|§483.15(c)(3) Notice before transfer. |
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.
§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.
§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.
§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.
§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).
Based on clinical record review and staff interviews it was determined that the facility failed to notify the resident/resident representative and the representative of the Office of the State Long-Term Care Ombudsman of resident transfers in writing and with required transfer information for one of three resident records reviewed (Resident 39).
Review of Resident 39's clinical record revealed diagnoses that included Atrial Fibrillation (irregular heartbeat) and Heart Failure (severe failure of the heart to function properly).
Further review of Resident 39's clinical record revealed that on September 16, 2019, he was transferred out of the facility to the hospital and returned on September 20, 2019, with a diagnoses of Congestive Heart Failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues) and Bilateral Effusion (an unusual amount of fluid around both lungs).
Review of Resident 39's clinical record revealed no letter was provided to the Resident 39 or Resident 39's representative regarding the transfer and including the required contents; reason for the transfer, effective date of the transfer, location to which the resident was transferred to, contact and address information for the Office of the State Long-Term Care Ombudsman, information for the agency responsible for the protection and advocacy of individuals with developmental disabilities. Further review of Resident 39's clinical record failed to reveal that a transfer notice was provided to the State Long-Term Care Ombudsman.
During an interview with the Nursing Home Administrator (NHA) on November 13, 2019, at 2:48 PM, the NHA confirmed that neither of the above referenced notices had been provided to the appropriate parties due to transition in facility management.
28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 12/06/2018
| ||Plan of Correction - To be completed: 01/07/2020|
I hereby acknowledge the CMS 2567-A, issued to CUMBERLAND CROSSINGS RETIREMENT COMMUNITY for the survey ending 11/14/2019, AND attest that all deficiencies listed on the form will be corrected in a timely manner.
Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.
1. Resident 39 had no negative outcomes due to the facilities failure to notify the resident/representative of resident's transfer in writing.
2. No additional residents have had negative outcomes to the facilities failure to notify the resident/representative of resident's transfer in writing.
3. Education will be provided to the IDT and licensed staff by the Director of Nursing or designee to assure written notifications are provided at time of transfer to resident/representative.
4. Fifty percent of resident transfers and discharges will be audited by the Social Services Director or designee weekly for 1 month and monthly thereafter for 3 months. Findings will be reported to the QAPI committee during monthly meeting for review and recommendation.