOWWOOD NURSING CENTER | 115327 | 4595 CANTRELL ROAD | FLOWERY BRANCH | GA | 30542 | 2013-06-06 | 156 | D | 0 | 1 | PDE711 | Based on record review and staff interview, the facility failed to provide the required liability and appeal notices for residents discharged from Medicare Part A services for two (2) residents (#75 and #110) from a sample of thirty four (34) residents. Findings include: Review of the clinical record for three (3) resident's discharged from Medicare Part A services revealed that the records for two (2) residents (#75 and #110) had no evidence that the required liability and appeal notices had been issued. Interview with the Social Services Director on 06/04/13 at 2:30 p.m., revealed that she was unable to locate the liability and appeals notices for residents #75 and #110, who had been discharged off Medicare Part A services. Interview with the facility's Administrator on 06/06/13 at 3:25 p.m.,revealed that when she started to work at the facility in April, she discovered that the Liability and Appeal Notices were not being issued. | 2015-09-01 |
| 8879 | 8879 | CEDAR SPRINGS HEALTH AND REHAB | 115381 | 148 CASON ROAD | CEDARTOWN | GA | 30125 | 2011-06-23 | 156 | D | 0 | 1 | 88CH11 | Based on review of the facility's Medicare Liability and Appeals notices, observation, resident and staff interviews, the facility failed to ensure that Medicare notices were signed and dated for one (1) of nine (9) residents reviewed and to post the name, address, and telephone number of the State Ombudsman program. Findings Include: 1. Observation conducted 6/22/11 at 1:00pm revealed that the facility did not have information regarding how to contact the State Ombudsman program posted in the facility. During interview with the administrator on 6/23/11 at 1:35pm, she acknowledged that there was no State Ombudsman program information posted in the facility. 2. Review of Medicare denial notice NEMB-SNF form for resident # 85 issued 05-06-2011 revealed the notice was mailed to the responsible party and there was no evidence the form had been signed and returned to the facility. Interview with Business Office Manager on 06-23-11 at 1:45 PM revealed that she mails out the notices. Sometimes the notices are returned and at other times, the responsible party will return the form in person. Continued interview revealed the facility has no system to ensure that mailed notices are returned. | 2015-09-01 |
| 8893 | 8893 | SUMMERHILL ELDERLIVING HOME & CARE | 115430 | 500 STANLEY STREET | PERRY | GA | 31069 | 2011-03-18 | 156 | B | 0 | 1 | 2WIT11 | Based on resident interviews the facility failed to inform residents aware that they had the right to notify the state agency if they felt the facility was not meeting their needs in an appropriate manner or according to state and federal guidelines for three (3) residents (Z, C and P) from a sample of forty-one (41) residents. Findings include: 1. Interview with resident Z on 03/15/11 at 9:15 a.m. revealed that the facility had not made residents aware that if they had concerns with the care provided by the facility or concerns about response to grievances, that they could call the state hotline number. Z was unaware of where the hotline number could be found or its purpose. Continued interview revealed that the resident was not aware that the hotline number was on the posters throughout the facility. 2. Interview with resident C on 03/17/11 at 3:44 p.m. revealed that he/she had recently moved to the nursing home from the assistive living facility. C indicated that it was common knowledge in the assistive living facility that if you were not pleased with your care and or if the facility did not handle your problems appropriately then you could call the state. C indicated that he/she was not informed of this when admitted to the nursing home side. C was not aware of a hotline number which could be called to voice concerns about the nursing home. 3. Interview with resident P on 03/17/11 at 4:36 p.m. revealed that the resident was not aware that he/she could call the state to report concerns related to care for themselves or any other resident. Continued interview revealed that no one had made him/her aware of this. Interview with Director Of Nursing (DON) on 03/16/11 at 8:45 a.m. revealed that there are posters throughout the facility that inform the residents that they can call the state hotline if they have issues which are not addressed or resolved to their satisfaction by the facility. | 2015-09-01 |
