§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.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.
§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).
§483.15(d) Notice of bed-hold policy and return-
§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1 ) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.
§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
§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:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
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Observations:
Based on review of facility policies, clinical records, and staff interview it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer and failed to have complete documentation related to a transfer for one of two residents reviewed (Closed Record Resident CR77).
Findings include:
Review of facility policy entitled "Transfer/Discharge Documentation" dated 2/18/25, indicated that when a resident is transferred to acute care the facility will:
the provider hospital, when possible, for admission arrangements.
copies of the transfer form and advanced directives will accompany the resident, and copies will be retained in the medical record.
information of the practitioner who was responsible for the care of the resident.
representative information, including contact information.
status, including baseline and current mental, behavioral and functional status, reason for transfer, and recent vital signs.
allergies, and medications (including when last received).
recent relevant labs, other diagnostics, immunizations.
instructions and/or precautions such as contact, droplet, or airborne.
risks such as falls, elopement, bleeding, pressure injury, and/or aspiration precautions.
care plan goals.
Resident CR77's clinical record revealed an admission date of 12/20/25, with diagnoses including partial intestinal obstruction, difficulty swallowing, unsteady on feet, weakness, and need for assistance with personal care.
A departmental progress note dated 1/02/26, at 12:33 a.m. indicated that Resident CR77 was transferred to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider.
During an interview on 3/06/26, at 11:00 a.m. the Director of Nursing confirmed that the facility lacked evidence that Resident CR77's necessary clinical information was provided to the receiving healthcare provider upon transfer, and his/her clinical record lacked complete documentation.
28 Pa. Code 201.14 (a) Responsibility of licensee
28 Pa. Code 201.18 (b)(3)(e)(1) Management
28 Pa. Code 211.12 (d)(1)(3) Nursing services
| | Plan of Correction - To be completed: 04/01/2026
Resident CR77 had no ill effect due to lapse in documentation. Resident chart reviewed to ensure proper documentation for transfers.
Education provided to licensed staff on transfer/discharge policy including physician notification, family and/or representative notification, advance directive information, physician orders, plan of care, discharge summary, bed hold notice.
Director of Nursing or designee will audit all resident transfer records four times a week for one week, three times a week for one week, two times a week for one week, then monthly until compliance is met. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.
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