§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 policy, 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 to the hospital for three of 18 residents reviewed (Residents R1, R3, and R77).
Findings include:
Review of facility policy entitled "Transfer or Discharge, Emergency" dated 11/3/25, indicated "Should it become necessary to make emergency transfer or discharge to a hospital or other related institution, our facility will prepare a transfer packet to send with the resident that includes; face sheet, administration record, order summary, bed hold policy, immunization report, recent weight and vitals, copy of advance directives, and complete e-interact form."
Resident R1's clinical record revealed an admission date of 8/27/25, with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), atrial fibrillation (A-Fib irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), and chronic obstructive pulmonary disease (COPD a condition that prevents airflow to the lungs resulting in difficulty breathing).
Resident R1's progress notes revealed a note dated 8/29/25,indicating transfer to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider.
Resident R3's clinical record revealed an admission date of 12/30/24, with diagnoses that included hypertension (high blood pressure), hyperlipidemia (high cholesterol), and heart failure (a condition where the heart cannot supply the body with enough blood).
Resident R3's progress notes revealed notes dated 5/18/25,8/11/25, and 8/14/25, indicating transfers to the hospital. The clinical record lacked evidence that his/her necessary clinical information was communicated to the receiving health care provider.
Review of Resident R77's clinical record revealed an admission date of 8/25/25, with diagnoses that included weakness, dysphagia (difficulty swallowing), and chronic respiratory failure.
Resident R77's progress notes revealed a note dated 9/5/25,indicating transfer 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 11/19/25, at 9:09 a.m. the Director of Nursing confirmed that Residents R1, R3, and R77s clinical records lacked evidence that the necessary clinical information was provided to the receiving healthcare provider upon transfer and when the transfers occurred clinical information should have been provided to the receiving healthcare provider.
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.29(c.3) (2) Resident rights
| | Plan of Correction - To be completed: 01/05/2026
1. Corrective Action Taken for Residents Found to Be Affected
- The Director of Nursing and Assistant Director of Nursing immediately reviewed the clinical records of Residents R1, R3, and R77. For each resident, the Director of Nursing reconstructed the complete transfer packet in accordance with §483.15(c)(2)(iii), including practitioner contact information, resident representative information, advance directives, special instructions, current care plan goals, current clinical summaries, and all other necessary documentation.
- Involved nursing staff were counseled and re-educated on correct transfer packet procedures.
2. Identification of Other Residents Potentially Affected
- Director of Nursing/Assistant Director of Nursing did an audit of all resident transfers that occurred within the past 60 days to determine whether all required clinical information was provided at the time of transfer.
- Where missing documentation was identified, it was immediately corrected and communicated to the receiving provider.
- No negative outcomes were identified for any residents.
3. Systemic Changes Implemented to Prevent Recurrence
The Lutheran Home at Kane has implemented the following corrective systems:
A. Revised Transfer Packet and Checklist
The facility's Emergency Transfer/Discharge Packet was revised to include a standardized checklist encompassing all required elements under:
- §483.15(c)(2)(iii)(A)–(F)
- §483.15(c)(3)–(6) and (d)(1)–(2)
- §483.21(c)(2)
The checklist must be completed and signed by the charge nurse before transfer.
B. EHR Workflow Enhancements
- The electronic health record was updated to include a required transfer packet prompt, preventing completion of a transfer note until all required documents are uploaded or verified.
C. Staff Education
Director of Nursing and Assistant Director of Nursing educated all licensed nursing staff, unit clerks, admissions staff, and nursing supervisors re-educated on:
- Regulatory requirements for resident transfer and discharge documentation
- Required content to be communicated to receiving facilities
- Documentation of reasons for transfer
- Bed-hold notice requirements under §483.15(d)(1)–(2)
- Discharge summary requirements under §483.21(c)(2)
- Staff unable to attend the initial session will receive education prior to their next shift.
D. DON Oversight Process
The Director of Nursing or designee will review all transfer packets within 24 hours of any resident transfer to ensure accuracy and completeness.
4. Monitoring to Ensure Ongoing Compliance
The DON or designee will conduct audits as follows:
- 100% of all transfers weekly × 4 weeks
- 50% of transfers weekly × 8 weeks
Audits will verify that all required information under §483.15(c)(2)(iii) was transmitted, including care plan goals, advance directives, practitioner contact information, representative information, special instructions, and clinical summaries.
Audit findings will be reviewed monthly during Quality Assurance Performance Improvement meeting.
Any identified non-compliance will result in immediate re-education and repeated focused audits until sustained compliance is demonstrated.
5. Completion Date
The facility will be in full compliance on or before: 1/5/2026
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