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Thomas was made aware that R1 was collecting SSI and didn’t have the funds to pay facility fees without insurance coverage. On 5/31/21 admission agreement was signed. On 7/28/2021 R1 moved in to facility even though resident hadn’t received approval from insurance company. Facility assure R1 that insurance company would be approved and costs would be covered. On 9/3/2021 resident received insurance claim denial notice. R1 has since been billed and is now responsible for repayment from 5/31/21 to 09/15/21 although R1 didn’t move into the facility until 07/28/21.
On 5/18/22 LPA Cardenas interviewed Thomas via telephone regarding allegation. He indicates that Long Term Care insurance claim can only be filed until resident is admitted to a care facility. Facility doesn’t conduct income verifications, R1 disclosed being employed and having savings, but never being on SSI. Facility doesn’t accept SSI eligible recipient. Facility is private pay and only accepts personal checks. R1 was working with a referral agent, not associated to the facility, who was responsible for reviewing residents’ budget and going over facility costs. Resident was presented with the option to move into the facility and was never pressured. Worst case scenarios were discussed with R1 such as insurance denial. R1 told Thomas this was not an issue because resident was already pre-approved and was formally going through the process. Thomas encourage R1 to reach out to insurance company to iron out the terms and conditions. Facility doesn’t get involved with insurance claims. R1 was told that per admission agreement, resident was taking financial responsibility as of 5/31/21 and payments would be expected thereon. Thomas states that R1s insurance claims was denied due to physician submitted paperwork to residents insurance determining that R1 didn’t need to live at a facility due to resident was self-sufficient due to still working and driving.
On 5/18/22 LPA Cardenas interviewed Joshua Castillo who indicate that Facility doesn’t not conduct a income verification regarding residents source of income. Facility takes resident self-attestation that they have the funds to cover the cost. It is ultimately the residents decision to move in and make arrangements to ensure they have sufficient funds to cover cost.
On 5/18/22 LPA Cardenas reviewed R1’s admission agreement with Joshua to clarify charges. Per admission agreement: Rate: you agree to pay the basic service rate and, if applicable the Personal service rate as indicated in Exhibit A. We do not accept SSI/SSP eligible residents for admission to the community. Per Exhibit A Schedule of services and rates: “I agree to above scheduled of services and rates to commence as of May 31, 2021. I have reviewed Exhibit X, selected services listed…I agree that I will be charged each time I utilize one of those services at the community. Admission agreement is signed by R1 dated 5/31/2021. R1 was considered a community member as of that date and charges started to accrue thereon.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited, Exit Interview conducted, and report given facility representative.
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