DISCHARGE

FROM  A  NURSING  HOME

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    Regulatory restrictions for Medicare/Medicaid certified facilities clearly define what conditions may lead to discharge.  These regulatory processes assure residents and their families that the nursing home will not arbitrarily discharge anyone.  There must be a substantial reason for discharge which goes through a clearly defined process including the opportunity of a State supervised appeal process. Those provisions significantly restrict the possibility of a resident’s discharge with or without cause.


    The foundation of a discharge plan should be developed for most residents at the time of admission. Some will be admitted for rehabilitation therapies and clearly planning to return home to go back to a full active life. The goal for others will be to improve their condition enough to step down in level of care to an assisted living facility or return home to be under the care of family or a home nursing service.  Those with long term or indefinite health care needs may still meet conditions that can lead to discharge.


  


                                       PAGE CONTENTS

                 Discharge restrictions.

            Notification of discharge.

            Preparation and orientation for discharge.

            Bed-holds.

            ∆  Returning to the facility.

            ∆  Discharge appeal.




  ∆  Discharge restrictions.

    The regulation §418.12 (a), Transfer and Discharge Requirements describes why and how nursing home residents can be discharged.  Discharge is moving a resident outside the certified facility but not movement to a bed within the same certified area of a Medicare/Medicaid facility.  Even when a resident agrees to the facility’s discharge decision, these requirements apply whenever a facility initiates a discharge.


    A resident may not be discharged unless:

   1. The discharge is necessary to meet the resident’s welfare and the resident’s welfare cannot be met in the facility.

   2. The discharge is appropriate because the resident’s health has improved sufficiently and the resident no longer requires the facility’s care.

    3. The safety of individuals in the facility is endangered.

   4. The health of individuals in the facility would be endangered.

    5. The resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility.

    6. The facility ceases to operate.


    The reasons for discharge must be documented in the resident’s clinical record for all items except 6. above.  Documentation by the resident’s physician is necessary to justify a decision to discharge based on 1. and 2. above.  A physician’s documentation is necessary but it can come from any physician in situation 4. above.


    If discharge is due to a significant change in the resident’s condition but not an emergency requiring immediate hospitalization, then prior to any action, the facility must make an appropriate assessment to determine if a new plan of care would allow the facility to meet the resident’s needs.


    Conversion from a higher private rate of payment to payment for services at the lower Medicaid rate does not constitute nonpayment. A resident cannot be transferred for non-payment if he or she has submitted to a third party payor all the paperwork necessary for the bill to be paid.  Nonpayment would occur if a third party payor, including Medicare or Medicaid, denies the claim and the resident refused to pay for his or her stay.


    Exercising the right to refuse treatment would not constitute grounds for transfer, unless the facility is unable to meet the needs of the resident or protect the health and safety of others under the conditions established by that refusal.



   To access the full content and supportive guidelines of regulation §418.12 (a) Transfer and Discharge Requirements, use the following link:

https://www.cms.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf



  Notification of discharge.

    Before a discharge takes place, the
facility must notify the resident, and if known, the family member, legal surrogate, or personal representative of the pending discharge and the reasons for such action.  The notice must include the reason for discharge, the effective date of discharge, the location to which the resident is to be discharged, an explanation of the rights of appeal to the State, and the name, address, and phone number of the State long-term care Ombudsman.  In the case of a developmentally disabled individual, the notice must include the same information for the agency responsible for advocating for the developmentally disabled.  Information on the agency advocating for the mentally ill would be included for the discharge of a mentally ill individual.


    Generally, discharge notices must be initiated at least 30 days prior to discharge but there are exceptions.  Notice must be provided as soon as practical before the discharge in the case of:

    * Endangerment to the health or safety of others in the facility.

    * When a resident’s health has improved enough to allow a more immediate discharge.

    * When a resident’s urgent need for more complex medical care requires immediate discharge

        to another level of care.

    * When a resident has not lived in the facility for 30 days.


  Preparation and orientation for discharge.

    The facility is required to provide sufficient preparation and orientation to residents to ensure safe and orderly discharge from the facility.  Sufficient preparation includes informing the resident where he or she is going and assuring safe transportation.  The resident and their family should be involved in selecting the new residence if possible.


