1. Involuntary Discharge Procedures and FAQ’s
Lauren Meeker
State Long Term Care Ombudsman

2. 42 C.F.R. §
Admission, transfer, and discharge rights.
Tenn. Comp. R. & Regs
Special Federal Requirements Pertaining to Nursing Facilities
Applicable Rules

3. Transfer and Discharge
Grounds For Involuntary Transfer or Discharge:
Necessary for resident’s welfare and resident’s needs cannot be met in the facility;
Resident’s health has improved;
Safety of individuals in facility is endangered due to clinical or behavioral status of the resident;
Health of individuals in the facility would otherwise be endangered;
Resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility; or
Facility ceases to operate.
42 C.F.R (c); Tenn. Comp. R. &
Regs (2)(d)(1)(i)
Transfer and Discharge

4. The nursing home carries the burden of proving by a preponderance of evidence that it has a legal basis for involuntary transfer or discharge of a resident.
Tenn. Comp. R. & Regs (7)
Burden of Proof

5. Documentation Requirement
Look to documentation requirements of
Tenn. Comp. Rules & Regs (2)(d)(1)(ii)
“The basis for the transfer or discharge must be documented in the resident’s clinical record. In the cases described in items (I) [welfare/needs] and (II) [health improved] above, the documentation must be made by the resident’s physician, and in the case described in item (IV) [safety issue to others] above, the documentation must be made by a physician.”
Documentation Requirement

6. The Resident’s Health has Improved
This can come in the form of:
No longer meets the Nursing Home Level of Care on PAE
No longer meets the Nursing Home Level of Care on PASRR
Medical Director or Physician states resident has gotten better.
When any of these reasons occur please make sure that this is documented in the residents clinical record and is accompanied with the supporting documents.
Tip: When sending the Notice of 30 day Involuntary Discharge attach the supporting document.
The Resident’s Health has Improved

7. The Facility Ceases to Operate
When this is the case please notify the District and State Long Term Care Ombudsman and the Regional Supervisor at the Department of Health before you give the notices to the residents.
The Facility Ceases to Operate

8. Resident’s Needs Cannot be Met in the Facility
When using this reason for discharge you must have the following documented in the residents clinical record, and be able to provide it to all of the agencies notified:
Why the residents needs cannot be met in your facility.
Supporting documents such as doctors orders and nurses notes.
Where the resident is being transferred to and what that facility can do to meet their needs that you facility cannot.
Resident’s Needs Cannot be Met in the Facility

9. Why the residents needs cannot be met in your facility.
When using this reason for discharge you must have the following documented in the residents clinical record, and be able to provide it to all of the agencies notified:
Why the residents needs cannot be met in your facility.
Supporting documents such as doctors orders and nurses notes.
Show what steps the facility has taken to reduce/eliminate the dangerous behavior.
Change of Status PASRR
Where the resident is being transferred to and what that facility can do to meet their needs that your facility cannot.
Safety of Individuals in Facility is Endangered due to Clinical or Behavioral Status

10. Health of Individuals in the Facility Would Otherwise be Endangered
When using this reason for discharge you must have the following documented in the residents clinical record, and be able to provide it to all of the agencies notified:
Why the residents needs cannot be met in your facility.
Supporting documents such as doctors orders and nurses notes.
Where the resident is being transferred to and what that facility can do to meet their needs that your facility cannot.
Health of Individuals in the Facility Would Otherwise be Endangered

11. Failure to Pay Failure to pay basis:
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. Non-payment 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.
Failure to Pay

12. Q: What should we do when the family refuses to give documents to assist with the Medicaid application?
A: Contact your District LTC Ombudsman
Undue Hardship Waiver
Safety Letter
Q: What should we do when the failure to pay is a result of the family (POA) misusing the residents funds to pay for things other than the residents care?
A: You may send a letter or request a meeting with the family. If that does not resolve the issue, contact your District LTC Ombudsman.
Letter
Care Plan
Assistance with Legal resources for the resident
Failure to Pay FAQ’s

13. Financial Exploitation
APS Referral
Call
Complete the form online at
Investigation
APS, Ombudsman, and/or Law Enforcement will investigate the case.
Prosecution
If financial exploitation is determined the DA will prosecute.

14. Financial Exploitation Keep an eye on the TCAD website
A resource page that you can give to families who are allegedly misappropriating funds.
When to pursue Involuntary Discharge.

15. 30 Day Notice Before Transfer
Nursing home is required to provide a resident and the resident’s representative with notice of the reason for discharge, effective date, location of transfer, appeal rights, contact information for State Long-Term Care Ombudsman and Advocacy Protection Groups.
42 C.F.R (3) and (5); Tenn. Comp. R. &
Regs (2)(d)(4).
A copy must be sent to the State Long-Term care Ombudsman, District Ombudsman, HCFA Commissioners Designee and the Department of Health Regional Supervisor.
Excluding exceptions, the Notice must be made at least 30 days before transfer.
42 C.F.R (4).
30 Day Notice Before Transfer

16. Discharge Notice: Page 1 Available on the TCAD website https://www. tn
All highlighted sections are required to be filled out.
Please also add a contact .
This form may also be used for 5 (business) day emergency discharges-please be aware that this section must be filled out correctly.
Where the resident is going must be filled in and this must be a safe and appropriate location.
Please note the 4 reasons that require a doctors signature.

