Health inspection·April 25, 2019

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 Based on medical record review, staff interview, and facility policy review, the facility failed to provide evidence of written notification to the resident and/or representative regarding beneficiary notices. This affected two residents (Residents #40 and #87) out of three residents (Residents #40, #87, and #88) reviewed for beneficiary notices. The facility census was 88. Residents Affected - Few Findings include: 1. Resident #40 was admitted to Medicare part A services on 02/23/19 and issued a last covered day of 03/08/19. A Notice of Medicare Non-Coverage (NOMNC) form was issued on 03/05/19 by the Admissions Coordinator (AC) #501. The NOMNC form stated Resident #40's resident representative was notified by phone on 03/05/19 skilled Medicare part A services would end on 03/08/19 and financial liability would begin on 03/09/19. Review of Resident #40's medical record revealed it was silent as to documentation regarding resident representative notification of last covered day and AC #501 was unable to provide information of the NOMNC having been mailed to Resident #40's resident representative. According to Centers for Medicare and Medicaid Services (CMS) form, Form Instructions 10123-NOMNC, undated, if a provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice and the facility needs to confirm the telephone contact by written notice mailed on the same date. The instructions further state if direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested and the date someone at the representative's address signs (or refuses to sign) the receipt is the date of receipt. When notices are returned by the post office with no indication of a refusal date, then the resident's liability starts on the provider's mailing date. Staff interview with AC #501 on 04/22/19 at 3:17 P.M. confirmed Resident #40's NOMNC was not mailed, for written notice, to the resident representative after phone notification. Facility policy review revealed the facility did not previously have a NOMNC policy and only created a NOMNC policy dated 04/24/19 which stated if the resident representative is not present to sign the NOMNC, the NOMNC will be sent certified mail to the resident representative after verbal confirmation. 2. Resident #87 was admitted to Medicare part A services on 02/12/19 and issued a last covered day of 03/06/19. A NOMNC form was issued on 03/04/19 by AC #501. The NOMNC form stated Resident #87's resident representative was notified by phone on 03/04/19 skilled Medicare part A services would end (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 365927 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365927 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/25/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Regina Health Center 5232 Broadview Rd Richfield, OH 44286 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)