Per Part 1 of our review of F622, there is a heavy emphasis on documentation throughout the regulatory requirements. A facility must be able to demonstrate that one of the situations discussed in the previous post is applicable for it to initiate a transfer or discharge, including having the required physician documentation in place. As a reminder, the resident’s physician must document the basis for the resident’s transfer or discharge. In emergent circumstances, a physician who is not necessarily the attending physician may provide this documentation.
In addition to all the information that should be included in the resident record, there are also specific requirements for the information that must be conveyed to the receiving provider, whether it is a hospital or a different level of care. We discussed this information in general in our recent Ftag of the Week post for F843 Transfer Agreement, but let’s take a more in-depth look at what is required.
What Needs to be Provided to the Receiving Provider
The information that needs to be provided when a resident is being transferred and expected to return to the facility or is being discharged from the facility, where he/she would not be expected to return, would differ, but there is a long list of information that needs to be provided when a resident is being transferred. This includes:
- Contact information for the resident’s attending physician while at the facility.
- Contact and other information for the resident representative
- Advance Directives
- Comprehensive care plan goals
- Any special instructions and/or precautions in place, including, but not limited to:
- Treatments
- Devices
- Precautions
- Risk for issues such as falls, pressure injury, aspiration precautions, bleeding and/or elopement.
- All other information that could be needed to meet the resident’s needs, including:
- Resident’s baseline status
- Resident’s current mental, behavioral and functional status
- Diagnoses
- Allergies, if any
- Medication list, including time of last administration.
- Most recent, relevant labs/ testing/ immunizations
- Recent vital signs
- Reason for transfer
- Any additional information that has been defined in the transfer agreement with the receiving acute care provider.
If a resident is being discharged, the facility is responsible for providing all of the above-mentioned information as well as all of the information that is required as part of the resident’s discharge summary (F661). Providers can provide this information in whatever format they choose so long as all of the necessary information is included. Don’t forget that the IG states that this information should be provided as close as possible to the time of transfer or discharge. Facilities are frequently cited for not providing this important information in a timely manner to the receiving setting. Don’t forget – it is also the responsibility of the facility to provide orientation to the resident for transfer and discharge, per the requirements for F624.
Emergency Transfers to Acute Care
If a resident is sent to the hospital for an emergency, this is considered a facility-initiated discharge because the resident is usually expected to return. Any resident who is sent to the emergency room must be permitted to return to the facility unless the resident has met one of the criteria in this regulation that allows the facility to initiate a discharge. If this occurs, the facility must have evidence that the resident’s status is not based on his/her condition at the time of the emergency transfer. This is reiterated throughout the regulation, so it is essential to have a sound system in place where appropriate information and documentation is available to justify a facility-initiated discharge under one of the permissible situations.
Resident Appeal of Transfer/ Discharge
Facilities may not transfer or discharge residents who have appeals pending for a transfer or discharge unless failing to transfer or discharge the resident would endanger the health or safety of the resident or others who are in the facility. The facility is responsible for documenting the danger that necessitates the transfer or discharge. Other things to be aware of:
- If a resident’s initial Medicaid application is denied but appealed, then the resident is not considered to be in non-payment status, so facility-initiated discharge would not be permissible here.
- If the resident/representative appeals a discharge while the resident is in the hospital, the facility must allow the resident to return pending the appeal, unless there is evidence that the facility is unable to meet the resident’s needs or if the resident returned, it would jeopardize the health or safety of the resident or others in the facility.
On Survey
On survey, the surveyors will use the Hospitalization Critical Element Pathway or the Discharge Critical Element Pathway to determine a provider’s compliance with transfer or discharge requirements.
Issues surrounding transfer, and more frequently, discharges, are frequent areas of complaint, and this can also very easily lead to a substantiated finding. Additionally, the Office of the Inspector General is reviewing facility-initiated discharges and will be issuing two separate reports in the near future. Issues with facility-initiated discharges have often been a stated concern for State Long-Term Care Ombudsman programs, and State Agencies are moving towards less COVID-19-focused work, which means closing the gap on the backlog of complaints and overdue recertification surveys. When coupled with the OIG focus, it makes sense for providers to review their systems surrounding transfer and discharge.
