- Date
- 1/13/2016
- Report number
- OR0001050200
- Type
- Licensing Violation
- Level
- 1 - No harm or potential for minor harm
- Allegation
- Failed to make facility or resident records accessible
- Result
- Substantiated
- Findings
- 4110540025 Facility Administration (10) DISCLOSURE RESIDENCY AGREEMENT. The facility must provide a Department designated Uniform Disclosure Statement (form SDS 9098A) to each individual who requests information about the facility. The residency agreement and the disclosure information described in subsection (a) of this section must be provided to all potential residents prior to movein. All disclosure information and residency agreements must be written in compliance with these rules. (B) Payment provisions including the basic rental rate and what it includes, cost of additional services, billing method, payment system and due dates, deposits, and nonrefundable fees, if applicable; (D) Policy for increases, additions, or changes to the rate structure. The disclosure must address the minimum requirement of 30 days prior written notice of any facilitywide increases or changes and the requirement for immediate written notice for individual resident rate changes that occur as a result of changes in the service plan; On January 19, 2016, Resident 1 was interviewed and he/she indicated he/she does not remember being asked to sign a residency agreement. Resident 1 confirmed he/she has not received any paper work from the facility except a room and board contract. Additionally, Resident 1 has not received any written notice of any additions or changes to residency agreement.On January 19, 2016 Staff 2 was informed of the complaint and asked to provide a copy of a signed residency agreement. Staff 2 requested we wait until Staff 1 is available to go over everything and Compliance Specialist (CS) agreed.On April 19, 2016, Staff 1 was interviewed and indicated the facility did not provide Resident 1 a payment provision (basic rent & costs of additional services), including a breakdown of Medicaid payment, Resident 1's contribution and payment due dates. Staff 1 also confirmed there is no signed Residency Agreement in Resident 1's file. Staff 1 added, since filing of the complaint Resident 1 has been asked multiple times to meet and go over, sign paperwork Resident 1 states he/she did not have an opportunity to sign; but since filing of this complaint, Resident 1 has refused to follow through and sign anything. Staff 1 confirmed Resident 1 did sign a Medicaid Addendum in MidJanuary 2016.On April 22, 2016, Staff 1 provided CS copies of documents from Resident 1's file including: Schedule of Services and Rates indicating Resident 1's monthly fee for room and board is $570.00. This does not include Resident 1's Medicaid required payment of $689 which is outlined in Department of Human Services Form 512. The facility is not required to provide Resident 1 a copy of the Department of Human Services (DHS) Form 512 indicating Resident 1's total monthly obligation to be $1,259.00 (including his $570 room & board charge from the facility and his Medicaid contribution of $689). $1,259.00 remains Resident 1's monthly financial obligation for being a resident at the facility.