| 8933 | 8933 | WOODLANDS HEALTH CARE | 115553 | 652 COASTAL HIGHWAY 17 NORTH | MIDWAY | GA | 31320 | 2011-09-29 | 156 | C | 0 | 1 | ZNQD11 | Based on record review and staff interview, it was determined the facility failed to issue the mandatory written Notice of Provider Noncoverage (form CMS- ) and a completed Skilled Nursing Facility Advance Beneficiary Notice (form CMS- ) to three of three residents (#107, #81, and #70) reviewed who had been discharged from Medicare Part A services. Findings include: The facility issued a Skilled Nursing Facility Advance Beneficiary Notice (form CMS- ) to resident #107 on 7/14/11, to resident #81 on 8/26/11, and to resident #70 on 6/6/11 notifying them of their discharge from Medicare Part A services on 7/17/11, 8/25/11, and 6/8/11 respectively. However, the facility failed to complete the estimated cost section of the form. Additionally, the facility had failed to issue the required Notice of Provider Noncoverage (CMS- ) to residents who had been discharged from Medicare Part A services. During an interview on 9/28/11 at 3:10 p.m., the business office manager, who was responsible for issuing the mandatory liability forms, said that she was not aware of the form CMS . She said that the facility had issued notices to the 12 residents who had been discharged from Medicare Part A services since June 2011. | 2015-09-01 |
| 9073 | 9073 | EARLY MEMORIAL NURSING HOME | 115271 | 11740 COLUMBIA ROAD | BLAKELY | GA | 39823 | 2010-10-07 | 156 | B | 0 | 1 | 4TFW11 | Based on a review of the facility's "Skilled Nursing Facility Advance Beneficiary Notice: (CMS form ), and the Notice of Provider Non-Coverage" (CMS form ), it was determined that the facility failed to provide the resident or authorized representative with the specific services that they determined would not be covered by Medicare payment and did not provide the estimated costs for those services in order to allow them to make an informed decision about whether or not they wanted to pay for the services prior to their discharges from Medicare Part A services between 5/24/10 and 9/7/10 in a sample of three residents discharged from Medicare Part A. Findings include: The facility believed that three residents were to be discharged from Medicare Part A services because they no longer required "skilled care." Although the facility issued CMS from on 5/24/10, 5/25/10 and 9/7/10, they did not include the specific skilled care services and the estimated cost for those services in order for the residents or authorized representatives to make an informed decision about whether or not they wanted to pay for continued services. The facility's description of the services for all three residents was documented as "room and board." The facility issued CMS form but, documented that the ending dates of coverage for the three residents' current skilled nursing services as the same date the notices (CMS forms and ) were issued. The residents or authorized representatives were not given notices prior to their discharges from Medicare Part A. | 2015-08-01 |
| 9079 | 9079 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2011-01-07 | 156 | B | 0 | 1 | TLCS11 | Based on a review of the facility's "Skilled Nursing Facility Advance Beneficiary Notice" (CMS form ) and "Notice of Medicare Provider Non-Coverage" (CMS form ), it was determined that the facility failed to specify the care items or services for which Medicare Part A was expected not to pay, did not provide the estimated cost of continued services, and did not provide notices in a timely manner for two residents ("A" and "B") or their legal representatives in order to allow them to make an informed decision about whether or not they wanted to pay for the continuation of services in a sample of three residents who had been discharged from Medicare Part A services since January 2010. Findings include: According to the Centers for Medicare and Medicaid Services (CMS) 70.4.3.2- Specifications Required for the "Items or Services" Section of the form CMS , the specification must be in sufficient detail so that the patient understands precisely what extended care items or services may not be furnished. According to CMS S&C-09-20, issuing the CMS form to a beneficiary conveys notice to the beneficiary of his or her right to an expedited review of a service termination. 1. Resident "A" was discharged from Medicare Part A on 11/30/10. The facility's 12/9/10 "Skilled Nursing Facility Advance Beneficiary Notice" form (CMS- ) documented that Medicare would probably not pay for "skilled services or special therapies". However, the facility failed to specify the care items or services for which Medicare Part A was expected not to pay and failed to provide the reasons for non-payment so the resident's legal representative understood precisely what might not be furnished and why. The facility failed to provide an accurate estimated cost for those services to help the resident's legal representative make an informed choice about whether or not she/he wanted to pay for the continuation of those services for the resident that would not be paid for by Medicare. The facility documented the rate for room and board in the section of th… | 2015-08-01 |
