Nursing Home Refusal to allow residents to return post-hospitalization “Let Me Return Home” Nursing Home Refusal to allow residents to return post-hospitalization Training for Hospital Discharge Planners Office of Ombudsman for Long-Term Care Minnesota Board on Aging 2016 I kind of like the “around the room” info to start a presentation with those numbers in mind.  Gives presenter an idea of frequency, urgency, and where to stress certain parts of the presentation.   Example:  “So before we get started, can we go around the room so I can get an idea of how many to RtR occurs here – and how your role/how you fit into that event (d/c planner, physician, nurse)?”  F/U with “and how many times does RtR happen at 4:00 on a Friday?” (little humor – but builds some empathy between presenter and audience) – and then proceed with how we’re hoping to help present some advocacy strategies to help our mutual clients?

Ms. Simpson’s First Day of Work June Simpson– Hospital Discharge Planner Mr. Milton – wants to return to his home at Harbor View NH after a one week hospital stay

Mr. Milton’s Story Before Hospital Admission During Hospital Stay Mr. Milton had raised his cane and threatened roommate to a “beat down” History of “behaviors” at Harbor View (HV) including pinching and grabbing staff and residents Physicians made adjustments to medications Treated for bladder infection Mr. Milton is tolerating medication changes and bladder infection resolved He is ready to return to HV

So Ms. Simpson Calls Harbor View… Mr. Milton Ready To Return Home to Harbor View Harbor View’s Social Worker Says “No” - Citing Concerns About Resident and Staff Safety

To Ms. Simpson’s Surprise… ? Social Worker says Harbor View “discharged Mr. Milton to hospital” Harbor View will not be “readmitting” Mr. Milton Social Worker says June is to call other NHs to find alternative placement

What Do You Call This Situation? Involuntary Discharge Ask for audience participation – how does your audience currently describe and understand this scenario? Dumping? Transferred? Refusal to readmit? Then try to encourage your audience to frame this issue as an involuntary discharge

This Is A Serious Problem NH Residents & Families Admitting Hospital Violates residents’ rights Isolates residents and families from their homes and communities Creates resident anxiety due to uncertainty about being able to go home Risk of transfer trauma due to multiple placements Expends hospital time and resources Compels hospital staff to quickly find alternative placement for patients being involuntarily discharged

Today’s Training Objectives Understand Mr. Milton’s rights about involuntary discharge Suggest advocacy strategies for Mr. Milton & his family Identify resources to help Mr. Milton return to HV

So, Ms. Simpson – What’s Next For Mr. Milton?

How Does Ms. Simpson Advocate For Mr. Milton? Ask Mr. Milton if he wants to return to Harbor View?* Yes Inform of right to appeal and Right to return to Harbor View No Help Mr. Milton find another home LTC Ombudsman Office is here to help! *If appropriate, contact Mr. Milton’s surrogate decision-maker

Office of Ombudsman for Long-Term Care Minnesota Board On Aging Empowers consumers to advocate for themselves and their rights Provides advocacy services and education to LTC consumers With consent, works to resolve problems about care and rights Phone: 651-431-2555 Toll-Free: 1-800-657-3591 Fax: 651-431-7452

LTC Ombudsman Viewpoint Regulations require that Mr. Milton be issued a “Bed Hold Notice” HV has a legal obligation to follow federal regulations if it intends to involuntarily discharge Mr. Milton HV should allow Mr. Milton to return to HV once he is ready to discharge from the hospital Absent extraordinary circumstances, residents have a right to return to their nursing homes and the right to due process, even if a notice of discharge has been issued

Types of Transfers & Discharges Voluntary Involuntary When a resident initiates a request for transfer or discharge When a facility initiates the transfer or discharge Regardless of the resident’s choice or preference Even if the resident does not object to it

The “Voluntary Discharge” Dialogue “We can’t meet your husband’s needs.” “You need to find another place.” “This isn’t the best place for your father.” These Situations are NOT Voluntary Discharges Because NH Initiates These Dialogues

Why Not “Voluntary Discharge?” “We can’t meet your husband’s needs.” “You need to find another place.” “This isn’t the best place for your father.” Discuss the implied coercion in these statements. Seek input from audience about what they have been told by facility staff on this issue. Ask for examples of other similar statements. Discuss Each Scenario

Involuntary Discharge Regulations Resident must receive a written involuntary discharge notice Notice must contain specific and detailed legal requirements, including reason for discharge and location of discharge Must provide 30 day* timeframe to exercise right to appeal (see exceptions on slide 19) Right to remain in or return to NH pending appeal to an administrative law judge, absent extraordinary circumstances *The exceptions to the 30 day notice rule are discussed in later slides

