§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(k).
|
Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or their responsible party in writing of a transfer to the hospital with the required information for five of nine residents reviewed (Residents 11, 16, 24, 30, and 50).
Findings include:
Clinical record review for Resident 16 revealed that they were transferred to the hospital on August 31, 2024, after a change in their condition. There was no documentation that the facility provided written notification to the resident's responsible party regarding the transfer that included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred, a statement of the resident's right to appeal, including the name, contact, email, and address, how to obtain and appeal form, assistance completing and submitting the appeal form and hearing request, contact, email, and address information for the Office of the State Long-Term Care Ombudsman, and information for the agency responsible for the protection and advocacy of individuals with developmental disabilities.
Clinical record review for Resident 30 revealed that they were transferred to the hospital on January 27, 2024, after there was a change in their condition. There was no documentation that the facility provided written notification to their responsible party as required regarding the transfer that included the required contents listed above.
Clinical record review for Resident 50 revealed that they were transferred to the hospital on December 29, 2023, after there was a change in their condition. There was no documentation that the facility provided written notification to their responsible party, or the State Ombudsman as required regarding the transfer that included the required contents listed above.
The surveyor reviewed the above information for Residents 16, 30, and 50 during an interview with the Nursing Home Administrator and Director of Nursing on September 12, 2024, at 2:20 PM.
Clinical record review for Resident 11 revealed that she was transferred to the hospital on January 30, 2024, after there was a change in her condition. There was no documentation that the facility provided written notification to her responsible party as required regarding the transfer that included all the required contents as listed above.
Clinical record review for Resident 24 revealed that they were transferred to the hospital on June 13, 2024, after there was a change in his condition. There was no documentation that the facility provided written notification to his responsible party, or the State Ombudsman as required regarding the transfer that included the required contents listed above.
Interview with Employee 1 (business office manager) on September 13, 2024, at 9:16 AM confirmed these findings.
28 Pa. Code 201.14 (a) Responsibility of license
28 Pa. Code 201.29(a) Resident rights
| | Plan of Correction - To be completed: 11/01/2024
There were no adverse effects to residents 16, 30, 11, 24 and 50 because the form did not include all of the required contents. June 2024's and December's 2023 transfer logs were updated with resident 24 and resident 50's information and resent to the Ombudsman.
An audit of the last 12 months of transfer logs was completed to verify all transfer logs sent to the Ombudsman were completed timely and with all of the residents who are required to be on the form. The transfer letter was reviewed and updated to ensure all of the required information is on the letter.
The Business Office Manager and Accounts Payable Coordinator were in-serviced on the required contents of the transfer letter and to ensure transfer logs are sent to the Ombudsman in the proper timeframe.
An audit will be completed weekly for 4 weeks to verify all residents who are to be on the transfer log sent to the Ombudsman are on the form. Form will be reviewed weekly to ensure all required contents of the form are on the form. Audits will be reviewed at QAPI.
|
|