Without a Home: Transfer and Discharge Dos and Don'ts SLCR Provider Meeting, Fall 2018 Without a Home: Transfer and Discharge Dos and Don'ts Department of Health and Senior Services Section for Long Term Care Regulation Tracy J. Niekamp, Assistant Administrator

Transfer and Discharge Objectives Define transfer and discharge (per CMS’ regulations) Explore the 6 reasons a resident can be transferred or discharged Learn about appeal rights for residents Review discharge planning requirements Discuss requirements for notification to the Long Term Care Ombudsman Program

Transfer and Discharge Transfer and Discharge Includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility. Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected.

Transfer and Discharge Facility-initiated transfer or discharge A transfer or discharge which the resident objects to, did not originate through a resident’s verbal or written request, and/or is not in alignment with the resident’s stated goals for care and preferences.

Transfer and Discharge Federal regulations state: The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless….” This means that once admitted, for most residents (other than short-stay rehabilitation residents) the facility becomes the resident’s home.

Six Reasons a Resident May Be Discharged #1- The discharge or transfer is necessary for the resident’s welfare and the facility cannot meet the resident’s needs. Specialized medical services are required after a significant change in condition Hospitalization for an acute event

Six Reasons a Resident May Be Discharged #2- 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. Resident admitted after a hospital stay, requiring IV antibiotics and short-term monitoring. All goals met and resident no longer needs SNF services.

Six Reasons a Resident May Be Discharged Facility must document the basis for the transfer, including the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). There must be documentation made by the resident’s physician when transfer or discharge is necessary because the home is no longer able to meet the residents needs or if their health has improved to where they no longer need services. What specifically has changed in the residents condition?

Six Reasons a Resident May Be Discharged #3- The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident Worsening of psychiatric condition, requiring resident to be placed into custody or long-term inpatient psychiatric stay

Six Reasons a Resident May Be Discharged #4- The health of individuals in the facility would otherwise be endangered; Resident diagnosed with an illness requiring isolation procedures not available in the LTC facility

Six Reasons a Resident May Be Discharged Facility must document the basis for the transfer or discharge and there must be documentation made by a physician providing evidence of the safety or health of individuals being at risk due to clinical, behavioral, or health conditions.

Six Reasons a Resident May Be Discharged #5- 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. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid;

Six Reasons a Resident May Be Discharged #6- The facility ceases to operate. Medicare/Medicaid certified SNFs are required to provide a 60 day notice.

Appeal Rights Per state and federal regulations, the facility may not transfer or discharge the resident while the appeal is pending, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

Appeal Rights CMS analysis of federal deficiencies indicate that some discharges are driven by payment concerns, such as when Medicare or private pay residents shift to Medicaid as the payment source. Most common reported reason that residents are discharged is due to behavioral, mental, and/or emotional expressions or indications of resident distress. Sometimes facilities discharge residents while the resident is hospitalized for health concerns unrelated to the behaviors that form the alleged basis for the discharge.

Appeal Rights CMS currently reviews deficiencies precipitated by facility-initiated discharges. State survey agencies are required to transfer any case involving facility initiated discharge violations to the CMS RO for review where there is placement in a questionable or unsafe setting, where residents remain hospitalized, where there is a facility pattern, or other circumstances that the RO may identify of cases they would like transferred. Following review, the ROs may take enforcement action (including imposition of fines) if they deem it is proper.

Discharge Planning Requirements F660 Discharge Planning Begins Upon Admission -Involves the Interdisciplinary team -Must focus on discharge goals -Must prepare resident to effectively transition -Must reduce factors that lead to preventable readmissions Individualized discharge plan that addresses -Resident’s goals -Any necessary support (caregiver, referral to local contact agencies, etc.) -Provides education regarding post discharge care

Discharge Planning Requirements F660 SLCR Provider Meeting, Fall 2018 Discharge Planning Requirements F660 Discharge to the Community Discharge planning must identify the destination and ensure it meets the resident’s health and safety needs If a resident wishes to be discharged to a setting that does not appear to meet his/her post-discharge needs, or appears to be unsafe, the facility must treat this situation as similar to refusal of care and must: Discuss with the resident and/or representative and document the risks and implications Document that other more suitable location options equipped to meet the resident’s needs were discussed Document the resident’s refusal Determine if a referral to Adult Protective Services is necessary The referral should be made at the time of discharge if the facility is aware of the unsafe discharge. Facilities should follow their policies for AMA

Discharge Planning Requirements - F660 SLCR Provider Meeting, Fall 2018 Discharge Planning Requirements - F660 Discharge to another SNF, HHA, or LTCH The facility must assist the resident in choosing an appropriate post- acute care provider that will meet the resident’s needs The facility must assist by presenting information about the potential receiving provider and must include: Publicly available standardized quality information such as Nursing Home Compare, Home Health Compare, Inpatient Rehabilitation Compare and Long-Term Hospital Compare websites Resource information on the number of residents discharged to the community and rates of potentially preventable hospital readmissions The facility mush also provide evidence this information was provided. Facilities must assist the resident or rep. in understanding the data presented.

Discharge Notice Requirements F623- Notice Before Transfer Before a facility transfers or discharges a resident, the facility must— Notify the resident and the resident’s representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.

Notice to Ombudsman Program Intent to provide added protection to residents from being inappropriately discharged, provide residents with access to an advocate who can inform them of their options and rights, and to ensure that the Office of the State LTC Ombudsman is aware of facility practices and activities related to transfers and discharges.

Notice to Ombudsman Program Timing Notice to the Office of the State LTC Ombudsman must occur before or as close as possible to the actual time of a facility- initiated transfer or discharge. Documentation The medical record must contain evidence that the notice was sent to the Ombudsman.

Discharge Notice Requirements F623- Contents of the notice. The written notice must include the following: The reason for transfer or discharge; The effective date of transfer or discharge; The location to which the resident is transferred or discharged; A statement of the resident’s appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;

Discharge Notice Requirements F623- Contents of the notice, continued The written notice must include the following: The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; For nursing facility residents with intellectual and developmental disabilities, mental disorders, or related disabilities, the mailing and email address and telephone number of the agency responsible for Missouri Protection and Advocacy.

Notification to Ombudsman Program Emergency Transfers--When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer and a notice of transfer must be provided to the resident and resident representative as soon as practicable. Copies of notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis.

Notification to Ombudsman Program Facility-Initiated Transfers and Discharges If the facility decides to discharge the resident while the resident is still hospitalized, the facility must send a notice of discharge to the resident and resident representative, and a copy of the discharge notice to the Office of the State LTC Ombudsman. Notice to the LTC Ombudsman must occur at the same time the notice of discharge is provided to the resident/representative. For any other types of facility-initiated discharges, the facility must provide notice of discharge to the resident and resident representative along with a copy of the notice to the LTC Ombudsman at least 30 days prior to the discharge or as soon as possible. The copy of the notice to the ombudsman must be sent at the same time notice is provided to the resident and resident representative.

Notification to Ombudsman Program Resident-initiated transfers or discharge information is not required to be reported since the notice requirement does not apply to resident-initiated transfers or discharges.

Notice in Advance of Facility Closure Administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents. Must provide 60 days advance notice when related to facility closure.

Tracy Niekamp tracy.niekamp@health.mo.gov 573-526-0706