| 9133 | 9133 | PRUITTHEALTH - VALDOSTA | 115377 | 2501 NORTH ASHLEY STREET | VALDOSTA | GA | 31602 | 2010-12-02 | 156 | B | 0 | 1 | LSPQ11 | Based on a review of the facility's Skilled Nursing Facility Advance Beneficiary Notice (CMS form ), it was determined that the facility failed to specify the care items or services for which Medicare Part A was expected not to pay and did not provide the estimated cost of continued services to three residents ("A", "B", and "C") or their legal representatives in order to allow them to make an informed decision about whether or not they wanted to pay for the continuation of services in a sample of three resident who had been discharged from Medicare Part A services since November 2010. Findings include: 1. Resident "A" was discharged from Medicare Part A on 11/21/10. The facility's 11/15/10 Skilled Nursing Facility Advance Beneficiary Notice form documented that Medicare would probably not pay for therapy or skilled nursing services because "therapy and/or skilled nursing services not covered by Medicare A at this time." However, the facility failed to specify the care items or services for which Medicare Part A was expected not to pay so the resident or legal representative understood precisely what might not have been furnished. The facility failed to provide an estimated cost for those services to help the resident or legal representative make an informed choice about whether or not she/he wanted to pay for the continuation of those services for the resident that would not be paid by Medicare. 2. Resident "B" was discharged from Medicare Part A on 11/4/10. The facility's 11/3/10 Skilled Nursing Facility Advance Beneficiary Notice documented that Medicare would probably not pay for therapy or skilled nursing services because "therapy and/or skilled nursing services not covered by Medicare A at this time." However, the facility failed to specify the care items or services for which Medicare Part A was expected not to pay so the resident or legal representative understood precisely what might not have been furnished. The facility failed to provide an estimated cost for those services to help the resident or legal… | 2015-08-01 |
| 9226 | 9226 | LILLIAN G CARTER HEALTH AND REHABILITATION | 115550 | 225 HOSPITAL STREET | PLAINS | GA | 31780 | 2011-02-09 | 156 | B | 0 | 1 | 1SFM11 | Based on a review of the facility's "Notice of Medicare Provider Non-Coverage" form and "Skilled Nursing Facility Advanced Beneficiary Notice" form, it was determined that the facility failed to include the specific items or services that would be denied and the estimated cost for those services for two residents (#21 and #22) in order to allow them to make an informed decision about whether or not they wanted to continue to receive specific items or services, knowing that they might have to pay for those items or services themselves. Findings include: The standards for use by Skilled Nursing Facilities (SNF) in implementing the CMS- form as described in the "70-Form CMS- Skilled Nursing Facility Advance Beneficiary Notice", instructed the SNF to give the specific reason(s) why it expected Medicare to deny payment. The reason(s) cited were to be in understandable lay language and sufficiently specific to allow the resident to understand the basis for the expectation that Medicare would deny payment. Estimated cost amounts could be provided either with the description of extended care items and services or on the "estimated cost" line. The facility believed that two residents' (#21 and #22) continued stay in the facility would not be paid for by Medicare Part A. However, the " Skilled Nursing Facility Advance Beneficiary Notice" form (CMS- ) did not include the specific items or services that would not be covered by Medicare and an estimated cost for the continuation of those items or services. 1. The facility issued a "Skilled Nursing Facility Advance Beneficiary Notice" to resident #21 on 11/16/10. The facility documented on that form that the current skilled nursing facility services would end on 11/19/10. An authorized representative of the resident signed the form 11/17/10. However, the facility failed to complete that form to describe the specific items or services that were to have been discontinued and an estimated cost for the items or services. 2. The facility issued a "Skilled Nursing Facility Advance B… | 2015-08-01 |
