Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
Kadima Rehabilitation and Nursing at Irwin was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding the notice requirements before transferring or discharging residents. The facility failed to provide transfer notices to the representatives of the Office of the Long-Term Care Ombudsman Division for four months, from January 2024 through April 2024. This deficiency was identified during a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and an Abbreviated survey in response to four complaints. The facility's policy on 'Admission Transfer and Discharge' was reviewed, and it indicated that no resident would be discharged without timely notification to the resident, responsible party, or authorized representative. However, the facility did not adhere to this policy, as confirmed by the Nursing Home Administrator during an interview. The federal regulations require that a copy of the transfer or discharge notice be sent to a representative of the Office of the State Long-Term Care Ombudsman, which was not done for the specified period.
Plan Of Correction
The facility will provide transfer notices to representatives of the Office of the Long-Term Care Ombudsman Division. The facility cannot retroactively correct the concern identified during the annual survey. The facility will send the discharge/transfer list to the state Ombudsman monthly. The Nursing Home Administrator or Designee will re-educate the Director of Social Services on federal tag F0623. The Nursing Home Administrator or Designee will complete an audit monthly for three months to validate the transfer/discharge list is completed and sent to the state Ombudsman monthly. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.