This week’s “Ftag of the Week” on the CMSCG Blog is F843 Transfer Agreement, which is part of the Administration regulatory group. F843 is another one of those regulations that can fall off a provider’s radar, so this week’s post is a reminder to review your transfer agreement(s).
Nursing homes must have in effect a written transfer agreement with one or more Medicare/Medicaid-certified hospitals that covers two main points. First, the agreement has to provide reasonable assurance that the nursing home’s residents will be transferred to the hospital and ensured a timely admission when the attending physician has determined it is medically appropriate or in the event of an emergency, a different practitioner in accordance with State law and the facility’s policy.
Second, the agreement needs to reasonably assure that medical information needed to provide treatment and care for the resident, or to determine if the resident can receive appropriate services, is exchanged between the providers. Additionally, if the transferring provider believes a resident may be able to receive services in a less restrictive setting than the nursing home or the hospital, this medical and other information should be provided.
Good Faith Effort
The second part of the regulation states that if a facility has made a good faith attempt to enter into a transfer agreement with a hospital that is sufficiently geographically close enough to make transfer feasible, that the facility is considered to have a transfer agreement in effect. While that seems like a potential work-around, the Interpretive Guidance points out that it will only be considered a good faith effort when the facility has “exhausted all reasonable means” and “taken every necessary and appropriate step” to try to get a transfer agreement in place. Thus, it may prove difficult to provide evidence of those efforts if they have not been made.
Link to F622 Transfer and Discharge Requirements
F843 requires that the agreement considers the information that is listed under F622, as well as any other information that is necessary to ensure a safe and orderly transfer and to help ensure the resident receives appropriate care and treatment from the receiving provider. When the RoPs were updated a few years ago, a list of information that should be given to the receiving provider was included in the regulatory requirements of F622 (§483.15(c)(2)(iii)). These include, at a minimum:
- Contact information for responsible practitioner.
- Resident representative information, including contact information.
- Advance Directives
- All special instructions/precautions for ongoing care. Per the IG, this includes information for treatments and devices, any precautions in place, and special risks.
- Comprehensive care plan goals
- Cope of the resident’s discharge summary
Additionally, all information necessary for the receiving provider to meet the resident’s needs must be provided. This includes, but is not limited to:
- Resident status – baseline and current mental/behavioral/functional status
- Reason for transfer
- Recent vital signs
- Medications, including last received.
- Most recent relevant labs/tests
- Recent immunizations
The IG states that this may not all be readily available for urgent transfers, but this information should be provided as soon as possible to the receiving provider.
F843 – On Survey
While F843 is not one of the most frequently cited deficiencies, providers do indeed end up with receiving a citation for not having a valid transfer agreement in place. Unfortunately, in many cases, the only time a provider has to give this information to a surveyor is when there is an Extended Survey because Substandard Quality of Care (SQC) has been identified. A deficiency is considered SQC when it is cited at a Scope/Severity of F, H, I, J, K or L, and there are almost 50 Ftags that, if cited and at the appropriate S/S, will result in a SQC deficiency. The purpose of the Long-Term Care Survey Process (LTCSP) Extended Survey (CMS-20091) is to determine which factors could have contributed to systems issues that caused SQC.
For the Extended Survey, the survey team will expand what it is looking at, including reviewing documentation that relates to requirements where deficiencies exist. Let’s take a look at an actual survey to understand how a transfer agreement issue could arise.
Complaint Survey – Multiple Citations
A facility was put into Immediate Jeopardy when surveyors identified that the facility failed to have a system in place to ensure portable liquid oxygen tanks were adequately filled at all times during resident use. Several residents were found to have empty portable oxygen tanks and the facility did not have a schedule in place for ensuring the checking and refilling occurred at routine intervals.
The facility received a S/S: J deficiency related to F695 Respiratory/Tracheostomy Care and Suctioning. F695 happens to be one of those SQC deficiencies, and this triggered an Extended Survey. Surveyors requested lots of documents, including the facility’s written transfer agreement. Unfortunately, the facility did not have a written transfer agreement in place and was cited under F843 S/S: D in addition to having to deal with the IJ situation.
In addition to the Extended Survey triggering a review of a facility’s documentation, there are other circumstances where a transfer agreement may have slipped through the cracks. Providers have been cited under F843 for failing to have current transfer agreements in place after the following occurred:
- The facility had a change in ownership and the transfer agreement was in place with the previous owners and had not been transferred to the new owners.
- The facility had a transfer agreement in place that expired on a set date and it was not renewed.
Seems easy enough to avoid a deficiency related to Transfer Agreement if a facility has a system in place for periodic review/monitoring of all transfer agreements to ensure that they do not need to be renewed, new ownership had agreements transferred, when a new relationship is established with a local hospital that an agreement is signed, etc. While it won’t be cited here, it would not be a bad idea to look at your practices related to information/ documentation provided when you are transferring a resident to an alternate location for care/ service.