Ftag of the Week – F622 Transfer and Discharge Requirements (Pt 1)

Next up in our “Ftag of the Week” series on the CMSCG Blog is F622 Transfer and Discharge Requirements, which is part of the Admission, Transfer, and Discharge regulatory group. The purpose of this regulation is to limit the circumstances under which a nursing home can initiate a transfer or discharge of a resident. It also includes the documentation requirements, outlines who is responsible for writing the documentation and what information must be provided to the receiving provider for a resident who is being either transferred or discharged to a different healthcare setting.

First, let’s look at some definitions:

  • Facility-initiated Transfer or Discharge – This refers to a transfer or discharge which either a resident objects to, did not originate via a resident’s verbal or written request, and/or does not align with the resident’s stated goals for care and preferences.
  • Resident-initiated Transfer or Discharge – This refers to a transfer or discharge that has been requested by the resident, or if appropriate, the resident’s representative, either verbally or written. The resident/ representative is providing notice of intent to leave the facility. The definition provided in the State Operations Manual (SOM) clearly states that generally expressing a desire to return home/ to the community or an elopement by a resident with cognitive impairment do not qualify as providing notice of intent to leave the facility.

Here is an actual citation where a facility was cited for inappropriately discharging a resident based on his desire to leave the facility to socialize independently for the day, which the facility used as a basis for discharge:

Immediate Jeopardy Citation Example – Complaint S/S: J

A facility was put into Immediate Jeopardy after alleging that a resident initiated an Against Medical Advice (AMA) discharge with the basis that the resident verbally expressed a desire to leave the facility. A staff member stated that the resident had simple stated that he wanted to go into the town that day. Facility staff initiated the discussion about discharging AMA.

The resident returned to the facility twice later that day and was only permitted to call family members. Discharge to the community was not listed in the CCP discharge plan goals, and assessments of the resident had found that he/she required supervision outside of the building and had poor judgement and safety awareness.

Facility-Initiated versus Resident-Initiated

The Interpretive Guidance (IG) requires surveyors to determine whether a transfer or discharge has been initiated by the resident or by the facility. If a discharge is resident-initiated, documentation in the resident record should include:

  • Resident/resident representative’s verbal/written notice of the resident’s intent to leave the facility
  • A discharge care plan
  • Documented discussions with the resident and/or the representative (if appropriate) that include information on discharge planning and arrangements for post-discharge care.

As you can see from the citation discussed above, as well as throughout the rest of this post, surveyors will be looking for pre-planning as it relates to a resident’s discharge.

It is important to have comprehensive documentation in place regarding conversations with the resident/ resident representative, particularly around the resident’s goals, status and discharge goals. In the above example, discharge to the community was not an identified – or feasible – goal for the resident since he required supervision and lacked appropriate safety awareness and judgement to be safe in the community. Discharges are expected to be safe, and appropriate plans need to be in place for each resident, including post-discharge care to ensure continuity for the resident.

Facility Requirements

The facility is required to permit residents to stay in the facility and not transfer or discharge the resident from the facility except under a few limited circumstances:

  1. The transfer/discharge is necessary for the resident’s welfare and the facility cannot meet the resident’s needs.

The regulation requires that facilities permit residents to remain in the facility and not transfer or discharge the resident except under certain circumstances. Nursing homes are expected, as part of the Facility Assessment, to identify the types of residents that they are capable of caring for and should not admit residents that they cannot care for.

For this type of discharge, the IG requires surveyors confirm that the facility completed a full evaluation of the resident and that the discharge is not based on the resident’s status the time of transfer. If the transfer is related to a significant change in a resident’s condition but is not an emergency requiring an immediate transfer, the expectation is that the facility will complete an appropriate assessment to determine if it could revise the resident’s care plan to allow the resident to stay in the facility.

Let’s look at a citation where a facility attempted to discharge a resident based on it not being able to meet the resident’s needs, but where a physician had not completed the necessary documentation as required by the regulation:

Citation Example – Complaint S/S: E

A resident was transferred to a hospital and when the hospital contacted the facility to let it know the resident was ready to return, the facility told the hospital it could no longer meet the resident’s needs due to the resident’s bariatric status. The hospital stated that the resident did not have bariatric status prior to admission.

The resident remained in the hospital while appealing the discharge and a surveyor confirmed that there was no documentation from a physician indicating that the resident had specific needs that could not be met in the facility. The resident remained in the hospital awaiting placement in the facility for nearly 6 months while the appeal was pending, and the DON stated that the facility had realized it could not accommodate the resident’s increasing weight.

