Lack of Written Hospital Transfer Agreement
Summary
The facility failed to maintain a written transfer agreement with a hospital certified by Medicare or Medicaid, which is necessary to ensure the timely transfer and admission of residents requiring emergency hospitalization. This deficiency was identified during a review of the facility's policies and procedures, where no such agreement was found. During an interview, the Director of Nursing (DON) confirmed the absence of a written transfer agreement and acknowledged that no good faith effort had been made to establish one with a hospital. The facility's policy on hospital transfers, dated November 10, did not address the requirement for a transfer agreement with a hospital.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility did not maintain or provide a written transfer agreement policy or documentation of formal arrangements with a Medicare- or Medicaid-certified hospital to ensure timely transfer of residents needing acute care. During surveyor review, no written policy outlining the process for hospital transfers could be produced. The Administrator reported that important document binders had been relocated during a recent facility-wide evacuation and the requested policy and transfer agreement documentation could not be located or verified.
Facility staff did not provide evidence of a current hospital transfer agreement, as the only agreement on file was with the previous owner and no updated contract had been established under the new ownership. This deficiency was identified through staff interviews and document review, potentially affecting all residents.
Surveyors found that the facility did not have a written transfer agreement with any local hospital certified by Medicare or Medicaid, as confirmed by the Regional Director of Clinical Operations during interviews and record review.
Surveyors found that the facility did not have a required transfer agreement with a local hospital, as confirmed by the NHA during documentation review and staff interviews.
The facility did not have a valid written transfer agreement with a Medicare or Medicaid-certified hospital for several months after the closure of its previous partner hospital, and was unable to provide evidence of any active agreement during that time.
The facility failed to provide a written transfer agreement with a local GACH, as required by federal regulations. The DON was unable to produce the agreement during multiple interviews, acknowledging the requirement but failing to locate it. This deficiency could potentially risk residents' continuity of care and treatment.
Failure to Maintain Written Hospital Transfer Agreement Policy and Documentation
Penalty
Summary
The facility failed to maintain and provide a written transfer agreement policy and documentation of formalized arrangements with a Medicare- or Medicaid-certified hospital to ensure residents could be transferred when medically necessary. During document and policy review, surveyors were unable to obtain a written transfer agreement policy outlining the process for transferring residents to a hospital for acute care. In an interview, the Administrator stated she could not provide the requested transfer agreement policy at the time of survey, explaining that binders containing important documents had been relocated during a recent facility-wide evacuation and the documentation could not be produced. The facility also could not provide evidence of a current written transfer agreement or other documentation verifying formal transfer arrangements with a hospital for timely resident transfers. No specific residents, medical histories, or clinical conditions at the time of the deficiency were described in the report.
Lack of Updated Hospital Transfer Agreement
Penalty
Summary
Facility staff failed to provide evidence of an updated hospital transfer agreement, as required for ensuring residents can be transferred quickly to a hospital when necessary. Document review showed that the only available agreement was with the previous owner, a company that no longer exists, and there was no current contractual agreement with a hospital under the new ownership. During staff interviews, the executive director explained that the process of updating contracts with all vendors, including hospitals, had been slow due to the recent acquisition of multiple facilities by the new company. No updated agreement was presented prior to the survey exit, potentially affecting all 86 residents in the facility. No specific residents or their medical conditions were mentioned in the report, and the deficiency was identified through staff interviews and document review.
Lack of Hospital Transfer Agreement
Penalty
Summary
The facility failed to establish and maintain a written transfer agreement with at least one area hospital that is approved for participation in Medicare or Medicaid programs. During an interview, the Regional Director of Clinical Operations confirmed that the facility did not have a transfer agreement with any local hospital. This deficiency was identified through interviews and record review, and it was noted that the facility was unable to provide documentation of such agreements when requested by surveyors. No specific residents or their medical conditions were mentioned in the report, and the findings were based on staff interviews and the absence of required documentation.
Lack of Required Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain a transfer agreement with a local hospital as required by federal regulations. During an extended survey, the surveyor requested documentation of a transfer agreement, and the Nursing Home Administrator confirmed that no such agreement existed between the facility and a local hospital. This deficiency was identified through review of documentation and staff interviews. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Maintain Current Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain an up-to-date written transfer agreement with a hospital certified by Medicare or Medicaid, as required. The existing agreement was with a local hospital that had closed, and the facility did not have a valid transfer agreement in place from the time of the hospital's closure until a new agreement was established several months later. During this period, the facility was unable to provide evidence of any active transfer agreement, as confirmed by the administrator during an interview and review of facility records.
Failure to Provide Written Transfer Agreement with Local Hospital
Penalty
Summary
The facility failed to ensure there was a written transfer agreement with a local General Acute Care Hospital (GACH), as required by federal regulations. During an interview on March 12, 2025, the Director of Nursing (DON) was unable to provide a copy of the facility's transfer agreement with a local hospital upon request. Despite multiple follow-up interviews on the same day and the following day, the DON confirmed that she was still unable to locate the transfer agreement. The DON acknowledged the requirement for such an agreement but was unable to produce it, potentially placing residents at risk for inadequate continuity of care and treatment.
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