Health inspection·May 14, 2025

California Code of Regulations, Title 22, Section § 72433(b)(5) Social Work Service Unit – Services (b) Social work services unit shall include but not be limited to the following: (5) Discharge planning for each patient and implementation of the plan. California Code of Regulations, Title 22, Section § 72521(c)(2) Administrative Policies and Procedures (c) Each facility shall establish at least the following: (2) Policies and procedures for patient admission, leave of absence, transfer, pass and discharge, categories of patients accepted and retained, rate of charge for services included in the basic rate, type of services offered, charges for extra services, limitations of services, cause for termination of services and refund policies applying to termination of services. On 4/29/25, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate an inappropriate transfer/discharge. As a result of the investigation, the CDPH determined that the facility failed to ensure , Residents 1 and 2 who were Medi-Cal beneficiaries were appropriately transferred and discharged to facilities contracted with Department of Health Care Services (DHCS) for Medi-Cal Subacute Care in accordance with the “Subacute Contracting Unit [SCU] Medi-Cal Provider List (MPL)” provided to the facility’s Administrator (ADM 1) by the DHCS due to the facility’s proposed plan to close the Sub Acute Unit (SAU). This failure resulted in Residents 1 and 2 being transferred to a non-authorized facility and had the potential to cause psychological distress, disruptions in care, potential health complications, and physical decline to Residents 1 and 2. a. A review of Resident 1’s “Admission Record” (AR) indicated Resident 1, a 43- year-old-male was originally admitted to the facility on 11/9/22 and was readmitted on 11/28/22 with multiple diagnoses including chronic respiratory failure with hypoxia paraplegia, unspecified and personal history of transient ischemic attack without residual deficits. The “AR” indicated, Resident 1 was a Medi-Cal beneficiary. A review of Resident 1’s “Minimum Data Set (MDS, a resident assessment and care planning tool),” dated 2/27/25, indicated Resident 1’s cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 1 required oxygen therapy and tracheostomy care. A review of Resident 1’s “History and Physical (H&P),” dated 3/8/25, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s “Post Discharge Plan of Care and Summary (PDS),” dated 4/21/25, timed at 5:03 p.m. indicated the Social Services’ (SS) discharge recommendation was to discharge Resident 1 to the Congregate Living Health Facility (CLHF) 1 per Resident 1’s family’s choice/request. A review of Resident 1’s “Notice of Transfer/Discharge (NTD),” dated 4/22/25, indicated Resident 1’s family requested to discharge Resident 1 to CHLF 1. A review of Resident 1’s “Progress Notes (PN),” dated 4/22/25, timed at 11:40 a.m., indicated Resident 1 was discharged to CLHF 1, accompanied by transportation staff with Respiratory Therapist (RT) on 4/22/25 at 11:30 a.m. A review of Resident 1’s CLHF 1’s “Daily Nurses Notes (DNN),” dated 4/22/25, timed at 2:00 p.m. indicated CLHF 1 admitted Resident 1. b. A review of Resident 2’s AR indicated Resident 2, a 66 - year -old -male, was originally admitted to the facility on 11/22/24 and was readmitted on 4/3/25 with multiple diagnoses including chronic respiratory failure with hypoxia, type 2 diabetes mellitus with hyperglycemia and personal history of transient ischemic, and cerebral infarction without residual deficits. The “AR” indicated, Resident 2 was a Medi-Cal beneficiary. A review of Resident 2’s “MDS,” dated 2/28/25, indicated Resident 2’s cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 2 required oxygen therapy and tracheostomy care. A review of Resident 2’s “H&P,” dated 4/4/25, indicated Resident 2 did not have the capacity to understand and make decisions. A review of Resident 2’s “PDS,” dated 4/21/25, timed at 5:03 p.m., indicated, the SS’s discharge recommendation was to discharge Resident 2 to the CLHF per family’s choice/request. A review of Resident 2’s “NTD,” dated 4/22/25, indicated Resident 2’s family requested to discharge Resident 2 to CLHF 1. A review of Resident 2’s “PN,” dated 4/22/25, timed at 2:20 p.m., indicated Resident 2 was discharged to CLHF 1, accompanied by transportation staff with RT on 4/22/25 at 2:20 p.m. A review of Resident 2’s CLHF 1’s “DNN,” dated 4/22/25, timed at 4:00 p.m., indicated, CLHF 1 admitted Resident 2. A review of the “Email Correspondence (EC),” between the DHCS and the facility dated 4/22/25, timed at 9:48 p.m., indicated an understanding between ADM 1 and the DHCS that all Medi-Cal beneficiaries must be discharged to facilities contracted with DHCS for Medi-Cal subacute care. The “EC” indicated, the “MPL” was provided to ADM 1 for reference to help the facility locate placement of SNFs that were contracted with DHCS. The “MPL,” updated 4/14/25 did not indicate CLHF 1 was on the list. During an interview on 4/28/25 at 10:35 a.m. with CLHF 1’s Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Residents 1 and 2 were admitted to CLHF 1 on 4/22/25. LVN 1 stated, Residents 1 and 2 were no longer in CLHF 1 due to both Residents 1 and 2 being transferred out of CLHF 1 to a General Care Acute Hospital (GACH) 1. LVN 1 stated Resident 1 was transferred to GACH 1 on 4/26/25. LVN 1 stated Resident 2 was transferred to GACH 1 on 4/24/25. During an interview on 4/28/25 at 11:00 a.m. with CLHF 1’s Administrator (ADM 2), ADM 2 stated, Residents 1 and 2 were transferred to GACH 1. During an observation on 4/28/25 at 1:25 p.m. in GACH 1’s Stepdown Unit, Resident 2 was lying in bed and non-responsive. Resident 2 had a tracheostomy connected to a ventilator. During an interview on 4/28/25 at 1:39 p.m. with Resident 2’s Responsible Party (RP 2), RP 2 stated, RP 2 “did not feel good,” about Resident 2’s transfer and RP 2 did not want Resident 2 transferred to CLHF 1. RP 2 stated, CLHF 1’s location was too far from RP 2’ home. RP 2 stated, RP 2 told the facility’s Case Manager (CM) to transfer Resident 2 to the CLHF while the CM finds a facility closer to RP 2’s house. During an observation on 4/28/25 at 2:20 p.m. in GACH 1’s Medicine/Oncology Unit, Resident 1 was lying in bed. Resident 1 was able to follow simple commands (close eyes, squeeze hand) from the surveyor but was nonverbal. Resident 1 had a tracheostomy tube attached to supplemental oxygen. During an interview on 4/29/25 at 12:37 p.m. with the facility’s SS, the SS stated Residents 1 and 2 were transferred to CLHF 1. The SS stated, the SS was not aware that residents could only be discharged to the facilities on the MPL. The SS stated discharging Resident’s 1 and 2 to CLHF 1 could result in having to move Residents 1 and 2 again and causing distress to Residents 1 and 2. During an interview on 4/29/25 at 1:26 p.m. ADM 1 stated, the facility was aware CLHF 1 was not on the MPL, but the resident’s families were requesting other options beside the facilities on the MPL. During an interview on 4/29/25 at 1:36 p.m. with the facility’s CM, the CM stated, the CM did not understand the facility’s SAU residents could only be discharged to the facilities listed on the MPL. The CM stated that RP 1 was happy with the transfer of Resident 1 since CLHF 1 was closer to where RP 1 lived. The CM stated, RP 2 wanted to transfer Resident 2 to a “home like environment” and the CM presented CLHF 1 to RP 2. A review of the facility’s policy and procedure (P&P) titled, “Transfer and Discharge (including AMA),” revised 12/19/22, indicated, “facility-initiated transfer or discharge” is a transfer or discharge which the resident objects to, or did not originate through a resident’s verbal or written request, and/or is not in alignment with the resident’s goals for care and preferences. The facility failed to ensure Residents 1 and Resident 2 who were Medi-Cal beneficiaries were appropriately transferred and discharged to facilities contracted with DHCS for Medi-Cal Subacute Care in accordance with the SCU MPL provided to the ADM 1 by the DHCS due to the facility’s proposed plan to close the SAU. This failure resulted in Residents 1 and 2 being transferred to a non-authorized facility and had the potential to cause psychological distress, disruptions in care, potential health complications, and physical decline to Residents 1 and 2. This violation jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Residents 1 and 2.