1. 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?

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

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

10. 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

11. 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:
Toll-Free:
Fax:

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. *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

19. 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

20. 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

21. 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

22. 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

23. 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!

24. 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.”

25. 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!

26. 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

27. Advocacy Steps for Mr. Milton1
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.

28. Suggested Advocacy Steps4
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.

29. Suggested Advocacy Steps
MN Department of Health’s Office of Health Facility Complaints (OHFC):
Website:
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 ed Pat F. with this language, asking for her feedback about whether or not this is a fair summary of OHFC role in this context

30. Suggested Advocacy Steps
Refer Mr. Milton to the Office Of Ombudsman for Long-Term Care for appeal assistance: or

31. Suggested Advocacy Steps8
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 or visit its website: www. Mnfindalawyer. com.
Minnesota Legal Services Coalition may be another resource:

32. 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

33. Suggested Advocacy Strategies
Share possible resources for facility to address resident’s needs:
MN/ND Alzheimer’s Association: ;
National Alliance for Mental Illness (NAMI): ;
Office of Ombudsman for Mental Health and Developmental Disabilities: (651) or ; if resident has MI diagnosis.
Back To Milton
Suggested Advocacy Strategies

34. 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.

35. 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)

36. “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

37. “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

38. Understanding AL/HWS Regulations38
Landlord
Home Care Provider
Landlord – Tenant Lease Contract
Service Agreement Between Provider and Tenant

39. For HWS/AL: Ask These Questions39
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.

40. 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

41. Office of Ombudsman for Long-Term Care Minnesota Board On Aging
Phone Intake Line: or
Mailing: PO Box 64971, St. Paul, MN, Site: 540 Cedar St., St. Paul
Website: mnaging.org\advocate\ooltc.htm

42. Thank you for your time and attention!
QUESTIONS?
Thank you for your time and attention!
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