Failure to Provide Appeal Information in Transfer Notices
Penalty
Summary
The facility failed to provide residents and their representatives with written transfer or discharge notices that included the option to appeal the transfer or discharge. This deficiency was identified for nine residents who were transferred to hospitals for various medical reasons, such as dehydration, urinary tract infections, and altered mental status. The notices provided to these residents did not contain essential appeal information, including the contact name, telephone number, or address of the entity to which appeals could be directed. The review of the facility's documentation revealed that the Notice of Emergency Transfer forms lacked the necessary details about the residents' rights to appeal the transfer decisions. For instance, the forms did not include the name, address, and telephone number of the entity that receives appeal requests, nor did they provide information on how to obtain and complete an appeal form. This omission was consistent across all reviewed cases, indicating a systemic issue in the facility's discharge process. Interviews with facility staff, including the Social Services Director and the Administrator, confirmed that the current forms used for discharge notices did not include the required appeal rights information. The staff believed that the facility was compliant with regulations because residents were given the bed hold policy upon admission and were always allowed to return to the facility. However, the forms used were not in alignment with the guidance provided by the New Jersey Department of Health, which mandates the inclusion of specific contact information for appeal processes.
Plan Of Correction
1/7/25 The Emergency [R] Notice letter was updated to include the appeal information required before NJ Ex Order 26.4(b)(1). Residents R21, R27, R75, R9, R60, R69, R71, R91, R86 were previously provided an Emergency Letter of [R] prior to their discharge. All residents have returned from their NJ Ex Order 26.4(b)(1) stay. All residents discharged/transferred to the hospital have the potential to be affected. The Emergency [R] Notice letter was revised by the Administrator to include more detailed appeal information. The Administrator inserviced the [R] and all facility social workers on the regulatory requirements for the appeal information for Emergency Transfer Notification (ETN) to the resident, the resident's representative and the NJ Long Term Care Ombudsman's office. The Social Service Director will submit the Emergency Transfer Notifications to the Administrator on a monthly basis to assure the appeal information is in the letter. Administrator will audit this on a monthly basis. The Director of Social Services will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters. Evaluation by the committee to determine continuing frequency of audits.