Trust Fund Accounts Exceed Medicaid Eligibility Limit
Summary
The facility failed to ensure that two residents' trust fund accounts remained under the $2,000 limit necessary to maintain eligibility for Medicaid services. The facility's policy, dated 1/9/2022, required that accounts exceeding $2,000 be spent down within 10 days. However, a review of Resident 38's fund statement from 10/1/2024 to 12/31/2024 showed a beginning balance of $2,801.28 and an ending balance of $3,743.51, both exceeding the limit. Additionally, a trial balance document revealed that Resident 8's balance on 2/22/2025 was $2,075.58, also above the threshold. Interviews with the Regional Human Resource Coordinator and the Administrator confirmed that the accounts of these residents exceeded the Medicaid eligibility limit. The Business Office Manager was in the process of obtaining a burial policy for residents with balances over $2,000, and the Business Office Department was identifying affected residents to establish a burial fund.
Penalty
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Surveyors found that the facility did not notify multiple Medicaid residents or their representatives when resident trust fund balances approached the SSI resource limit, as required. Review of medical records and quarterly fund statements showed that several residents with conditions such as CHF, Alzheimer’s disease, diabetes, epilepsy, ESRD, anxiety disorder, and prior CVA, ranging from cognitively intact to severely impaired and all needing ADL assistance, had account balances between roughly $1,600 and $7,400 over several quarters. Despite these balances reaching the point at which notification is mandated, there was no documentation that any notifications were provided, and the Administrator confirmed that such notifications had not been made.
A resident with severe cognitive impairment had a trust account balance of over $14,000, far above the $2,000 threshold that staff, including the DAR and BOM, identified as placing Medicaid/SSI eligibility at risk. Although facility practice required notifying the resident or RP and arranging an IDT meeting to discuss spend down when a trust account exceeded this limit, there was no documentation that the RP was informed. The RP later stated she did not know a trust account existed, believed the resident’s Social Security income was used entirely for room and board, and had never been told about the balance or its impact on Medi-Cal/SSI eligibility. Requested policies on notification of account balances and benefit eligibility limits were not provided.
A resident with COPD, depression, and adult failure to thrive died, and the facility did not refund the remaining resident trust fund balance within the required 30-day timeframe. Review showed a returned check for $1,285.81 was issued 33 days after the deadline. The BOM stated the timeframe was overlooked, and the Administrator confirmed the funds should have been sent within 30 days.
The facility failed to timely provide final accountings and proper disposition of resident trust funds after death for multiple residents. In several cases, only part of a deceased resident’s trust balance was reported to the state TPL unit, while remaining funds were withdrawn for current or back room and board without written authorization or were left unreported for extended periods. Interest that continued to accrue in deceased residents’ accounts was also held for months without required Personal Funds Account Balance Reports. During interviews, the Administrator and BOM attributed these issues to turnover in the business office, ongoing attempts to "clean up" accounts, uncertainty about handling interest, lack of awareness that transferred funds were personal trust funds, and an incorrect assumption about the allowed timeframe for completing required financial reports and refunds.
A facility failed to notify a resident and/or her representative when trust fund balances were within $200 of the SSI limit and when the account exceeded the $2,000 cap. The resident had severe cognitive impairment with a BIMS of 5 and diagnoses including dementia, while staff interviews showed the VP of Revenue Cycle Management, receptionist, and Social Services did not ensure written financial notices were sent to the family representative, who said she never received any financial statements or notices.
Failure to convey resident funds and close accounts within 30 days for three closed residents. Facility policy required final accounting and return of personal funds after discharge, eviction, or death, but trust fund records still showed balances for residents who had died or been transferred out. The RBO Manager confirmed the accounts remained open and funds were not conveyed as required.
