§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 a review of clinical records, facility policy, resident interviews, and staff interviews, it was determined the facility failed to develop and implement an individualized discharge planning process that addressed residents' discharge goals and incorporated those goals into the resident's comprehensive care plan for two of seven residents reviewed (Residents 3 and 4).
Findings include:
A review of Resident 3's clinical record revealed the resident was admitted to the facility on September 5, 2025, with diagnoses including schizophrenia (a severe mental disorder that affects how a person thinks, feels, and behaves and may involve hallucinations, delusions, and disorganized thinking).
A review of a quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 2 2026, revealed that Resident 3 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status a tool within the cognitive section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 indicates cognition is intact). The assessment documented in Section Q (the portion of the MDS used to record resident discharge goals and preferences) that the resident's overall discharge plan was unknown and indicated that no active discharge planning process was occurring for a potential return to the community.
A review of Resident 3's comprehensive care plan, initiated September 16, 2025, and reviewed March 11, 2026, revealed the care plan did not include interventions, goals, or planning related to discharge preferences, discharge planning activities, or barriers to discharge.
Review of the clinical record and resident information revealed Resident 3 expressed a desire to return to the community and live with his sister. During an interview, the Director of Nursing on March 11, 2026 at 1:30 PM she stated the resident's sister did not want the resident to live with her and the resident had a complex history that made discharge to the community difficult; however, documentation reflecting these discharge considerations, planning activities, or barriers was not incorporated into the resident's care plan.
A review of Resident 4's clinical record revealed the resident was admitted to the facility on August 19, 2025, with diagnoses including dementia (a condition characterized by the progressive loss of cognitive functioning, including memory, reasoning, and the ability to perform everyday activities).
A review of a quarterly MDS dated February 27, 2026, revealed that Resident 4 was moderately cognitively impaired with a BIMS score of 12 (a score of 8 through 12 indicates moderate cognitive impairment). The MDS indicated in Section Q that the resident's overall discharge plan was unknown and documented that no active discharge planning process was occurring for the resident to return to the community.
A review of Resident 4's comprehensive care plan, initiated August 19, 2025, and reviewed March 11, 2026, revealed the care plan did not include discharge planning goals, interventions, or evaluation of discharge options.
The clinical record revealed Resident 4 was previously discharged from the facility on June 21, 2025, but returned to the facility on August 19, 2025, following an unsuccessful discharge. Documentation in the record indicated the resident continued to express a desire to return to her home.
During an interview on March 11, 2026, at 9:40 A.M., the Social Services Director stated Resident 4 occasionally expressed a desire to return home but the discharge was considered unsafe due to the resident's inability to care for herself and the condition of the home environment, which was described as uninhabitable. The Social Services Director confirmed a discharge care plan addressing the resident's stated preference, barriers to discharge, or alternative discharge options had not been developed.
During an interview on March 11, 2026, at 2:15 P.M., the Nursing Home Administrator and Director of Nursing were unable to provide documentation demonstrating individualized discharge care plans had been developed for Residents 3 and 4.
28 Pa. Code 201.29(a) Resident rights.
28 Pa. Code 201.18(e)(1) Management.
28 Pa Code 211.10 (a)(c) Resident care policies.
| | Plan of Correction - To be completed: 03/27/2026
Residents 3 and 4 had individualized discharge planning processes completed, including identification of discharge goals, preferences, barriers, and integration into the comprehensive care plan.
An audit of all current residents was completed to ensure discharge goals, preferences, and planning were identified, documented, and incorporated into the care plan.
Interdisciplinary team members were re-educated on development and implementation of discharge planning process, including discharge goals, preferences, and barriers as part of the individualized comprehensive care plan.
The DON/designee will audit 5 residents weekly x4 weeks, then monthly x3 months to ensure discharge goals, preferences, and planning were identified, documented, and incorporated into the care plan. Findings will be reviewed through QAPI.
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