Grounds for NH Discharges Common Needs (welfare) cannot be met at NH Safety of individuals in the facility is endangered Health of individuals in the facility is endangered Less Common NH ceases to operate Nonpayment, after appropriate notice Improved health - no longer requires NH level care

*Exceptions To 30 Day Notice Period * Needs cannot be met at NH * No longer requires NH level of care * Health or safety of individuals in the facility is endangered * Has resided in NH for fewer than 30 days

Required Documentation “Can’t Meet Needs” “Danger To Self or Others” Clinical documentation from resident’s physician stating resident’s health care needs cannot be met at NH Clinical documentation from a physician stating health of other individuals at NH is endangered by the resident - and the basis for the endangerment Remind that any basis for discharge must be documented in the residents clinical record Resident has right to review documentation, with rare exceptions

Bed Hold Notice “Bed Hold Notice” defines under what circumstances MA will pay to hold the bed Bed hold notice also contains HV’s bed-hold policies Harbor View must give Mr. Milton option to pay to “hold” his bed regardless of NH current occupancy Must be in writing Should be provided to Mr. Milton and/or his representative before transfer to hospital Obtaining resident signature on the bed hold notice is not required, but best practice If unable to provide bed hold notice at time of transfer to the hospital, bed hold notice should be provided within 24 hours Add Cory’s Technical Note – Cory will supply

Does Mr. Milton Have a Signed BED HOLD? Request to Hold Bed at Harbor View Proceed with discharge planning for return to HV Elected Not to Hold His Bed at Harbor View Discuss with Mr. Milton why he decided not to hold his bed No Bed Hold On File At Hospital Assist Mr. Milton in requesting copy of notice from NH; call LTC Ombudsman immediately if NH refuses to issue one

Bed Hold Notice, continued Medical Assistance (MA) pays to hold bed for 18 days in Minnesota Includes NH’s policy if Mr. Milton’s hospital stay exceeds 18 days If >18 days, Mr. Milton’s right to return to the first available semi-private NH bed as long as he requires skilled nursing care

Why Does a Bed Hold Notice Matter? Explains Mr. Milton’s rights Lack of Bed Hold Notice identifies potential transfer/discharge issues Understanding the policy and regulations prepares you to advocate for Mr. Milton’s rights If the NH refuses to provide a Bed Hold Notice to your patient, consult with LTC Ombudsman office immediately!

Additional Protections as “Prohibited Practice” Under Medical Assistance Rules MN Statute 256B.48 CONDITIONS FOR PARTICIPATION Subdivision 1. Prohibited Practices. “A nursing facility is not eligible to receive medical assistance payments unless it refrains from all of the following: (g) refusing, for more than 24 hours, to accept a resident returning to the same bed or a bed certified for the same level of care, in accordance with a physician’s order authorizing transfer, after receiving inpatient hospital services.”

General Advocacy Strategies On Day of Hospital Admission Confirm resident’s desire to return to facility and facility’s preparation for return before the resident is medically ready for discharge from the hospital Ask resident or surrogate decision - maker if a bed hold notice was received If Yes – get a copy If N0 – assist resident in requesting a copy and discuss resident rights with facility staff General Advocacy Strategies Be Proactive!

BE PRO-ACTIVE Suggested Advocacy Strategies Questions to ask if NH refuses to accept resident back: Ask resident or representative if the facility has issued an Involuntary Discharge Notice If Yes – inform resident of the right to return to the NH during the 30-day notice period* If Yes – inform the resident of the right to appeal the discharge notice; contact the OOLTC If No – advise resident to request a written notice of discharge; contact OOLTC *subject to exceptions stated in slide 19 BE PRO-ACTIVE Suggested Advocacy Strategies

Advocacy Steps for Mr. Milton 1 Ask Mr. Milton if he wants to return to Harbor View NH. 2 Review Bed Hold Notice from Harbor View sent with Mr. Milton to hospital ASAP. Identify any problems now to avoid crisis later. 3 Contact OOLTC, assist Mr. Milton in speaking to the NH Administrator about his desire to return Harbor View.

Suggested Advocacy Steps 4 If Administrator refuses, ask if Mr. Milton has been issued a “Notice of Involuntary Discharge” and the effective date. 5 If No Notice: Refer Mr. Milton to advocacy agencies to begin appeal in absence of proper discharge notice. If Yes: Remind Administrator that HV is still legally responsible for Mr. Milton’s return until discharge date and of Mr. Milton’s right to appeal the involuntary discharge.

