08/07/2025

Survey Tip of the Week: Transfer of Information

The Long-Term Care Survey Process (LTCSP) requires surveyors to closely review records for residents who have been transferred to the hospital. This includes evaluating whether proper communication occurred between the nursing facility and the receiving healthcare provider. In the State Operations Manual Appendix PP, CMS provides an example of noncompliance: A facility transferred a resident to the hospital emergently due to a change in condition. However, the facility failed to provide the hospital with the contact information of the practitioner responsible for the resident’s care, resulting in a delay in hospital admission.

Under §483.15(c)(2), when a facility transfers or discharges a resident, it must ensure the transfer or discharge is properly documented in the medical record and that appropriate information is communicated to the receiving healthcare institution or provider. At a minimum, this includes:

• Contact information of the practitioner who was responsible for the care of the resident;
• Resident representative information, including contact information;
• Advance directive information;
• All special instructions and/or precautions for ongoing care, as appropriate such as:
• Treatments and devices (oxygen, implants, IVs, tubes/catheters);
• Transmission-based precautions such as contact, droplet, or airborne;
• Special risks such as risk for falls, elopement, bleeding, or pressure injury and/or aspiration precautions;
• The resident’s comprehensive care plan goals; and
• All other information necessary to meet the resident’s needs, which includes, but may not be limited to:
• Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs;
• Diagnoses and allergies;
• Medications (including when last received); and
• Most recent relevant labs, other diagnostic tests, and recent immunizations.
• Additional information, if any, outlined