| 9231 | 9231 | CAMELLIA GARDENS OF LIFE CARE | 115570 | 804 SOUTH BROAD STREET BOX 1959 | THOMASVILLE | GA | 31792 | 2010-10-14 | 156 | B | 0 | 1 | E49P11 | Based on record review and staff interview, it was determined that the facility failed to provide five residents ("A", "B", "C", "D", and "E") with a Notice of Medicare Provide Non-Coverage and a Skilled Nursing Facility Advance Beneficiary Notice prior to the discontinuation of skilled services paid for by Medicare Part A and failed to provide 15 residents with an Advanced Beneficiary Notice of Non-coverage prior to the discontinuation of services paid for by Medicare Part B. Findings include: According to the Centers for Medicare and Medicaid Services (CMS), a 'Skilled Nursing Facility Advance Beneficiary Notice' (CMS-1055 form) and a Notice of Medicare Provider Non-coverage (CMS- ) should be given to a Medicare Part A beneficiary or to his/her authorized representative before extended care services or items are reduced or terminated when the nursing facility believes that Medicare will not pay for, or will not continue to pay for services that the nursing facility furnishes and that a physician ordered. An Advanced Beneficiary Notice of Non-coverage (CMS-R-131) should be issued for non-covered Medicare part B services. 1. The Social Service Director stated during an interview on 10/14/10 at 12:40 p.m. that she was not aware of the form CMS-R-131 and had not been using it to notify residents that services covered under Medicare Part B would be terminated. A review of 15 residents, whose Medicare Part B services were terminated between 6/25/10 and 10/15/10, revealed that the facility had only issued a Notice of Medicare Provider Non-coverage (CMS- ) notice to those residents. 2. The Social Service Director stated during an interview on 10/14/10 at 12:40 p.m. that she was not aware that forms CMS and CMS were to be used to notify residents about a reduction or termination of services under Medicare Part A coverage. A review of residents, whose Medicare Part A services were terminated between 6/10/10 and 9/8/10, revealed that five residents ("A", "B", "C", "D", and "E") were only provided a "Skilled Nursing Facili… | 2015-08-01 |
| 9304 | 9304 | EMANUEL COUNTY NURSING HOME | 115704 | 117 KITE ROAD | SWAINSBORO | GA | 30401 | 2011-10-06 | 156 | C | 0 | 1 | O4KP11 | Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) for three (3) of three (3) residents reviewed (#15, #33 and #44), who were discharged off skilled services and remained in the facility. Findings include: On 10/05/11 at 2:15 p.m., the Business Office Manager (BOM)/Social Services Director/Admissions Coordinator stated that residents #15, #33, and #44 were all discharged from Medicare Part A services, including skilled nursing and therapy, and all three remained in the facility. The Notices of Medicare Provider Non-Coverage (Generic Notice) were provided, but the BOM stated she never issued the SNFABN unless the resident or responsible party requested more information. | 2015-08-01 |
| 9325 | 9325 | SENIOR CARE CENTER - BRUNSWICK | 115721 | 2611 WILDWOOD DRIVE | BRUNSWICK | GA | 31520 | 2011-02-23 | 156 | B | 0 | 1 | X28E11 | Based on a review of the facility's " Notice of Medicare Provider Non-Coverage " form, it was determined that the facility failed to issue the mandatory denial notices to three residents (#25, #26 and #27) that included their potential liability for payment of non-covered services in order to allow them to make an informed decision about whether or not they wanted to continue to receive specific items or services, knowing that they might have to pay for those items or services themselves, and failed to specify the reason why the facility expected Medicare to deny payment. Findings include: According to CMS' "Liability Notices/Notice of Medicare Provider Non-coverage" instructions, the "Notice of Medicare Provider Non-Coverage" form (CMS- ) was supposed to be issued when all covered services ended for coverage reasons. If the facility expected the beneficiary to remain in the facility in a non-covered stay, either the CMS- form or a Denial Letter was required to be issued to inform the beneficiary of the potential liability for the non-covered stay. The standards for use by Skilled Nursing Facilities (SNF) in implementing the CMS- form as described in the "70-Form CMS- Skilled Nursing Facility Advance Beneficiary Notice", instructed the SNF to give the specific reason(s) why it expected Medicare to deny payment. The reason(s) cited were to be in understandable lay language and sufficiently specific to allow the resident to understand the basis for the expectation that Medicare would deny payment. Estimated cost amounts could be provided either with the description of extended care items and services or on the "estimated cost" line. However, the facility failed to issue either a CMS- form or a denial letter to residents #25, #26, and #27. The facility believed that three residents' (#25, #26 and #27) continued stay in the facility would not be paid for by Medicare Part A. However, the "Notice of Medicare Provider Non-Coverage" form issued to those residents on 9/16/10, 12/4/10 and 12/10/10 respectively, did not con… | 2015-08-01 |
