Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
Horsham Center for Jewish Life was found to be non-compliant with specific requirements of 42 CFR Part 483, Subpart B, and the 28 PA Code during a series of surveys, including a Medicare/Medicaid Recertification survey and a State Licensure survey. The deficiency was identified in the facility's failure to notify the Office of the State Long-Term Care Ombudsman about facility-initiated emergency transfers to the hospital for two residents. This oversight was discovered through a review of facility documentation, clinical records, and staff interviews. The first resident, identified as R67, experienced an unwitnessed fall and was transferred to a local hospital for evaluation. Additionally, this resident had previously been admitted to the hospital for symptoms of nausea and dizziness, with a note indicating observation for syncope. The second resident, R237, had multiple incidents leading to hospital transfers, including pulling out a hypodermoclysis and a PEG tube. Despite these transfers, the facility failed to notify the Ombudsman as required. The Assistant Administrator, identified as Employee E15, confirmed on February 6, 2025, that the Ombudsman was not informed of these emergency transfers. This lack of notification is a violation of the specified regulations, which require that the Ombudsman be made aware of such transfers to ensure proper oversight and advocacy for the residents involved.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance. Ombudsman was made aware of R67 and R237 facility initiated emergency transfers to the hospital. Audit was completed of facility initiated emergency transfers to the hospital in the past 30 days to ensure Ombudsman notification. Administrator/designee re-educated Social Services staff on notification of ombudsman of facility initiated emergency transfers to the hospital. Social Services director/designee will audit facility initiated emergency transfers to the hospital monthly x3 to ensure that Ombudsman notification is completed and report findings to OAPI committee monthly.