Health inspection·March 6, 2025

F622 42 CFR §483.15(c) Transfer and discharge §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. §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. (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. 22 CCR § 72521. 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. 22 CCR § 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (1) To be fully informed, as evidenced by the patient's written acknowledgement prior to or at the time of admission and during stay, of these rights and of all rules and regulations governing patient conduct. (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. An unannounced visit was conducted by California Department of Public Health (CDPH) on 2/14/2025 at 10:30 AM to investigate a facility reported incident (FRI) regarding Resident 1 being evacuated from the facility (Facility 1) due to a wildfire. Resident 1 was subsequently discharged and permanently placed in Facility 3. The facility failed to provide discharge requirements in accordance with the facility’s policy and procedure (P&P) titled Transfer and Discharge for Resident 1. This resulted in having the potential to violate the rights of Resident 1. A review of Resident 1’s Admission Record indicated Resident 1, a 70-year-old-female, was admitted to the facility on 6/10/2024 with diagnoses that included hypertension (HTN-high blood pressure) and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of Resident 1’s History and Physical (H&P) dated 6/16/2024, H&P indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS; a care assessment and screening tool) dated 11/19/2024, indicated the resident was assessed to have moderately impaired cognition (capable of remembering, learning new things, concentrating, or making decisions that affect everyday life) and required maximal assistance (helper does more than half the effort) for showering and moderate assistance (helper does less than half the effort) for toileting hygiene. The resident was also assessed with moderate assistance for upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene requiring supervision assistance (helper provides verbal cues and touching assistance) for upper body dressing, eating and oral hygiene. An interview with Resident 1 on 2/14/2025 at 8:53 AM. Resident 1 stated she preferred to stay at Facility 3. Resident 1 stated, the resident did not remember if Facility 1 asked the resident prefers to stay at Facility 3 or to return to Facility 1. An interview and record review of the facility’s P&P titled, Transfer and Discharge was conducted on 2/16/2025 at 4:02 PM with the director of nursing (DON) that indicated: 1. Purpose: to provide complete, safe and appropriate discharge planning and necessary information to the continuing care provider. 2. Residents are transferred/discharged based on physician order unless the resident signs out against medical advice. 3. Facility staff will provide the resident with reasonable advance notice of the transfer or discharge before it occurs. Unless exigent circumstances exist, the notice should be provided 30 days prior to the proposed date of transfer/discharge. 4. Documentation relating to resident’s transfer/discharge will be maintained in the resident’s medical record. The DON stated, “there was no transfer documentation or doctor’s order to discharge Resident 1 to Facility 3 DON stated Facility 1 should have followed up with Resident 1, after Resident 1 was temporarily placed at Facility 3. The DON stated according to Facility 1’s P&P, a doctor’s order is necessary to transfer or discharge residents. In addition, the DON stated there was no documented evidence of a doctor’s order to transfer/ discharge residents to Facility 3 or home and the consequences of not having a doctor’s order for transfer are that the residents may not receive appropriate care at the admitting facility or may be missing treatments and it may be an unsafe transfer. The DON stated, there was no documentation that Resident 1 was notified in advance of their transfer or discharge.” The facility failed to provide discharge requirements in accordance with the facility’s P&P, titled Transfer and Discharge for Resident 1. This resulted in having the potential to violate the rights of Resident 1. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.