Suggested Advocacy Steps MN Department of Health’s Office of Health Facility Complaints (OHFC): 1-800-369-7994 Website: http://www.health.state.mn.us/divs/fpc/ohfcinfo/contohfc.htm OHFC investigates complaints about: quality of care violations of rights for NH residents including refusal to take back residents transferred to hospitals If OHFC substantiates a complaint, it has discretion to issue a deficiency, state licensing orders, and fines. I’ve emailed Pat F. with this language, asking for her feedback about whether or not this is a fair summary of OHFC role in this context

Suggested Advocacy Steps Refer Mr. Milton to the Office Of Ombudsman for Long-Term Care for appeal assistance: 1-800-657-3591 or 651-431-2555

Suggested Advocacy Steps 8 Mr. Milton and/or his family may benefit from legal advice. Some elder law attorneys specialize in nursing home law. To find an attorney, contact the Minnesota State Bar Association Lawyer Referral System at 1-800-292-4152 or visit its website: www. Mnfindalawyer. com. Minnesota Legal Services Coalition may be another resource: 1-651-228-9105.

Suggested Advocacy Strategies Facilitate Mr. Milton’s communication with staff at HV Try to understand Harbor View’s point of view; clarify facility concerns about Mr. Milton’s return Work with HV social worker to provide seamless care coordination in Mr. Milton’s best interest Continue progress achieved at Hospital Develop proper discharge plan Back To Mr. Milton Suggested Advocacy Strategies

Suggested Advocacy Strategies Share possible resources for facility to address resident’s needs: MN/ND Alzheimer’s Association: 1-800-272-3900; www.alz.org National Alliance for Mental Illness (NAMI): 1-651-645-2948; www.namihelps.org Office of Ombudsman for Mental Health and Developmental Disabilities: (651) 757-1800 or 1-800-657-3506; http://mn.gov/omhdd/ if resident has MI diagnosis. Back To Milton Suggested Advocacy Strategies

Goals with Advocacy Strategies Mr. Milton is informed of his right to appeal an an involuntary or discharge. Mr. Milton has the right to return to Harbor View. Mr. Milton - and every resident - has the right to proper notification and due process.

Assisted Living & Housing with Services Not subject to the same laws/rules as NHs In MN, these establishments are subject to: Landlord and Tenant Law - MN Stat. 504B et. Seq. Terms and conditions of the tenant’s lease and service agreement MN Stat. 144D (housing with services) and 144G (assisted living establishments) Fair Housing Act protects consumers from disability-related discrimination Americans with Disabilities Act (ADA)

“Housing With Services” Residential setting (primarily for ages 55 and older) that arranges for health-related services on-site. The housing provider may also be the arranged home care provider/home health care agency license holder Or the housing provider contracts with a licensed home health care agency (HCA) Must register with the Minnesota Department of Health (MDH) MN Statutes 144D apply Eviction Process under Landlord Tenant Laws apply

“Assisted Living” in Plain Language Package of health-related services provided in a housing with services (HWS) setting Must be provided under appropriate licensure and quality of care standards Generally have a Comprehensive Home Care License Licensed by MN Dept. of Health (MDH) MN Statutes 144G apply Service Agreement termination under MDH scope – 30-day notice necessary *Ask About Additional OOLTC Training on Curriculum Available

Understanding AL/HWS Regulations 38 Landlord Home Care Provider Landlord – Tenant Lease Contract Service Agreement Between Provider and Tenant

For HWS/AL: Ask These Questions 39 Confirm provider’s status: comprehensive license and assisted living (AL) provider. Has AL provider appropriately re-assessed resident? Has AL provider given tenant a service agreement termination in writing with at least 30 day notice? Has HWS establishment given an eviction notice/lease termination in writing? Has AL provider reviewed options with tenant for alternate agencies to provide health-related services? Is consumer receiving EW/CADI/CAC/BI waivered services? If so, there may be additional protections to discuss with waiver case manager.

Additional Training Available Let Me Return Home: Assisted Living Edition Eviction and Service Termination in Housing with Services/Assisted Living Establishments Training Objectives: Strategies to resolve/address an Assisted Living provider’s statement that a tenant cannot return to the establishment post-hospitalization Understand consumer rights Understand current laws and regulations regarding HWS/AL settings Additional Training Available

Office of Ombudsman for Long-Term Care Minnesota Board On Aging Phone Intake Line: 1-800-657-3591 or 651-431-2555 Mailing: PO Box 64971, St. Paul, MN, 55164-0971 Site: 540 Cedar St., St. Paul Website: mnaging.org\advocate\ooltc.htm

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