Health inspection·November 19, 2024

F622 Section §483.15(c) Transfer and discharge-  Section §483.15(c)(1) Facility requirements-  (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. (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.

F623 §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.

F660 §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.   On 10/11/2024 at 8:30 AM, an unannounced visit was made by the California Department of Public Health (CDPH) to conduct the facility's annual health recertification survey. As a result of the investigation, CDPH determined that the facility failed to provide adequate discharge planning to two patients [Patients 1 and 2) when: 1. Patient 1 was informed by the Social Services Director [SSD] that Patient 1 did not meet the criteria to stay at the facility on 7/25/2024, after being admitted to the facility on 7/24/2024. Patient 1 was provided an option to pay out of pocket for Rehabilitation Services or sign the Against Medical Advice [AMA, when a patient chooses to leave the facility before a doctor recommends discharge] on 7/25/2024. The facility did not provide adequate discharge planning for Patient 1, resulting in an unsafe discharge against medical advice [AMA] on 7/25/2024. 2. Patient 2, who had moderately impaired cognition (ability to reason and thought process), was not allowed to come back at the facility after the patient went out-on-pass (OOP, a temporary permission of a patient to leave the facility in a specified time) for a therapeutic leave [The State Operations Manual defined Therapeutic Leave as a type of resident-initiated transfer. However, if the facility makes a determination to not allow the resident to return, the transfer becomes a facility-initiated discharge] with family on 7/27/2024. On 7/28/2024, Licensed Vocational Nurse (LVN) 4 informed Patient 2 that she could no longer come back to the facility despite Patient 2 verbally informing LVN 4 of her desire to return to the facility. The facility did not provide adequate discharge planning for Patient 2, resulting in an unsafe discharge against medical advice [AMA] on 7/28/2024. As a result of these deficient practices, Patient 1 signed the AMA form as instructed by the SSD and pre-emptively left the facility on 7/25/2024 and Patient 2 was not allowed to return to the facility after being allowed to go on a therapeutic leave or OOP with the family. Both Patients 1 and 2 did not receive discharge planning and resources such as medications, treatments, and post discharge plan of care and services from the facility. 1. A review of Patient 1’s medical records inquiry from the General Acute Care Hospital [GACH], signed on 6/20/2024, sent by the GACH to the facility on 7/19/2024, indicated the Patient 1 “will need to be in a nursing home post-operatively.” A review of Patient 1’s “Patient Medical Information” from the GACH, dated 7/23/2024, timed at 3:39 PM, that was sent to the facility, indicated the patient “will need Morphine (a pain medication) for pain as needed as well as Zofran (a medication that helps to relieve nausea and vomiting) 4 mg (milligrams, a unit of measure) every 6 hrs. Please start [patient] on IV (Intravenous, given into a person’s veins) when she arrives to the facility.” A review of Patient 1’s Admission Record (AR) indicated Patient 1 is a 51-year-old female who was admitted to the facility on 7/24/2024 with diagnoses that included gender identity disorder and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). A review of Patient 1’s Order Summary Report (a set of physician’s order) for the month of July 2024, included a physician order dated 7/24/2024 that indicated “Admit to Skilled Nursing [Facility name] from [General Acute Care Hospital (GACH)].” Another physician order dated 7/24/2024 indicated “admitted to custodial (non-medical care provided to assist people with daily living) 7/24/2024.” A review of Patient 1’s History and Physical (H&P, a comprehensive physician’s note regarding the assessment of the patient’s health status), dated 7/25/2024, indicated the patient have the capacity to understand and make decisions. The H&P indicated “after arriving to the facility, she Patient 1] decided to leave AMA to [Family Member (FM) 2]’s house.” A review of the Patient 1’s form titled, “California Standard Admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities and Intermediate Care Facilities,” included the sections titled “Consent to Treatment,” “Your Rights as a [Patient],” and “Financial Agreement.” The form indicated “Financial Arrangements” were discussed with Patient 1. The form was electronically signed by the admissions coordinator (AC) on 7/25/2024 at 11:32 AM, and Patient 1 on 7/25/2024 at 11:17 AM. A review of the Patient 1’s “Progress Notes,” indicated a “Social Service Entry Note” authored by the Social Services Director (SSD) dated 7/25/2024 at timed 11:38 AM, indicated Patient 1 “does not meet the criteria for rehab therapy and had not been stably housed for some time. [Patient] requests to be discharged” to family. The Progress Notes did not indicate Patient 1 was provided an option to apply for insurance coverage or appeal the insurance’s decision, as indicated in the facility’s policy and procedure titled, “Transfer and Discharge, Facility-Initiated”, revised 10/2022. The Progress Notes did not indicate the patient received any post discharge assistance or resources such as home health services (medical care delivered in the patient's home), medications, or medication prescription (a written order