17. Discharge Notice: Page 2 Available on the TCAD website https://www. tn
All highlighted sections are required to be filled out.
It is required that this section be filled out. For most reasons, it would be best to also state that your supporting documents (PAE/PASRR/Doctors Order) are attached.
Please make sure that this section is signed-especially if your reason requires a doctors signature.

18. Discharge Notice: Page 3 Available on the TCAD website https://www. tn
If the resident refuses to sign or is incompetent-Please note this here and have a witness sign off.
Additionally, make sure that it is noted that the Representative was given the notice.
All highlighted sections are required to be filled out.
The State Long Term Care Ombudsman must receive the notice on the same day as the resident. Please it, so that it will arrive the same day.
Do NOT fax the notice.

19. Contact Sheet for Involuntary Discharges
Please send the notice to all required parties for your area.
State LTC Ombudsman
Lauren Meeker
*Must receive at the same time as the resident.
District LTC Ombudsman
See next slide for all contact info.
HCFA’s Commissioner’s Designee
Administrative Law Judge
(Appeal Officer)
Audrey Seamon
Department of Health
Regional Supervisors
EAST
Tamra Tuberville
MIDDLE
Donna Smith
WEST
Paula Tipton

20. Tennessee Long Term Care Ombudsman Contact Sheet
District 1-First Tennessee
Debby Morrell
Counties Served: Carter, Greene, Hancock, Hawkins, Johnson, Sullivan, Unicoi & Washington
District 2-East Tennessee Thomas Kahler x4223
Counties Served: Anderson, Blount, Campbell, Claiborne, Cocke, Grainger, Hamblen, Jefferson, Knox, Loudon, Monroe, Morgan, Roane, Scott, Sevier & Union
District 3-Southeast Tennessee
Kaitlyn Goffin
Counties Served: Bledsoe, Bradley, Grundy, Hamilton, McMinn, Marion, Meigs, Polk, Rhea & Sequatchie
District 4-Upper Cumberland
Kim Fowler
Counties Served: Cannon, Clay, Cumberland, DeKalb, Fentress, Jackson, Macon, Overton, Pickett, Putnam, Smith, Van Buren, Warren & White
District 5-Greater Nashville
Richard Robinson, Melinda Lunday and Marchell Gardner
Richard Robinson
Counties Served: Rutherford & Williamson
Melinda Lunday
Counties Served: Davidson, Sumner, Trousdale, & Wilson
Marchell Gardner
Counties Served: Cheatham, Davidson, Dickson, Houston, Humphreys, Montgomery, Robertson & Stewart
District 6-South Central
 Andrea Morrow
Counties served: Bedford, Coffee, Franklin, Giles, Hickman, Lawrence, Lewis, Lincoln, Marshall, Maury, Moore, Perry & Wayne
District 7-Northwest Tennessee
 Kim Boyd
Counties Served: Benton, Carroll, Crockett, Dyer, Gibson, Henry, Lake, Obion & Weakley   
District 8-Southwest Tennessee
Norma Bell
Counties Served: Chester, Decatur, Hardeman, Hardin, Haywood, Henderson, McNairy & Madison
District 9-Memphis-Delta
 Zev Samuels & Carlos Royston
Counties Served: Fayette, Lauderdale, Shelby & Tipton
Zev Samuels
Carlos Royston

21. How to Appeal an Involuntary Discharge
An IVD can be appealed by any of the following methods:
Mail: TennCare’s Commissioner’s Designee Unit, ATTN: Involuntary NF Discharge Appeals, 310 Great Circle Road- 3W, Nashville, TN 37243
Fax:
Phone:
Required information:
Nursing Facility Name
Resident Contact Information (and Representative)
Indication of intent to appeal
How to Appeal an Involuntary Discharge

22. Discharge During an Appeal
Nursing homes may not transfer or discharge the resident while the appeal is pending, unless the failure to discharge or transfer would endanger the health and safety of the resident or other individuals in the facility.
42 C.F.R (c)(1)(ii); Tenn. Comp. R. &
Regs (2)(d)(2)(iv) and (2)(d)(3)(i).
Further, the nursing home must document the danger that failure to transfer would pose.
42 C.F.R (c)(1)(ii).
Discharge During an Appeal

23. Pre-Transfer Nursing Homes Must Consider
Traumatic effect on the resident.
Proximity of the proposed location to the present nursing home and to family and friends of resident.
Availability of necessary medical and social services at the proposed nursing home.
Compliance by the proposed nursing home with all applicable federal and state regulations.
Tenn. Comp. R. & Regs (2)(d)(1)(v)
Pre-Transfer Nursing Homes Must Consider

24. RETURNING FROM HOSPITALIZATION AND THERAPEUTIC LEAVE
42 C.F.R. § (e)(1)(ii)
Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave.
The policy must provide for the following:
(1) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident
(a) Requires the services provided by the facility; and
(b) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services.
(2) If the facility that determines that a resident who was transferred with an expectation of returning to the facility cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges.
RETURNING FROM HOSPITALIZATION AND THERAPEUTIC LEAVE

25. 42 C.F.R. § (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.
ORIENTATION

26. Review of TCAD Website

27. State Long Term Care Ombudsman
Lauren Meeker
State Long Term Care Ombudsman