§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.
|
Observations:
Based on clinical record reviews, interviews with staff and hospital staff, reviews of hospital records, electronic communication records and facility policies and procedures, it was determined that the facility failed to permit one of one resident's reviewed to return to the facility after hospitalization. (Resident R10)
Findings include:
Review of the undated policy titled Holding Bed Space revealed that "AristaCare at East Falls shall inform residents upon admission and at a transfer for hospitalization or therapeutic leave of our bed-hold policy. Upon admission and when a resident is transferred for hospitalization or for therapeutic leave, a representative of the building will provide information concerning our bed-hold policy. 2. When emergency transfers are necessary, AristaCare at East Falls will provide the resident or representative (sponsor) with information concerning our bed-hold policy of such transfer. 3. The bed-hold information will include any charges that the resident may incur as well as the time limit established by the State Medicaid Plan for which, AristaCare at East Falls reserve the resident's bed-space. (Note: Reissuance of the "admission notice" will be made if the bed-hold policy under the State Medicaid Plan or the facility's policy changes.) 4. The maximum number of days that our State Medicaid Plan has a hold on a Medicaid resident's bed is fifteen (15) days per hospitalization. 5. Bed-hold days in excess of our State Medicaid Plan are considered non-covered services. A resident will be required to pay for any additional days that he/she wishes, AristaCare at East Falls to hold the bed. 6. Medicaid residents whose bed-hold days have expired and have chosen not to pay privately will be offered the next available appropriate bed. 7. Ma(Medicaid) pending residents, the facility treat as MA approved for the 15 day bed hold period. After that time the resident will follow the Non-Medicaid resident process. 8. Non-Medicaid residents will be required to provide, AristaCare at East Falls with authorization to reserve the bed within twenty-four (24) hours of the resident's transfer from the facility. 9. A Medicaid resident who elects not to pay for non-covered services and whose hospitalization or therapeutic leave exceeds the bed-hold period established by the State Medicaid Plan will be readmitted when a clinically appropriate bed in a semi-private room becomes available."
Clinical record review for Resident R10 revealed that this resident was admitted from the hospital on November 13, 2024, with diagnoses to include acute and chronic respiratory failure and tracheostomy (a surgical procedure where an opening (stoma) is created in the windpipe (trachea) in the neck to allow for breathing) status.
Review of clinical record revealed that the payor source for Resident R10's stay at the facility was documented as "Medicaid pending"
The nursing note dated February 22, 2025, indicated, that the resident was transferred to hospital for abnormal labs(low hemoglobin blood level).
Continued review of the nursing note dated February 22, 2025, indicated, that the resident was admitted to the hospital with sepsis(a life-threatening medical emergency that occurs when the body's response to an infection harms its own tissues and organs).
Review of MDS for Resident R10 revealed that the resident was discharged and return to the facility was anticipated.
Review of the clinical record from February 22 to May 6, 2025, revealed no evidence that the facility inquired about Resident R10, discharge plan or return status.
Interview with Case Management staff at the hospital on May 8, 2025, at 1:58 p.m. stated that the facility denied residents readmission to the facility. She stated resident stayed in the hospital to finish an antibiotic treatment which was expensive. After her antibiotic treatment from March first week to till May she has reached out to the facility numerous times to let the facility know that the resident was ready to return to the facility. Case Management staff stated facility told her that the facility won't readmit the resident if the resident/representative don't handover the financial statements.
Interview with the Director of Nursing on May 7, 2025, at 4:43 p.m. stated the resident was transferred to the hospital for medical reason.
Interview with the facility Liaison, Employee E7, who work for resident referrals from the hospital on May 12, 2025, at 12:21 p.m. stated she told the hospital case manager that she would accept the resident when the financial information. Employee E7 confirmed that the financial information was a condition for resident's readmission even though the resident was sent out for medical reason.
Review of text message communication between the hospital case manager and Employee E7 revealed that on March 3, 2025, asked about Resident R10's return to the facility, however Employee E7 stated that the facility don't have any open beds. On March 7 similar conversation happened for resident to return but no response was provided. On March 10, 2025, inquired about an available bed for Resident R10 but Employee E7 stated no beds were available. Hospital also inquired about beds availability for Resident R10 to readmit to the facility on on March 12, 13, 18 and April 18,
Review of hospital records from March 4, 2025, to May 7, 2025, revealed that the hospital faxed clinical record for
Resident R10 numerous times to transfer the resident back to the facility. However, facility did not review the record or accepted the resident.
Review of facility selected facility census on March 7, 12, 13, April 18, 22, 24, 25, 27, May 1, 2, 5, 2025, revealed that the facility had open beds for Resident R10.
Interview with the Administrator on May 13, 2025, confirmed that the facility needed financial information prior to resident's admission to the facility. Administrator confirmed that the facility put financial information as a condition for Resident R10 to readmit to the facility.
28 PA. Code 201.14(a)(b) Responsibility of licensee
28 PA. Code 201.29(c.3)(4) Resident rights
28 PA. Code 211.12(d)(1) Nursing services
| | Plan of Correction - To be completed: 06/16/2025
1. Identified resident is no longer at the facility.
2.NHA will review all residents currently on hospital or therapeutic leave with the admissions director to ensure that any decisions that were made regarding readmission are in full compliance per regulation F627.
3.Weekly admission meeting will take place to review residents on leave to ensure there were no barriers to readmitting the resident when clinically appropriate, weekly x4 and monthly x3.
4.Results of the audits will be reported to the QAPI committee.
|
|