    Orientation could include trial visits to the new location, assuring the resident their valued possessions will not be left behind or lost in the transfer, orienting staff of the receiving facility to the resident’s daily patterns and preferences, organizing staff to handle the discharge and transfer in a manner that minimizes unnecessary and avoidable anxiety or depression, and responding assuringly to known resident reactions to change if they are identified in the resident assessment and care plan.


 


    CMS has a useful publication, Your Discharge Planning Checklist: for patients and caregivers preparing to leave a hospital, nursing home or other care setting.  The checklist can be found at:              http://www.medicare.gov/Pubs/pdf/11376.pdf



  Bed-holds.

    When a resident leaves the facility for circumstances that would allow their return, a process called a bed-hold can or may be put into effect to hold their specific bed open until they return.  Medicaid in some states pays for a number of bed-hold days while in other states the returning Medicaid resident may have their empty bed assigned to another person unless someone pays for a bed-hold.  Even with empty beds available for new residents, a nursing home will ask the resident or their family to pay for a bed-hold not covered by that state’s Medicaid program or when the time away exceeds the state limit.


    However, if such a resident does not elect to pay with his or her own income to hold the bed, readmission rights to the next available bed assure the individual’s return to the facility but not necessarily the same bed.  Private pay residents are expected to cover the cost of any bed-hold out of pocket.  Paying for a bed-hold is a choice and the facility is not obligated to return the resident to the same bed without it.


    Under Medicaid, a participating facility is required to provide notice to its residents of the facilities bed-hold policies and readmission policies before transfer of a resident for hospitalization or therapeutic leave.  The nursing facility’s bed-hold policies apply to all residents. Upon such transfer, the facility must provide written notice to the resident and an immediate family member, surrogate, or personal representative of the length of any bed-hold.  The facility must develop policies that permit residents eligible for Medicaid, who were transferred for hospitalization or therapeutic leave, and whose absence exceeds the bed-hold period as defined in the State plan, to return to the facility in the first available bed.


    The bed-hold notification process requires two notices.  The first should be made well in advance of any transfer and will be done by most facilities at the time of admission and again if the bed-hold policy under the State plan or facility’s policy were to change.  The second notice specifying the duration of the bed-hold, must be issued at the time of discharge.  In a case of emergency transfer, the written notice must be made to the appropriate parties within 24 hours of the discharge.  The requirement is met if the resident’s copy of the notice is sent with other papers accompanying the resident to the hospital.



  More information on state bed hold policies may be found in the web publication Medicaid Bed Hold Policies by State at the following site.

www.ltcombudsman.org/sites/default/files/library/documents/State-BedHold-Chart-May-2011.pdf



  Return to the facility.

    A nursing facility must establish and follow a written policy under which a resident who requires the services provided by the facility and is eligible for Medicaid nursing facility services is readmitted to the facility into the first available bed in a semi-private room when their hospitalization or therapeutic leave exceeds the bed-hold period under the State plan.


   The facility is required to have a transfer agreement with one or more hospitals.  These agreements assure the resident can return to the facility after a hospital stay. No hospital would sign such a contract unless the nursing facility agrees to readmit the patient when discharge from that hospital if nursing home care is still required.


    Even if the resident has outstanding Medicaid balances, they must be readmitted.  Once in the facility, those residents with unpaid balances may be discharged if the facility can demonstrate that non-payment of charges exist and documentation and notice requirements are followed.


  Discharge appeal.

   Discharge from a nursing home for reasons that may seem inappropriate, uncalled for, discriminatory, or a threat to the resident’s well being can be appealed to the State with the best interest of the resident being the dominant consideration in such an appeal.  These regulatory procedures prevent arbitrary discharges assuring the resident cannot be dismissed at the whim of staff.  Under the regulatory process, admission to a nursing home is commitment by the facility to provide for the needs of the new resident.  The right to appeal directs the facility to work to overcome problems that might lead to discharge before such action is taken.



   End Note: The description of discharge rights above were edited from Appendix PP which describes the details and considerations used by a State inspection to conduct an inspection or complaint investigation.  Much of the material is copied from the public domain regulations and edited by rearranging information into a better order, some rewording, and deleting much bureaucratic material.  If you need to review the original document §418.12 (a), Transfer and Discharge Requirements, it can be accessed at the following link:

https://www.cms.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf




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