Health inspection·March 14, 2024

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a signed Notice of Medicare Non-Coverage (NOMNC) in order for an opportunity to appeal an insurance denial for 1 of 3 residents (R1) reviewed for Physical Therapy, in the sample of 3. Residents Affected - Few Findings include: R1's Facesheet dated 3/8/2024 documents R1 was admitted to the facility on [DATE]. It further documents, admission reason for stay: Short term skilled nursing and rehabilitation care. R1's Critical Incident Form from R1's insurance provider, dated 3/11/2024 documents, Member admitted to Greenville Nursing and Rehab for skilled care with intent to return home. Member admitted on [DATE] and skilled care ended on 2/19/24 but therapy did not work on standing or walking. Member is not able to return home and additional therapy is not approved. Member was provided with phone number for Ombudsman. Member stated to this nurse that she was not notified that her therapy was ending. Member was provided with phone number for Ombudsman. On 3/8/2024 at 9:15 AM, R1 stated, I've talked to (V5, Insurance Case Worker) maybe twice. They said they didn't give me a paper to sign. They weren't standing me up because the doctor (surgeon) hadn't released me. I'm going home today-my ride just walked in. I never had a meeting with anyone about it. On 3/8/2024 at 10:45 AM, V1 Administrator, stated, We have a NOMNC (Notice of Medicare Non-Coverage) but it is not signed. Looks like we received it in the mail, which sometimes we don't get them until after the date that services will end. On 3/8/2024 at 11:27 AM, V1 stated, (R1) was on a managed Medicaid/Medicare plan. Initially (R1) was not progressing because the doctor put her on restrictions. When she saw the doctor again and he lifted the restrictions, she was already off Med 'A' (skilled nursing care). I wonder why they didn't fax it. They sent it by mail (postal). I do not know who opened the letter. (V3) is supposed to. I think medical records may have opened it and not known (it needed to be signed/addressed with R1), but I honestly can't say that's what happened. Since the NOMNC wasn't signed, she was not able to appeal to get back on 'Med A. On 3/8/2024 at 12:41 PM, V3, Business Office Manager (BOM) stated, If the resident is coherent, I talk to them, and they sign it (NOMNC and ABN) to show that they understand. I do not know why it wasn't signed. It should have a confirmation cover sheet to show that it got sent back to the insurance Page 1 of 2 145909 145909 03/14/2024 Greenville Nursing & Rehab 400 East Hillview Avenue Greenville, IL 62246

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few company. I have done so many of these I can't always remember. I do not have any documentation to show proof of her receiving the notice. On 3/11/2024 at 9:45 AM, V5, Insurance Case Worker, stated, (R1) was getting physical therapy but she couldn't even stand. Our Utilization Management Department does the authorizations and they told me she (R1) should have contested the denial of coverage when the NOMNC was given to her. On 3/14/2024 at 8:45 AM, V1 verified that they did not have a NOMNC signed by R1. The Facility's Medicare Beneficiary Notice Policy, undated, documents, Notice of Medicare Non-Coverage (NOMNC) Advanced written notice to enrollees must be provided before termination of services in a Skilled Nursing Facility (SNF). If an enrollee files a Feature Focus appeal, then the plan must deliver a detailed explanation of why services should end. The two notices used for this purpose are: Notice of Medicare Non-Coverage (NOMNC) Form CMS-10123-NOMNC, and Detailed Explanation of Non-Coverage (DENC) Form CMS-10124-DENC. A Notice of Medicare Non-Coverage (NOMNC) to Medicare health plan enrollees is required when their Medicare covered service(s) are ending. The NOMNC informs enrollees on how to request an expedited determination from their Quality Improvement Organization (QIO) and gives enrollees the opportunity to request an expedited determination from a QIO. The Facility's Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) documents, The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed. Use of assistive devices may be used to obtain a signature. Signature line: The beneficiary/enrollee or the representative must sign this line. 145909 Page 2 of 2