Failure to Notify Medicaid Residents of Trust Fund Balances Near SSI Limit
Penalty
Summary
The deficiency involves the facility’s failure to notify Medicaid residents or their representatives when resident trust fund balances approached the Supplemental Security Income (SSI) resource limit. Surveyors reviewed medical records, resident fund account statements, and conducted staff interviews, and determined that six of seven sampled residents with Medicaid payor sources did not receive required notifications when their account balances reached $200 less than the SSI resource limit. There was no documentation of such notifications in the records for these residents, despite quarterly fund statements showing balances at or above the threshold. One affected resident had congestive heart failure, Alzheimer’s disease, and aphasia, was severely cognitively impaired, and required staff assistance with ADLs; this resident’s account balance during one quarter ranged from $2270.97 to $1888.16 without any documented notification. Another resident with type 2 diabetes mellitus, PTSD, and osteoarthritis, who was cognitively intact but required ADL assistance, had a quarterly account balance that increased from $1750.26 to $7395.49, again with no documentation of notification when the balance reached the required threshold. A third resident with type 2 diabetes mellitus, pulmonary hypertension, and generalized anxiety disorder, who was moderately cognitively impaired and needed ADL assistance, had a quarterly balance that decreased from $2193.82 to $1618.38, with no evidence of notification at the appropriate point. Additional residents with epilepsy, end stage renal disease, aphasia following cerebral infarction, anxiety disorder, cerebral infarction, type 2 diabetes mellitus, Alzheimer’s disease, and congestive heart failure were also affected. These residents ranged from cognitively intact to severely cognitively impaired and all required assistance with ADLs. Their quarterly resident fund statements showed balances between approximately $1600 and nearly $5000 over multiple quarters, yet there was no documentation that they or their representatives were notified when their balances reached $200 less than the SSI resource limit. In an interview, the Administrator confirmed that the facility had not provided the required notifications for these residents when their resident fund accounts reached the specified threshold.
Failure to Notify Representative of Excess Resident Trust Account Balance
Penalty
Summary
The facility failed to notify a resident’s representative when the resident’s trust account balance exceeded the Supplemental Security Income (SSI) resource limit. The resident, who had diagnoses including metabolic encephalopathy, dementia, and altered mental status, had a BIMS score of 0, indicating severe cognitive impairment, and her daughter was documented as her representative and primary financial contact. A review of the facility’s trust transaction history showed that the resident’s trust account balance was $14,545.99. Interviews with the Director of Accounts Receivable (DAR) and the Business Office Manager (BOM) confirmed that the facility’s process requires notification to the resident or representative when a trust account exceeds $2,000 so that a spend down can be arranged to maintain Medicaid/SSI eligibility. Despite this established process, both the DAR and BOM acknowledged there was no documented evidence that the resident’s representative had been notified of the elevated trust account balance or the need for a spend down. The BOM stated that the usual procedure would include arranging an IDT meeting with the resident and/or representative to discuss the trust account balance, the reason for the spend down, and the amount required, but this did not occur for this resident. In a subsequent interview, the resident’s representative reported she was unaware that the resident had a trust account balance at all and believed the resident’s Social Security income was fully applied to room and board. She stated the facility had never informed her of the trust account balance or how it might affect the resident’s Medi-Cal and Social Security benefits. When policies related to notification of account balances and eligibility limits for Medi-Cal/Social Security were requested, the facility did not provide them.
Failure to Timely Convey Resident Trust Funds After Death
Penalty
Summary
The facility failed to reimburse resident funds within 30 days after death for 1 of 1 sampled residents reviewed for personal fund accounts. The facility policy titled, Conveyance of Resident Funds Upon Death, stated that upon the death of a resident with personal funds deposited with the facility, the funds and a final accounting must be conveyed within 30 days to the individual or probate jurisdiction administering the resident’s estate. Resident #101 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Depression, and Adult Failure to Thrive, and later died. Review of the resident trust fund account showed a returned check for the account balance of $1,285.81, and 33 days had passed beyond the allotted 30-day timeframe before the balance was refunded to the resident’s estate. During interview, the Business Office Manager stated the 30-day timeframe was overlooked, and the Administrator stated the funds should have been sent within 30 days and completed in that time.
