Nursing Home Discharges Lisa Thomas RN-BC Office of Long Term Care

Objectives Review the federal regulations as pertains to discharges from the nursing home Briefly discuss the responsibility of the home and discharges Discuss the role of the family/responsible party in discharges

§483.12 (a)(2) F201 Transfer and Discharge Requirements The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless- (i) The transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility Lets talk about this one for a minute Most nursing homes use “cannot meet the residents needs” as a discharge reason However, the nursing home is responsible for the safety and welfare of ALL residents in the home Some examples of safety and welfare would be: for an individual resident, refusal to eat or drink for a period of time (lack of water can lead to death) refusal of needed medications for a period of time (serious medications such as insulin, blood thinners that could lead to death) refusal of treatments (infected wound or p.u.) I would ask the home what they have done to determine the reason for the behavior

§483.12 (a)(2) F201 Transfer and Discharge Requirements (ii) The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility; (iii) The safety of individuals in the facility is endangered (iv) The health of individuals in the facility would otherwise be endangered; The first area is not a bad thing to be discharged for. This means the resident needs a less skilled area of care such as an Assisted Living Facility, Independent Living etc. All residents in a home must need skilled care, we surveyors investigate whether each resident meets the criteria The medical needs determination unit reviews each applicant to determine if the person meets skilled criteria The home is responsible not only for the residents but also the staff. If a resident had an altercation with a resident or a staff member The home must attempt to prevent a reoccurrence of this behavior and most homes will err on the side of caution to prevent injury to all (iv) This could be from the residents failure to comply with isolation precautions such as an airborne illness or a highly contagious disease process where others could be infected easily

§483.12 (a)(2) F201 Transfer and Discharge Requirements (v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to the nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid: (vi) The facility cease to operate. Share examples of family failure to pay, this usually requires a significant amount of work on the homes part. Never done lightly, the resident has the right to an appeals process. Conversion from a private pay rate to payment at the Medicaid rate does not constitute non-payment Nursing homes are entitled to a payor source, nursing home care is expensive As a surveyor, when I have investigated complaints, the home has sometimes not received payment for several months to a year..

§483.12 (a)(3) F202 Documentation When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (a)(2)(i) through (v) of this section, the resident’s clinical record must be documented. The documentation must be made by- (i) The resident’s physician when transfer or discharge is necessary under paragraph (a)(2)(i) through (v) of this section So if the resident is transferred or discharged under any of the previously discussed reasons, then the chart must reflect said transfer or discharge If the transfer is due to a significant change in the resident’s condition, but not an emergency requiring an immediate transfer, then prior to any action, the facility must conduct the appropriate assessment to determine if a new care plan would allow the facility to meet the resident’s needs.

§483.12(a)(5) F203 Timing of the notice (i) Except as specified in paragraph (a)(5)(ii) and (a)(8) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. Homes usually send certified letters to the resident and/or the responsible as evidence they met the 30 day requirement

§483.12(a)(7) F204 Orientation for Transfer or Discharge A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility Exceptions to this regulation would be in the event of a local, regional, state, or national emergency situation such as fire, tornado, hurricane etc. The facility administrator must provide written notice in advance of the facility closure In addition to written notification, facility staff should discuss (orally) this information with residents, their families and/or legal representatives in order to provide a better understanding of the situation and their rights Information must be provided in a language they understand the notice must include: the name, address and telephone number of the State LTC ombudsman, for residents with developmental disabilities, the mailing address and telephone of then agency responsible for the protection and advocacy of DD individuals, same as for the mentally ill residents

§483.12(b) F205 Notice of Bed – Hold Policy and Readmission Notice before transfer. Before a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies- If the home has no problem with availability of beds, then they may just state return is not a problem Sometimes though the condition of the resident changes so much the home cannot safely provide the care the resident needs or if specialized care such as a trach, may not have trained staff

§483.12(b) F205 Notice of Bed – Hold Policy and Readmission The duration of the bed hold policy under the state plan, if any, during which the resident is permitted to return and resume residence in the nursing facility; and The nursing facilities policies regarding bed-hold periods, which must be consistent with paragraph (b)(3) of this section, permitting a resident to return. Arkansas state plan states Medicaid will pay for up to 5 days.  AFTER the 5th day, there is no "bed hold policy".  It's all the agreement between the facility and the resident/family. 

§483.12(b) (2) F205 Bed – Hold Notice Upon Transfer At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specifies the duration of the bed hold policy described in paragraph (b)(1) of this section. The nursing homes policy apply to all residents. In cases of emergency transfer, notice “at the time of transfer” means that the family, surrogate, or representative are provided with written notification within 24 hours of transfer The regulation is met if the residents copy of the notice is sent with other papers accompanying the resident to the hospital. Bed-hold for days of absence in excess of the state’s bed-hold limit are considered non-covered services which means the resident could use his/her own income to pay for the bed-hold. Non-Medicaid residents may be requested to pay for all days of bed – hold.

§483.12(b) (3) F206 Permitting Resident Return to Facility A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the state plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident- If concern is regarding transfer/discharge, the surveyor will first review the facility’s policy regarding bed-hold and readmission to the facility

§483.12(b) (3) F206 Permitting Resident to Return to Facility Requires the services provided by the facility; and Is eligible for Medicaid nursing facility services “First available bed in a semi-private room” means a bed in a room shared with another resident of the same sex. Medicaid-eligible residents who are on therapeutic leave or are hospitalized beyond the State’s bed-hold policy must be readmitted to the first available bed even if the residents have outstanding Medicaid balances. Once readmitted, however, these residents may be transferred if the facility can demonstrate that non-payment of charges exist and documentation and notice requirements are followed. In other words, all parts of the regulation(s) must be met.

§483.12(c) (3) F207 Equal Access to Quality Care §483.12(c)(1) A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State Plan for all individuals regardless of source of payment;

§483.12(c) (3) F207 Equal Access to Quality Care §483.12(c)(2) The facility may charge any amount for services furnished to non-Medicaid residents consistent with the notice requirement in §483.12(c)(3) The State is not required to offer additional services on behalf of a resident other than the services provided in the State plan. Facilities must treat all residents alike when making transfer and discharge decisions. “Identical policies and practices” concerning services means that facilities must not distinguish between residents based on their source of payment when providing services that are required to be provided by law. All nursing services, specialized rehabilitative services, social services, dietary services, pharmaceutical services, or activities that are mandated by the law must be provided to residents according to residents’ individual needs, as determined by assessments and care plans.

Family/Responsible Party Role Be informed Know your rights and those of the resident Ask questions! If you have a complaint regarding transfer/discharge: call the OLTC at 1.800.582.4887 If you are the one admitting the resident to the facility, read or obtain a copy of the admission agreement, transfer/discharge and readmission should be included in the agreement We talked about the notice of transfer or discharge and evidence it was done, you can ensure you receive all notices from the facility by keeping your contact information up to date, name of notifying person, landline and/or cell phone, hospital preference etc. NOTE: EMS services will take the resident to the closest hospital in order to stabilize the resident before proceeding on to the preferred hospital Talk to the social services director concerning any questions about transfer/discharge before the event occurs! When the event is occurring, emotions get in the way of remembering details.