1. When nursing homes close: Learn the federal rules
Part 2
December 12, 2017
Dr. Cynthia Rudder, Founder and Former Executive Director, Long Term Care Community Coalition
Lori Smetanka, Consumer Voice
Alisha Lineswala, Consumer Voice
This project is funded by the Retirement Research Foundation.

2. Agenda
Introduction Alisha Lineswala, Public Policy & Program Specialist, Consumer Voice
Project Overview & Closure Recommendations Dr. Cynthia Rudder, Project Researcher and Trainer
Documentation, Notice, Orientation, and Administrator Duties
Alisha Lineswala, Public Policy & Program Specialist, Consumer Voice
Closure Plans, Policies and Procedures
Lori Smetanka, Executive Director, Consumer Voice
Q & A
Closing

3. NURSING HOME CLOSURES ARE BECOMING MORE FREQUENT
Both consumer preference for care in a community setting and state and federal government policy have driven these closings.
Why did we do this?

4. OVERVIEW
Resident stress of moving is occurring nationwide, and may be due to the fact that the closure of nursing homes seems to be inadequately addressed in state and federal laws and regulations and/or poor oversight and monitoring by states and the federal government.
When closures are inevitable, better policies and practices can be implemented to minimize the negative impact, including transfer trauma, on residents.

5. NEGATIVE IMPACTS OF NURSING HOME CLOSURE
Transfer trauma (also referred to as "relocation stress syndrome")
Self-care deficits - Impaired ability to perform or complete activities of daily living for oneself, such as feeding, dressing, bathing, toileting.

6. Increase in withdrawn behavior
Depression, sometimes manifesting as agitation
Increase in withdrawn behavior

7. Falls
Weight loss

8. WHAT ARE THE EXPERIENCES OF NURSING HOME CLOSURES NATIONWIDE?

9. WE DECIDED TO CONDUCT A NATIONAL STUDY TO FIND OUT.

10. NATIONAL STUDY FUNDED BY THE RETIREMENT RESEARCH FOUNDATION
Using online surveys and one-on-one interviews:
OBJECTIVES:
Identify obstacles
Identify policies and procedures for overcoming the obstacles
Identify best practices
Make recommendations
Click here to view the full report.

11. RESULTS: OBSTACLES TO A SUCCESSFUL CLOSING
Lack Of Appropriate And Nearby Placements
Poor Discharge Planning
Lack Of Communication
Poor Notice/Not Enough Time
Staffing Issues
Transfer Trauma
Do These Seem Like The Obstacles In Your State?
Are There Any Other Obstacles You Have Seen?

12. STUDY RECOMMENDATIONS
Click here for the full report:

13. MAJOR FINDING: Many local and some state ombudsmen did not know the federal or their state nursing home closure rules. MAJOR RECOMMENDATION: Educate all ombudsmen.

14. DOCUMENTATION
483.15(c)(2)
Facility must ensure that the transfer or discharge is documented in the resident’s medical record and appropriate information is communicated to the receiving health care institution or provider.
Documentation Requirements:
Must include reason for the transfer
Must be made by the resident’s physician

15. DOCUMENTATION
Information provided to the receiving facility must include at a minimum:
Contact information of practitioner responsible for the resident
Resident representative information, including contact information
Advanced Directive information
Special instructions for ongoing care
Comprehensive care plan goals
All other necessary information, including a copy of the resident’s discharge summary and any other documentation to ensure a safe and effective transition of care

16. NOTICE
483.15(c)(3)
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.
Facility must also send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
Contents of the Notice Must Include:
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 ), 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.

17. ORIENTATION
483.15(c)(7)
A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand.

18. ADMINISTRATOR DUTIES 483.70(l)(1)-(2)
Administrator of the facility must submit to the State Survey Agency, the State LTC ombudsman, residents of the facility, and the legal representatives of such residents or other responsible parties, written notification of an impending facility closure.
The administrator must also ensure that the facility does not admit any new residents on or after the date on which such written notification is submitted.

