This week’s Ftag of the Week on the CMSCG Blog is the second of two related Ftags in the Administration regulatory group, F846 Facility Closure. F846 requires that a nursing facility have policies and procedures in place that outline the duties of the Administrator in the event of a facility closure. This includes the provision of the appropriate notices related to the closure. The Administrator needs to be aware of his/her closure-related responsibilities, whether the facility’s provider agreement is being terminated by the Centers for Medicare and Medicaid Services (CMS) or the facility is voluntarily closing.
F846 – Regulatory Requirements
The facility cannot close until all residents are transferred, relocated or discharged in a safe and orderly manner to the most appropriate setting.
The facility must have policies and procedures in place that ensure:
Appropriate Notification to Multiple Parties
The Administrator is responsible for submitting the facility’s closure plan and providing timely written notice to all required parties. These parties include the State Survey Agency, the State Long-Term Care Ombudsman, all residents in the facility and their legal representatives, the CMS Regional Office, the State Medicaid Agency, and staff who are responsible for providing care and services to the facility’s residents.
How the Appropriate Setting for Each Resident will be Determined
The facility’s P&Ps must ensure that facility staff will work to identify available care settings in terms of quality, services, and location, by taking into consideration each resident’s individual needs, choices, and best interests to find the appropriate care setting for them. Residents must be provided with the opportunity to obtain information regarding various community options.
The P&P should address how the facility will prepare residents for a safe transfer from the facility, including how staff will identify the appropriate setting for each resident.
This means that staff should be interviewing residents/reps/ family members to determine what each resident’s goals, preferences and needs are related to the services that will be necessary and the type of setting that the resident will move to. If the resident is transferring to a similar level of care, such as another nursing facility, that will be a different process than for a resident whose family wishes to care for the resident in their home.
The facility should also consider the psychological/emotional preparation needs of each resident, for many of whom the facility is “home.” Understandably, many residents may be reluctant to change settings to one where they will have new roommates, new caregivers, and need to make new friends at the new facility. The sense of comfort and familiarity will be diminished in many instances, which is why It is necessary to ensure that all transfers and discharges are completed in a safe and orderly manner – and to an appropriate setting.
Communication with Receiving Provider
The facility must ensure it has procedures in place related to the transfer of pertinent resident information to the receiving provider. This includes:
- Resident’s complete medical record – including archived files
- MDS Assessments
- All physician orders/recommendations/guidelines
If you have never closed a facility, one of the best things to do is to create a checklist of the documents that are needed for each transfer/discharge to use as a guideline for ensuring all necessary documentation is provided. Remember this includes such things as vaccination cards, information on permanent pacemakers or other internal devices.
Other P&P Required Topics
- No new admissions to the facility will be allowed on or after the date that the written notice regarding the facility’s impending closure was submitted to the State Survey Agency.
This is not surprising, but once the facility has provided written notice of its impending closure, no new residents can be admitted. Any provider in this situation would likely have their hands full trying to transfer and discharge existing residents rather than worrying about admitting new residents, but it warrants mentioning who would be considered a “new admission. “
A smart plan includes having facility staff meet with the resident and/or representative regarding discharge to a new facility from the hospital versus returning to the facility for a short period of time (less than 30 days) and then being transferred again.
Generally, in these circumstances, residents who were temporarily in the hospital for care, who are on bed hold, or who are temporary therapeutic leave from the facility would not be considered new admissions. However, if the facility determines that it cannot meet the clinical or social needs of the resident due to the impending closure and the resident is not transferred back to the facility, this does not excuse the facility from not providing appropriate notification to all required parties just as though the resident was still living in the facility. A smart plan includes having facility staff meet with the resident and/or representative regarding discharge to a new facility from the hospital versus returning to the facility for a short period of time (less than 30 days) and then being transferred again.
- The roles and responsibilities of various individuals during the closure process, including the facility’s owner, Administrator and/or anyone who has been temporarily hired to replace the Administrator, or temporary monitors/managers who will oversee the closure. It is necessary to provide the contact information for these parties as well.
What about On-Going Operations and Management during Closure?
Providers are not off the hook when the facility is closing, since the facility cannot close until every resident has been transferred, relocated or discharged to the most appropriate setting in a safe and orderly manner. This means that the facility must have P&P in place that ensure there are provisions in place for ongoing management of the facility, facility residents and facility staff. These include:
- Payment of salaries and expenses to staff, vendors, contractors and other business entities
- Continuing to provide appropriate staffing and resources to meet the needs of all residents, including provision of services, treatments and care as ordered by the resident’s physician, as well as provision of medications, supplies, etc.
- Ensuring resident personal funds are accounted for, maintained, reported and disbursed per regulation
- Caring for resident’s personal belongings by labeling, safeguarding and ensuring the appropriate transfer of these belongings to the new care setting. These personal belongings include medications, clothing items, furniture, and personal items that belong to the resident. Contact information for someone who can assist with missing items after the facility has closed must be provided.
How It’s Cited
F846 is not frequently cited, but facilities are generally cited for not including all of the required elements of the closure plan set forth in the regulation, or not having any Policies & Procedures in place at all that would address the facility’s closure. Here are some actual citations:
Standard Survey S/S: F
The facility failed to develop a closure policy, resulting in the potential unsafe transfer of all residents. The information provided to the survey team lacked P&Ps for:
- Administrator’s responsibilities to provide appropriate notice in the event of closure, submitting a closure plan, and providing timely written notice to required parties
- How staff would identify available settings for residents to be transferred/ discharged to while considering quality, services and location, and each individual resident’s needs, choices and best interests
- Assurance that no new residents would be admitted to the facility on or after the date written notice of closure was provided to the State Survey Agency
Standard Survey S/S: F
The facility failed to have P&Ps in place in the event of a facility closure, placing residents at risk for unmet needs. The policy did not include:
- How pertinent information was communicated to the receiving provider
- The primary contacts responsible for daily operation and management during the closure process
- The roles and responsibilities of the owners, administrator, temporary management and contact information
- Provisions for ongoing operations and management during the closure process
If it seems like we cut and paste the regulation into these two citations, that’s understandable. However, these are actual citations where all of the necessary components were not in place for surveyor review. The requirements for F846 are laid out quite well, so ensure your organization’s P&Ps include all the required elements for compliance and the safe and orderly transfer of your residents should it be required. Lastly, the closing of a nursing home is generally a sad and emotional time for employees, residents and their families so with this in mind, the Operator and Administration need to stay focused on ensuring the process is organized and safe for all involved.