§483.15(c) Transfer and discharge-
§483.15(c)(1) Facility requirements-
§483.15(c)(1)(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A)The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B)The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C)The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D)The health of individuals in the facility would otherwise be endangered;
(E)The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F)The facility ceases to operate.
§483.15(c)(1)(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.
§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(i)Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii)The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.
§483.15(c)(7) Orientation for transfer or discharge.
A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand.
§483.15(e)(1) Permitting residents to return to facility.
A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following.
(i)A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident-
(A) Requires the services provided by the facility; and
(B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services
(ii)If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges.
§483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there.
§483.21(c)(1) Discharge Planning Process
The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and-
(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident.
(ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.
(iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan.
(iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.
(v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan.
(vi) Address the resident's goals of care and treatment preferences.
(vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community.
(A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose.
(B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities.
(C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why.
(viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences.
(ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer.
§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.
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Observations:
Based on clinical record review and staff interview, it was determined the facility failed to ensure that the discharge process honored the resident's preferences and goals and failed to demonstrate that the discharge was appropriate and necessary, for one of six sampled residents (Resident 1).
Findings include:
Clinical record review revealed the resident was admitted to the facility on May 6, 2025 with diagnosis to include, Wernicke's Encephalopathy (an acute inflammatory hemorrhagic encephalopathy caused by thiamine deficiency, often associated with chronic alcoholism or malnutrition, characterized by loss of muscle coordination, visual disturbances such as diplopia, and confusion), alcohol-induced psychotic disorder, alcoholic cirrhosis of the liver without ascites, and nicotine dependence. Documentation indicated the resident was cognitively intact. While it was noted that the resident had a legal guardian, the facility was unable to produce documentation confirming guardianship status during the survey.
A review of a social services note dated May 6, 2025, at 5:49 P.M. revealed, I allowed time for Resident 1 to vent his feelings related to his admission. The resident voiced his desire to move to a different facility located in a neighboring city. The social worker documented that she would contact the guardian the following day to discuss the resident's wishes.
A review of a social services note dated May 8, 2025, at 11:14 A.M. revealed, Social Services received a visit from Resident 1's Guardian today. This worker informed the Guardian that the resident would like to move to a facility in a local city. The guardian gave permission for the resident's records to be sent to two local skilled nursing facilities.
However, a social services note dated May 15, 2025, at 8:14 A.M., indicated the resident was being transferred to a facility located several hours away from the current facility, contradicting the resident's stated desire to remain in a local setting.
A nurses note dated May 15, 2025, at 9:39 A.M. revealed the resident was discharged from the facility to facility identified as located several hours distance away.
During an interview conducted on May 15, 2025, at 2:00 P.M., the facility social services worker stated that Resident 1 had clearly expressed his desire to be transferred to a local skilled nursing facility that permitted smoking. The social worker could not explain why the discharge did not align with the resident's expressed preferences, nor was there documentation justifying why an appropriate local discharge option could not be pursued or why the facility was no longer able to meet the resident's needs.
The facility failed to demonstrate that the discharge was based on the resident's goals or that it was necessary and appropriate. Furthermore, there was no evidence the resident was involved in the discharge decision-making process in a meaningful way that honored his preferences, nor was there documentation to show that alternative local placement options had been exhausted or deemed unsuitable.
Cross refer F 926
28 Pa. Code 201.29(h) Resident rights
28 Pa. Code 201.14(a) Responsibility of Licensee
| | Plan of Correction - To be completed: 06/04/2025
1) The facility is unable to retroactively correct the cited issue. Resident R1 was discharged from the facility on 05/15/2025 and relocated to another skilled nursing facility.
2) Remaining residents were reviewed to identify any potential similar situation. None could immediately be identified, as currently there are no residents residing within the facility, requesting a transfer to another facility.
3) The Social Service Director, was educated to involve the resident, based on their achieved goals or when necessary and appropriate, in their discharge process, to honor their preferences as much as possible. When placement options have been exhausted or deemed unsuitable and do not align with the resident's expressed preferences; this shall be documented to justify why the requested discharge option could not be pursued or why the facility was no longer able to meet the resident's needs
4) The Nursing Home Administrator/Designee will monitor to assure that any/all future transfers to another skilled facility, align with the discharged resident's preferences, when possible; and if not, that there is documentation why preferences could not be pursued or why the facility was no longer able to meet the resident's needs. This monitoring will be monthly for 3 months.
Results will be reviewed by the QA Committee for 2 months, then reevaluated.
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