for the preparation and use of a medicine). A review of the Patient 1’s “Notice of Proposed Discharge/Transfer,” dated 7/25/2024, indicated the patient’s reason for discharge was “against medical advice.” The document indicated the patient has “a right to appeal” the discharge and the “facility may permit the patient to remain until the decision is rendered if the facility chooses to.” The Notice indicated Patient 1 is “self-responsible.” The Notice did not include a signature of the patient or a representative in the section for “Signature & Date- Resident or Resident’s Representative.” During a phone interview on 10/13/2024 at 4:16 PM with Patient 1, Patient 1 stated she did not leave the facility against medical advice. Patient 1 stated the facility informed her that she did not have insurance coverage because she did not qualify for physical therapy (therapy that is used to preserve, enhance, or restore movement and physical function) and would have to pay for her stay at the facility. Patient 1 stated she did not have the financial capabilities to pay for the stay in the facility. During the same phone interview with Patient 1, Patient 1 stated the facility did not inform her that she could appeal the insurance’s decision nor that she could apply for emergency insurance coverage. Patient 1 stated the facility did not inform her that she could stay in the facility when an appeal is being processed and a decision from the insurance company is pending. Patient 1 stated she did not want to leave the facility because she wanted to recover from her surgery in the facility. Patient 1 stated she was not provided a form titled, “Notice of Proposed Transfer/Discharge” that indicated her appeal rights. Patient 1 also stated she signed a form titled, “Leave Hospital Against Advice,” but did not understand what the form was about because he did not have any other options. Patient 1 stated she would have appealed the discharge if she was made aware, instead of leaving the facility. During the concurrent phone interview and record review on 10/13/2024 at 4:24 PM with Patient 1, the document titled, “Leave Hospital Against Advice,” was reviewed. Patient 1 stated she did not understand the AMA form that he signed. Patient 1 stated the AMA form was not explained by any of the facility’s staff, he was just informed to sign it if he cannot pay for his stay to do physical therapy at the facility. During an interview on 10/13/2024 at 5:36 PM with the Director of Nursing (DON), the DON stated Patient 1 was admitted to the facility after the patient underwent facial surgery. The DON stated the patient was admitted to the facility to recover from the surgery. During an interview on 10/13/2024 at 5:43 PM with the Business Office Manager (BM), the BM stated before admitting patients into the facility, it is the facility’s process to review the patient’s financial documents, including the insurance, prior to accepting patients. The BM stated it is the facility’s process to request for authorization (approval from a health plan that may be required before a person receives services in order for the service be covered) before admitting patients. During a concurrent interview and record review on 10/13/2024 at 6:12 PM with the BM, Patient 1’s financial documents were reviewed. The BM stated the GACH that transferred Patient 1 into the facility did not provide an insurance authorization to the facility. The BM stated the facility had to submit the request to Patient 1’s insurance for an authorization. A review of Patient 1’s “Notice of Authorization Services,” dated 8/12/2024 [18 days after patient was discharged to the facility], indicated Patient 1’s stay at the facility was approved by the insurance. The BM stated because it was “approved,” the patient’s stay at the facility was pre-authorized, or paid by the insurance. During another interview on 10/13/2024 at 6:32 PM with the DON, the DON stated that on 7/25/2024, the morning after Patient 1 was admitted to the facility, the facility conducted a meeting with the IDT and during the meeting, the facility identified that Patient 1 did not have insurance coverage for her facility stay due to not qualifying for physical therapy services. The DON stated that after the meeting, the SSD informed Patient 1 that the patient’s stay will not be covered by the insurance. The DON stated before admitting a patient, the facility must ensure that all financial documents have been reviewed. The DON stated the BM is responsible for verifying all financial documents prior to a patient’s admission. During a phone interview on 10/14/2024 at 9:56 AM with the SSD, the SSD stated if a patient does not have a health insurance, the facility could apply for an “emergency insurance” for the patient’s behalf. The SSD stated he was not sure if he assisted Patient 1 in applying for “emergency insurance”. During a record review of the patient’s “Progress Notes”, from date ranges 7/13/2024 to 8/13/2024, did not indicate documented evidence that Patient 1 was assisted in applying for “emergency insurance.” During a concurrent interview and record review on 10/14/2024 at 2:53 PM with the DON, Patient 1’s “Notice of Proposed Discharge/Transfer” document was reviewed. The DON stated the document did not have Patient 1’s signature, which could mean the patient and/or representative did not receive the document during the stay/discharge from the facility. The DON stated the Notice indicated that the patient had an option to appeal the decision of the insurance to not approve the patient’s stay at