| 9381 | 9381 | PRUITTHEALTH - CRESTWOOD | 115385 | 415 PENDLETON PLACE | VALDOSTA | GA | 31602 | 2010-08-12 | 156 | B | 0 | 1 | 7Q4Y11 | Based on a review of the facility's liability notices, it was determined that the facility failed to provide the estimated cost of continued services to 28 residents in order to allow them to make an informed decision about whether or not they wanted to pay for the continuation of services in a sample of 28 residents who had been discharged from Medicare Part A since 9/1/09. Findings include: The administrator said in an interview on 8/12/10 at 10:10 a.m. that, since 9/1/09, the facility believed that 28 residents would be discharged from Medicare Part A services because, they no longer required skilled nursing and/or rehabilitation services. The facility had issued the CMS- (Skilled Nursing Facility Advance Beneficiary Notice). However, the facility failed to provide the resident or his/her legal representative with the estimated cost of those services in order to allow them to make an informed decision about whether or not they wanted to pay for those services themselves. During an interview on 8/12/10 at 8:30 a.m., the Minimum Data Set (MDS) Coordinator stated that the estimated cost was not included on the forms because, he/she did not know the cost of the services at the facility. | 2015-07-01 |
| 9394 | 9394 | OXLEY PARK HEALTH AND REHABILITATION | 115387 | 181 OXLEY DRIVE | LYONS | GA | 30436 | 2010-09-23 | 156 | B | 0 | 1 | FOKJ11 | Based on record review and staff interview, it was determined that the facility failed to provide three residents (#17, #18 and #19) with a Skilled Nursing Facility Advance Beneficiary Notice prior to the discontinuation of skilled services paid for by Medicare Part A. Findings include: According to the Centers for Medicare and Medicaid Services (CMS), a 'Skilled Nursing Facility Advance Beneficiary Notice' (CMS-1055 form) should be given to a Medicare beneficiary or to his/her authorized representative before extended care services or items are reduced or terminated when the nursing facility believes that Medicare will not pay for, or will not continue to pay for services that the nursing facility furnishes and that a physician ordered. However, the facility failed to provide the written notice prior to the discontinuation of skilled services for residents #17, #18 and #19. 1. The facility believed that continued skilled services for resident #17 would not be paid for by Medicare effective 8/17/09. However, the 'Skilled Nursing Facility Advance Beneficiary Notice' was not signed by the responsible party until 8/25/09. During an interview on 9/23/10 at 3:30 p.m., the facility's bookkeeper stated that the family member, who was the authorized representative for the resident, visited the nursing home every day. However, the bookkeeper had no explanation as to why the notice was not signed until 8/25/09 (eight days after discontinuation of services). 2. The facility believed that continued skilled services for resident #18 would not be paid for by Medicare effective 7/19/10. However, the 'Skilled Nursing Facility Advance Beneficiary Notice' was not signed by the resident's authorized representative until 7/23/10 (4 days after discontinuation of services). During an interview on 9/23/10 at 3:30 p.m., the facility's bookkeeper stated that the notice had been mailed but, had not been returned to the facility until 7/23/10. She had no evidence as to when the notice had been mailed to the resident's authorized representa… | 2015-07-01 |
| 9409 | 9409 | EAST LAKE ARBOR | 115482 | 304 FIFTH AVENUE | DECATUR | GA | 30030 | 2010-11-04 | 156 | E | 0 | 1 | H43P11 | Based on record review and staff interview the facility failed to administer appropriate liability notices for thirty-one (31) of thirty-five (35) residents discharged from skilled Medicare Services in the last six (6) month period. Findings include: Review of the facility's list of resident's discharged from Skilled Medicare Services in the last six (6) months revealed thirty-one (31) of thirty-five (35) residents were discharged before exhausting their one-hundred (100) days of coverage. There was no documentation these residents received notice # , also known as the Generic Notice of Right to an Expedited Appeal by an Quality Improvement Organization. Interview with the Bookkeeper and Social Worker on 11/4/2010 at 11:00 a.m. revealed they were both unaware of this notice regarding an expedited appeal, and therefore were not providing the notice to any resident. Review of the Advanced Beneficiary Notice (ABN) sent to one (1) resident, #91 revealed the notice was incomplete and not delivered to the resident or their responsible party at least two (2) days prior to the termination of skilled services. There is also no indication on either form which option, of three (3) provided, the resident or responsible party chose. The ABN notice for resident # 91 was signed by the resident's responsible party on 8/16/2010 the same day services were to end.. | 2015-07-01 |
