§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 demonstrate that a resident's discharge from the facility was appropriate and necessary for one of 30 sampled residents (Resident 94).
Findings include:
A review of the clinical record revealed Resident 94 was admitted to the facility on October 25, 2025, with diagnoses that included diverticulosis of the large intestine without perforation or abscess without bleeding (presence of one or more balloon-like sacs in the colon) and generalized anxiety disorder (a disorder characterized by excessive worry that interferes with daily functioning). Review of the admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 31, 2025, revealed that Resident 94 had a Brief Interview for Mental Status (BIMS), a cognitive assessment tool used in long-term care settings to evaluate cognitive function within the Cognitive Section of the MDS, with a score of 00. A BIMS score of 00 indicates severe cognitive impairment and suggests the resident required significant support for decision making during care planning and discharge planning.
A review of the facility policy, Discharge Planning Procedure, last reviewed January 20, 2025, revealed that social services are to establish a discharge plan upon admission and include the resident's goal for discharge as well as the resident representative's goal for discharge. The policy further revealed specific documentation regarding referrals made and services necessary for a successful discharge will be delineated in the Social Service Progress notes and/or the Social Service Discharge Referral Form. The policy noted that if discharge to the community is not feasible, the social worker will document who made the determination and why.
Review of the clinical record revealed Resident 94 was transferred to an acute care facility on October 28, 2025, due to a change in medical condition, specifically increased heart rate and difficulty breathing. Review of clinical records from both the facility and the acute care hospital revealed the change in condition was related to a medication error in the facility involving the duplicate administration of a vaccine. During hospitalization, all psychiatric medications were discontinued to address the acute medical condition. Resident 94 returned to the facility on October 31, 2025, once stabilized.
Further review of the clinical record revealed Resident 94 was transferred again to an acute care facility on November 6, 2025, due to a change in mental status and increased physical aggression, including punching staff. Review of the clinical record revealed a Bed Hold Agreement acknowledged by the resident's representative (brother) on November 6, 2025. A Bed Hold Agreement is a document informing the resident or resident representative that the resident's bed will be held during a temporary hospital transfer so the resident may return to the same bed. When a Bed Hold Agreement is acknowledged, it indicates understanding and agreement that the resident intends to return to the facility and that the bed will be held.
However, the medical record also revealed that a Discharge Return Not Anticipated (DRNA) Minimum Data Set (MDS), a federally mandated standardized assessment used to plan resident care, was completed on November 6, 2025. Completion of a DRNA MDS indicated the resident was not expected to return to the facility. The completion of a DRNA MDS directly conflicted with the acknowledged Bed Hold Agreement and demonstrated that the facility did not clearly determine, document, or communicate whether Resident 94 was being temporarily transferred or permanently discharged.
At the time of the survey, review of the clinical record lacked documentation of a discharge planning process including required information communicated to the receiving healthcare organization or provider, the resident's specific needs that could not be met at the facility, the services available at the receiving facility to address those needs, or documentation by the medical provider when discharge occurred. The record further lacked evidence that the discharge planning process addressed the resident's discharge goals and needs, including involvement of the resident representative and the interdisciplinary team.
An interview with the Director of Nursing (DON) on November 21, 2025, at 9:39 AM revealed that Resident 94 was discharged on November 6, 2025, due to safety concerns for staff and other residents and stated the resident posed a risk to others in the care environment. The DON acknowledged that the clinical record lacked documentation reflecting adequate discharge planning, including documentation from the facility medical provider and interdisciplinary team.
An interview with the Director of Social Work on November 21, 2025, at 10:42 AM confirmed concerns regarding safety and stated she could not provide a reason why the Bed Hold Agreement was acknowledged by the resident representative when the resident was discharged upon transfer to the acute care facility.
28 Pa. Code 201.29(h) Resident rights
28 Pa. Code 201.14(a) Responsibility of Licensee
| | Plan of Correction - To be completed: 01/13/2026
Elan Skilled Nursing and Rehab (facility) submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal regulations relating to long-term care. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or an admission of past or ongoing violations of State and Federal regulatory requirements.
Resident #94, since discharged on 11/6/2025. The situation could not be remedied.
NHA and DON audited discharges for November 2025. No residents were exhibiting behaviors or actions that would endanger the health or safety of our residents or other individuals in the facility. Presently, no in-house residents are exhibiting behaviors or actions that would endanger the health or safety of our residents or other individuals in the facility.
The NHA, DON and Director of Human Services will revise the Discharge Planning Procedure to include what is required when a resident who is transferred with an expectation of returning to the facility, cannot return to the facility as their return would endanger the health or safety of the resident or other individuals in the facility. The revision will include: the required information communicated to the receiving healthcare organization or provider, the resident's specific needs that could not be met at the facility, the services available at the receiving facility to address those needs, documentation by the medical provider, the residents discharge goals and needs and involvement of the resident representative and the interdisciplinary team.
The NHA will educate the DON/Director of Human Services and the Social Services Department on the Discharge Planning Procedure.
DON to educate MDS staff regarding completion of the appropriate Discharge Return Not Anticipated (DRNA) assessment.
An audit will be conducted by the NHA/designee of resident discharges to verify compliance with the revised Discharge Planning Procedure those residents who were assigned a DRNA. Audits will be completed weekly x4, then monthly x 33 to ensure ongoing compliance. Audit results will be brought to QAPI meeting for review and revision as needed.
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