19. ADMINISTRATOR NOTICE Interpretive Guidance: 483.70(l)
The facility’s notifications should be developed with input from the facility’s Medical Director and other management staff
It must include a summary of key details from the closure plan for the safe and orderly transfer, discharge and adequate relocation of all residents

20. TIMING OF NOTICE 483.70(l)(1)(i)-(ii)
For voluntary or State-mandated closures, the required written notification must not be later than 60 days prior to the date of such closure.
If the Secretary terminates the facility’s participation under this title (involuntary), notification must be provided no later than the date that the Secretary determines appropriate.

21. CONTENTS OF THE NOTICE 483.15(c)(5) 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 number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act
for residents with mental illness, the mailing address and telephone number of the agency responsible for the protection and advocacy of individuals with mental illness established under the Protection and Advocacy for Mentally Ill Individuals Act
Interpretive Guidance for (l): contact information for the primary facility contact(s) responsible for the daily operation and management of the facility during the facility’s closure process

22. ORAL NOTICE Interpretive Guidance: 483.70(l)
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. Notice of facility closure to residents and their legal or other responsible parties must be provided in a language and manner they understand.

23. FACILITY WILL NOT CLOSE & INFORMATION PROVIDED TO RECEIVING FACIILTY
Interpretive Guidance: (m)
The facility will not close until all residents are transferred in a safe and orderly manner to the most appropriate setting in terms of quality, services, and location, as available and determined appropriate by the resident’s interdisciplinary team after taking into consideration the resident’s individual needs, choices, and interests.
Each resident’s complete medical record information including archived files, Minimum Data Set (MDS) discharge assessment, and all orders, recommendations or guidelines from the resident’s attending physician must be provided to the receiving facility or other provider at the time of the resident’s discharge or relocation.

24. CLOSURE PLANS
LTC facilities must include in their closure notices a plan, approved by the State, for the transfer and adequate relocation of residents of the facility by a specified date prior to closure.
The notices must include assurances that the residents will be transferred to the most appropriate facility or other setting in terms of quality, services, and location, taking into consideration the needs, choice, and best interests of each resident.
483.70(l)(3)
The closure plan must contain information necessary to identify the steps for a safe and orderly facility closure.
Our study showed that many closures are chaotic, that necessary information is not shared in a timely way, and the process of moving residents to new care settings occurs without all of their belongings, medications, care plans, etc.
Also, oftentimes, residents are not included in the decision-making process around where they will go next – or even what type of care setting might be available, or most appropriate, for them.
Most appropriate facility or other setting in terms of quality, services, and location, taking into consideration the needs, choice, and best interests of each resident.
Focus on person-centered, individualized care – even in the transfer process when a facility is closing
It should not be appropriate for the closing facility to make the determination as to where a resident will go without including them in the decision-making process
Residents and their families should be told what options are available, and if possible, give them an opportunity to visit the other care settings so that they can make an informed decision
It’s not unusual for a corporation, or owner of multiple facilities to seek to send residents from the closing facility to sister facilities owned by the same company or individual –often with no input from the resident or family

25. CLOSURE PLANS - Steps
CMS expects that the closure plan would include sufficient detail to clearly identify the steps the facility would take, and the individual responsible for ensuring the steps are successfully carried out, such as:
Assurance that no new residents will be admitted to the facility on or after the date that the written notice of impending closure was provided to the State Survey Agency.
There is an expectation that the facility will develop a detailed plan that will identify the steps it will take, as well as who is responsible for each step. Things such as:
1. Assurances that no new residents are admitted on or after the date the written notice of impending closure is provided to the State Survey Agency

26. CLOSURE PLANS - Steps
The process and procedures for providing timely written notification of the facility’s impending closure, including its closure plan to the State Survey Agency, the State’s LTC ombudsman, residents, their legal representatives or other responsible parties - CMS Regional Office, State Medicaid Agency, staff, and the residents’ primary physicians.
Also notification to employees, vendors, contractors, hospitals, union representatives, community partners, etc.