| 9449 | 9449 | BAPTIST VILLAGE, INC. | 115615 | 2650 CARSWELL AVE | WAYCROSS | GA | 31502 | 2011-06-09 | 156 | D | 0 | 1 | RJCG11 | Based on staff interview, and review of the facility's "Skilled Nursing Facility Advance Beneficiary Notice" forms, it was determined that the facility failed to provide the estimated cost of continued services to three residents, who had been discharged from Medicare Part A services, in order to allow them to make an informed decision about whether or not they wanted to pay for the continuation of those services. Findings include: According to the CMS' instructions on the 70.4.3.5- "Providing Cost Estimations for Items or Services on the Form CMS- Skilled Nursing Facility Advance Beneficiary Notice (SNFABN)," estimated cost amounts could be provided either with the description of extended care items and services (i.e., in the "Items or Services" section) or on the "Estimated Cost" line. The facility believed that three residents were to be discharged from Medicare Part A services because they no longer required skilled rehabilitation and/or skilled nursing services. The facility had issued CMS form to those residents or authorized representatives on 12/08/10, 2/26/11, and 3/12/11. However, the facility failed to include the estimated cost for the continuation of the services for the three residents in order to allow them to make an informed decision about whether or not they wanted to pay for those services themselves. The facility's "Skilled Nursing Facility Advance Beneficiary Notice" forms (CMS ) for those three residents had no estimated cost and no contact information on the form. During an interview on 6/9/11 at 10:55 a.m., financial staff "OO" stated that the estimated cost (for the continuation of skilled services) was only filled out on the notice of discharge form for the Medicare Part B residents. She said that she had not ever provided that information to residents on the CMS forms. | 2015-07-01 |
| 9483 | 9483 | ABERCORN REHABILITATION CENTER | 115132 | 11800 ABERCORN STREET | SAVANNAH | GA | 31419 | 2011-01-27 | 156 | B | 0 | 1 | Q8K411 | Based on observation and resident and staff interview the facility failed to ensure that residents were notified of their right to make a formal complaint to the State Survey and Certification agency about their care. The facility also failed to ensure that there was information with phone numbers for the State Survey and Certification agency posted in the facility. Findings include: Interview on 1/26/11 at 12:45 p.m. with resident council president revealed that the staff had never been informed the resident council of their right to contact the State Survey and Certification office to make a complaint about their care. Interview with the Activities Director on 1/26/11 at 9:05 am revealed that she had told the residents in the council meeting about there rights and also goes over rights in trivia questions about how to follow the chain of command when they have a complaint. Further review with the resident council president on 1/26/11 at 9:40 am again revealed she had never been told in a resident council meeting or elsewhere about the right to make a formal complaint to the State Survey and Certification office. Further interview with the Activities Director on 1/27/11 at 9:55 am revealed she had no documentation of informing the resident council of their right to make a complaint to the State Survey and Certification office. She also confirmed that there was no information posted in the facility listing the number for the State Survey and Certification office On 1/25/2011 at 5:00 p.m. a tour of the facility was conducted to assure required information related to reporting allegations of abuse to the State Office was prominently displayed. The information was not posted in any area accessible to residents and visitors. On 01/27/11 at 12:15 p.m., resident "E" stated they were not aware of how to contact the State Complaint Intake number if they needed to, and had not seen the number posted anywhere in the facility. | 2015-06-01 |
| 9554 | 9554 | CHESTNUT RIDGE NSG & REHAB CTR | 115423 | 125 SAMARITAN DRIVE | CUMMING | GA | 30040 | 2011-11-10 | 156 | E | 0 | 1 | 06HO11 | Based on record review and staff interview the facility failed to maintain copies of approved, standardized Advance Beneficiary Notices with all required information completed. The facility also failed to provide evidence that the notices were provided far enough in advance to allow sufficient time for the beneficiary to consider all available options and failed to provide evidence that residents and/or their responsible parties were given the opportunity to make choices related to their future coverage. This affected all residents (census = 136) whose Medicare coverage ended while they were residing in the facility. Findings include: Record review for residents receiving Part A and Part B Medicare benefits revealed that the facility did not maintain the proper documents related to options available to residents when their benefits ended. The records maintained by the facility also did not include page 1 of form CMS- which indicated the date that the resident's skilled services ended. The facility also was unable to produce copies of forms CMS- and CMS-R-131 which allowed these residents or their responsible parties to request a demand bill to pay for continued skilled services after their Part A or Part B medicare coverage ended. | 2015-06-01 |