It is clear from this citation that the resident’s physician had not appropriately documented the specific needs of the resident that could not be met, and thus it was not an appropriate discharge. The IG states that documentation made by the physician must include the following to be a permissible facility-initiated transfer or discharge:

  • The specific needs of the resident that the facility could not meet
  • The facility’s efforts to meet those needs
  • The specific services that the receiving facility will be able to provide to meet the resident’s needs that cannot be met by the current facility

As mentioned above, the Facility Assessment details the services that a facility can provide, as well as the types of residents and the diagnoses/diseases that the facility can provide care and services for. If a surveyor identifies a concern regarding the facility’s determination that it cannot meet a resident’s needs, the IG instructs the surveyor to investigate whether the facility has admitted residents who have similar needs.

  1. The resident’s health has improved to the point that the resident no longer requires the facility’s services, and thus transfer/discharge is appropriate.

This one is relatively self-explanatory, especially for those patients who were in the facility for short-term rehab, met their goals and can safely be discharged. The physician is required to provide the same documentation as listed in #1. The Interpretive Guidance emphasizes that a discharge following a resident’s completion of skilled rehab may not necessarily be resident-initiated. In cases where a resident has not objected to or appealed the discharge, it could still be considered involuntary and all the regulatory requirements for F622 must be followed.

  1. The safety of those in the facility is endangered due to the clinical or behavioral status of the residents. and
  2. The health of individuals in the facility would otherwise be endangered.

We will look at #3 and #4 together. There is a need to ensure the safety of the resident, other residents and staff, but as mentioned above, the facility needs to have completed a full evaluation of the resident and not base that resident’s discharge on his/her status at the time of transfer to the acute care facility.

For #1 and #2, the resident’s attending physician is required to provide documentation regarding the above-mentioned details, but for either #3 or #4, the situation may be more urgent, and a physician still needs to provide documentation regarding the reason for transfer or discharge, but it does not specifically need to be the resident’s attending physician. Additionally, if permissible by state law, a non-physician practitioner may provide the transfer or discharge documentation.

Citation Example – Complaint S/S: G (Actual Harm)

A facility was cited for refusing to readmit a resident after the facility issued a notice of its intention to discharge a resident to the hospital with less than thirty days’ notice. The resident, who was moderately cognitively impaired, and care planned for potential for verbal/physical aggression and poor impulse control, threw a plate on the floor and grabbed a nurse by the neck. The resident was transferred to the hospital for an evaluation, and the notice did not indicate the reason for transfer.

The hospital cleared the resident to return to the facility, but the facility staff told the hospital that they did not feel safe having the resident return over the next few days. The hospital completed three psych evals and then contacted the facility again to let them know the resident was ready to return only to be told that the facility would not accept the resident back to the facility and faxed a discharge notice to the hospital. The resident was allowed to return after five days while the facility refused to rescind its notice of discharge.

  1. The resident has failed to pay for a stay at the facility, including if the resident has failed to submit the necessary paperwork for third-party payment for facility services, including Medicare and Medicaid.

In any circumstance, the resident must be provided with appropriate and reasonable notice. The facility is responsible for notifying the resident of changes in payment status, as well as helping the resident, if necessary, to submit any third-party paperwork. If the third-party denies the claim and the resident refuses to pay for his/her own stay, this is also an applicable circumstance. However, if a resident becomes eligible for Medicaid after admission to the nursing home, the facility is only allowed to charge a resident the Medicaid-allowable charged. Conversion from private pay to Medicaid is not considered non-payment.

Citation Example – Complaint S/S: G (Actual Harm)

The family member of a resident called 911 to have a resident evaluated at the hospital, and the facility refused to allow the resident to return to the facility for failure to pay an outstanding bill owed to the facility. There were no physician’s orders in the transfer notice because the facility believed it was a resident-initiated discharge and the corporate office told the facility not to allow the resident to return to the facility due to non-payment after the resident’s insurance provider denied coverage for the stay.

  1. The facility ceases to operate.

While this reason may be self-explanatory, it warrants a reminder that facilities are responsible for providing appropriate notice ahead of time to the health department and the residents regarding their intent to close. There are two separate regulations regarding this and other responsibilities, F845 Facility Closure – Administrator and F846 Facility Closure.

In Part 2 of CMSCG’s Ftag of the Week review of F622 Transfer and Discharge Requirements, we will look at the second component of this regulation surrounding documentation requirements, as well as look at emergency room transfers and discharges pending appeal.

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