Failure to Timely Account for and Properly Disburse Resident Trust Funds After Death
Penalty
Summary
The deficiency involves the facility’s failure to properly manage and disburse resident trust funds and to provide final accountings of resident fund balances within 30 days of a resident’s death, as required. Record review showed that for multiple deceased residents, the facility either did not report the full balance of funds to the Department of Social Services Third Party Liability (TPL) Unit, did not submit Personal Funds Account Balance Reports timely, or withdrew funds for room and board without written authorization or after the resident had expired. For one resident, the ledger showed a trust balance of $8,119.01 at the time of death, but only $3,904.41 was initially reported to TPL, while $3,311.00 was later withdrawn for current and back room and board and an additional $51.60 was withdrawn, leaving $2,311.60 unreported for over 200 days; interest of $2.22 was also held and not reported until more than two months after it was deposited. Another resident’s ledger showed a deposit of $1,073.37 from a previous facility that was documented as personal spending money, but the facility withdrew $690.00 for room and board without authorization and did not use those funds for cremation services or report them to TPL within the required timeframe. Additional record reviews showed similar issues for other deceased residents. One resident had $2,792.85 in the trust account and a subsequent direct deposit of $2,064.00; only $2,618.55 was reported to TPL more than 40 days after death, while $2,058.60 was withdrawn for room and board and not reported. Another resident’s $51.30 trust balance was withdrawn for back room and board and not reported to TPL for over 300 days, and interest of $0.04 remained without a Personal Funds Account Balance Report submitted for more than 300 days after the interest was deposited. A further resident’s $1,295.84 trust balance was not reported to TPL until 81 days after death, and interest of $1.15 was held without a balance report for over 200 days. For another deceased resident, interest of $3.46 continued to be held, and a Personal Funds Account Balance Report was not submitted for more than 200 days after the interest deposit. In an interview, the Administrator and Business Office Manager cited turnover in the Business Office Manager position, the new BOM’s efforts to “catch up” paperwork, uncertainty about how to handle remaining interest, lack of awareness that transferred funds were trust funds, and an incorrect belief that there were 60 days to complete the Personal Funds Balance Report and/or submit refunds.
Failure to Notify Resident and Representative of Trust Fund Balance Limits
Penalty
Summary
The facility failed to notify the resident and/or the resident’s responsible party when personal funds were within $200 of the SSI limit and when the account balance exceeded the allowable amount. Facility policy titled Resident Trust Fund stated that Medicaid recipients must be notified whenever their funds are within $200 of their resource asset limit and that balances should be monitored monthly to ensure state maximum balances are not exceeded. Review of the Resident Statement Landscape report showed that R45’s trust fund accounts exceeded the $2,000 SSI limit for 12 months, from February 2025 through February 2026. R45’s record showed diagnoses including dementia in other diseases classified elsewhere, severe without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, cognitive communication deficit, and dementia, mild, with agitation. The quarterly MDS documented a BIMS score of 5, indicating severe cognitive impairment. Interviews revealed the VP of Revenue Cycle Management was handling resident accounts after the BOM position was vacant and admitted she had not followed up with the Medicaid Eligibility Officer about R45’s account being over $2,000 for the last 12 months. The receptionist stated she was responsible for notifying residents and/or representatives when accounts reached within $200 of $2,000, but she had not sent written notifications to R45’s representative since June 2025 and had only given notices to R45. R45’s family representative stated she had never received any financial notices or statements from the facility, and Social Services stated she contacted the representative about spending down the account by prepaying burial/funeral arrangements but did not notify her that the account was over $2,000.
Failure to Convey Resident Funds After Discharge or Death
Penalty
Summary
The facility failed to convey resident funds and close resident accounts within 30 days after discharge, eviction, or death for three closed resident records: CR186, CR187, and CR188. Facility policy titled "Conveyance of Resident Funds" dated 10/29/25 stated that a resident's personal funds and final accounting are to be returned to the resident, the resident's representative, or the resident's estate, as applicable, within 30 days of discharge, eviction, or death. Review of the records showed CR186 was admitted with diagnoses of high blood pressure, hyperlipidemia, and unsteadiness on feet and ceased to breathe at the facility on 2/5/26. CR187 was admitted with diagnoses of high blood pressure, muscle weakness, and dysphagia and was transferred to the hospital on 9/24/25, where the resident ceased to breathe on 9/25/25. CR188 was admitted with diagnoses of hyperlipidemia, anxiety, and high blood pressure and ceased to breathe at the facility on 8/19/25. A review of the facility trust fund account dated 3/23/26 showed balances still held for CR186 in the amount of $3,778.30, CR187 in the amount of $240.54, and CR188 in the amount of $517.07. During interview, the Regional Business Office Manager confirmed the facility failed to convey resident funds and close the accounts within 30 days for all three closed residents.
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