27. CLOSURE PLANS - Steps
A process that provides for how the closing facility will identify available facilities or other settings in terms of quality, services, and location, taking into consideration the needs, choices, and best interests of each resident.

28. POLICIES To ensure resident safety, the plans should address:
The Administrator’s duties and responsibilities around notifications and assurances
The primary contact(s) responsible for the daily operation and management of the facility during the facility’s closure process.
The roles and responsibilities of the facility’s owners, administrator, or their replacement(s) or temporary managers/monitors during the closure process.
Also to be included in the plan is identification of those that will be primarily responsible for
Daily operation and management of the facility during the closure process
Oversight of those managing the facility operations during the closure process, and
The roles and responsibilities of the facility’s owners, administrator, or those serving in that capacity during the closure process
CMS recognized that others may be brought in as administrators or temporary managers to oversee the closure of the facility
New administrators or managers brought in are not relieved of the responsibility of implementing or developing the plans, procedures, and providing notifications as required

29. POLICIES
The provisions for ongoing operations and management of the facility and it’s residents and staff during the closure process that include:
payment of salaries and expenses to staff, vendors, contractors, etc.,
continuation of appropriate staffing to meet the needs of all residents,
continuation of resources to meet the needs of each resident including the provision of medications, services, supplies and treatments as ordered by the resident’s physician/practitioner.

30. POLICIES
ongoing accounting, maintenance and reporting of resident personal funds
the provision of appropriate resident care information to the receiving facility to ensure continuity of care
the labeling, safekeeping and appropriate transfer of residents’ personal belongings, such as clothing, medications, furnishings, etc. at the time of transfer or relocation including contact information for missing items after the facility has closed

31. Preparing Residents for Safe and Orderly Transfer
Provisions for sufficient preparation and orientation to residents to ensure a safe and orderly move from the facility might include:
interviewing residents and their legal or other responsible parties, where applicable, to determine each resident’s goals, preferences, and needs in planning for the services, location, and setting to which they will be moved
As part of the notification and orientation process for residents and families, CMS

32. Preparing Residents for Safe and Orderly Transfer
offering each resident the opportunity to obtain information regarding their community options, including setting and location; providing residents with information or access to information pertaining to the quality of the providers and/or services they are considering; psychological preparation or counseling of each resident as necessary
making every reasonable effort to accommodate each resident’s goals, preferences and needs regarding receipt of services, location and setting

33. CMS Guidance
Facility staff should make every possible effort to lessen transfer trauma for residents, which may include:
Reviewing the resident’s care routines, needs, and preferences with staff at the receiving facility who will be caring for the resident, and
Assisting residents and or their representatives with obtaining information required to make an informed decision about facility relocation

34. FEDERAL RULES: ADMINISTRATOR SANCTIONS
A civil monetary penalty of up to $100,000.
A minimum of $500 for the first offense.
A minimum of $1,500 for the second offense
A minimum of $3,000 for the third and subsequent offenses.
An administrator could be subject to higher amounts of CMPs (not to exceed $100,000)
May be subject to exclusion from participation in any Federal health care program.
Shall be subject to any other penalties that may be prescribed by law.
Any sanctions that have been levied against an administrator would also be reviewed by the State’s licensing agency for possible disciplinary action including suspension and termination of the administrator’s license.
Where notice requirements were not met by the previous or current administrator, the State Survey Agency and the CMS RO may take action against that person

35. FEDERAL RULES: PAYMENTS
When a notification is made the Secretary will continue to make payments to the SNF or, for a NF, to the State, as the Secretary considers appropriate, during the period beginning at the time the notification is submitted and until the resident is successfully relocated.
(c)(2)

36. Question and Answer

37. Contact Information
Cynthia Rudder
Lori Smetanka
Alisha Lineswala