| 9775 | 9775 | PRUITTHEALTH - OCILLA | 115608 | 209 WEST HUDSON STREET | OCILLA | GA | 31774 | 2011-01-27 | 156 | B | 0 | 1 | BHN711 | Based on a review of the facility's " Notice of Medicare Provider Non-Coverage " form, it was determined that the facility failed to issue the mandatory denial notice to two residents (#16 and #17) of their potential liability for payment of non-covered services in order to allow them to make an informed decision about whether or not they wanted to continue to receive specific items or services, knowing that they might have to pay for those items or services themselves. The facility failed to issue notices in a timely manner and failed to include the specific items or services that would be denied and the estimated cost for those services. Findings include: According to CMS' "Liability Notices/Notice of Medicare Provider Non-coverage" instructions, the "Notice of Medicare Provider Non-Coverage" form (CMS- ) was supposed to be issued when all covered services ended for coverage reasons. If the facility expected the beneficiary to remain in the facility in a non-covered stay, either the CMS- form or a Denial Letter was required to be issued to inform the beneficiary of the potential liability for the non-covered stay. The standards for use by Skilled Nursing Facilities (SNF) in implementing the CMS- form as described in the "70-Form CMS- Skilled Nursing Facility Advance Beneficiary Notice", instructed the SNF to give the specific reason(s) why it expected Medicare to deny payment. The reason(s) cited were to be in understandable lay language and sufficiently specific to allow the resident to understand the basis for the expectation that Medicare would deny payment. Estimated cost amounts could be provided either with the description of extended care items and services or on the "estimated cost" line. The facility believed that two residents' (#16 and #17) continued stay in the facility would not be paid for by Medicare Part A. However, the "Notice of Medicare Provider Non-Coverage" form issued to those residents on 4/12/10 and 8/2/10 did not conform with the notice requirements to explain to the beneficiary his/her… | 2015-05-01 |
| 9811 | 9811 | SCOTT HEALTH & REHABILITATION | 115671 | 12 SMITH LANE | ADRIAN | GA | 31002 | 2010-06-24 | 156 | D | 0 | 1 | 581G11 | Based on record review and staff interview the facility failed to issue Medicare beneficiary liability notices which included the resident's right to an expedited appeal, rationale for discharge from Medicare services and the potential liability to the resident for a non-covered stay for two (2) of the four (4) random residents records reviewed. Findings include: Review of the facility's Liability Notices and Appeal Rights records for four (4) residents revealed no evidence that the facility had issued a liability notice in accordance with CMS S&C-09-20, for one (1) resident discharged from Medicare services. Continued review revealed that one (1) resident and/or responsible party had received the denial notice, but the notice was issued two (2) days after services had been discontinued. During interview on 06/23/10 at 2:30 p.m. the Financial Controller acknowledged these findings. | 2015-05-01 |
| 9828 | 9828 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2010-11-04 | 156 | B | 0 | 1 | IGRP11 | Based on record review and staff interview the facility failed to provide appropriate notification of Medicare non-coverage for three (3) residents (#21, #43 and #51) on a sample of thirty-one (31) residents. Findings include During an interview on 11/04/10 at 2:15 p.m. the Business Office Manager stated she called the responsible parties of residents #43, #51 and #21 and notified them of the resident's date to be discharged from skilled Medicare services and informed them of their right to have a demand bill submitted. She stated she then mailed the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (CMS form- ) to the responsible party. Review of the SNFABN for the resident's revealed there was no signature and no indication on the form as to the decision to submit a demand bill. Further review revealed these residents remained in the facility after they were discharged from skilled Medicare services. She stated she usually received the forms returned to the facility with a signature. She further stated she does not have documentation of the decision as to whether a demand bill was to be submitted. She does not provide the resident or the responsible party with the Notice of Medicare Provider Non-coverage (CMS form ). She stated she was not aware she had to issue the notice. | 2015-05-01 |
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CREATE TABLE [cms_GA] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );