Ftag of the Week – F627 Inappropriate Transfers (Pt. 1)

Our next “Ftag of the Week” on the CMSCG Blog is a new Ftag, F627 Inappropriate Transfers. F627 came about as the result of the recently implemented revised guidance to surveyors. The revised guidance included changes to the list of Ftags, including major revisions to the Admission, Transfer and Discharge Regulatory Group.  As we indicated in Part 1 of our Ftag of the Week series for F628 Discharge Process, several tags were collapsed into the two newly-created Ftags which address transfer and discharge.

Ftags which no longer exist (but the requirements remain)

• F622 Transfer and Discharge Requirements was split into F627 and F628.
• F624 Orientation for Transfer or Discharge (view our Ftag of the Week for F624 from 2017 here – we’ll provide more details later related to F627.)
• F626 Permitting Residents to Return to the Facility

Transfer and Discharge Requirements

There are several regulatory requirements which nursing homes need to adhere to related to transferring or discharging a resident from the facility. Note that these are not new requirements, but they have been relocated to this Ftag and there is expanded Interpretive Guidance associated with it. Transfer or discharge would be permissible if:

• It is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility.
• It is appropriate because the resident’s health has improved sufficiently so that the services provided by the facility are no longer needed.
• The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident.
• The health of individuals in the facility would otherwise be endangered.
• The facility ceases to operate.
• After reasonable and appropriate notice, the resident has failed to pay for (or have paid for by Medicare or Medicaid) a stay at the facility.

Regarding the last item about nonpayment, Appendix PP of the SOM indicates that this would apply:

• If the resident fails to submit necessary paperwork for 3^rd-party payment.
• If the claim is denied and the resident refuses to pay for his/her stay.

Nursing homes are only allowed to charge a resident for allowable charges under Medicaid if he/she becomes eligible for Medicaid after being admitted to the facility.

Appeal Pending

The facility is also prohibited from transferring or discharging a resident who has an appeal pending after receiving a transfer or discharge notice from the facility. The exception to this would be if failure to transfer or discharge the resident would endanger the health or safety of the resident or others. The facility must document the danger that would be posed if the resident is not transferred or discharged.

While there are a several rationales that the provider could present as to why a resident needed to be transferred or discharged due to safety or behavioral concerns, note that these often don’t “stick” when they are appealed. These types of events are also a big factor in why we now have a new tag that’s called “inappropriate” transfers.

F627 – Revised Intent

The Centers for Medicare & Medicaid Services (CMS) is hammering home the point that we’ve got to do a better job with the residents we have admitted and attempt to discharge them in a safe manner. Note that the intent of F627 has been revised to include:

• Ensuring that facilities develop and implement policies which allow residents to return to the facility following hospitalization or therapeutic leave
• Ensuring that a facility does not transfer or discharge a resident in an unsafe manner. This includes sending a resident to a location that does not meet his/her needs, does not provide the support and resources needed or does not meet the resident’s preferences.

Can all preferences be accommodated? Of course not. We can’t send a resident to home that he/she no longer has in the community, or to an assisted living when there’s clearly a need for additional assistance. We often see residents attempting to make arrangements with independent living advocacy groups – when they definitely do not meet the criteria for “independent.” So there’s residents like those, but then there’s the resident who refuses to make the transfer to another provider at the same level of care where your team has helpfully sent a PRI in hopes that someone else can make the resident happier than you can . . . if he/she wants to stay with you and you can provide the needed care, you can’t pack their stuff and say goodbye.

What’s in the Medical Record May Not Support Your Discharge

This is another one of those regulations where your documentation – or lack thereof – can really create an impact. The revised guidance to surveyors directs the surveyor to use the guidance provided under F627 Inappropriate Transfers “when evidence suggests” that the resident should not have been transferred or discharged at the time of discharge – or potentially at all. There’s a long list of potentially inappropriate circumstances which surveyors could review if there is insufficient information in the medical record to support the basis for discharge. Let’s review some of them in more detail now.

• A resident is discharged based on inability to meet the resident’s needs but there’s no evidence that the facility tried to meet these needs or that an assessment was completed at the time of discharged which identified what needs could not be met.

This guidance is clearly not referring to a service need which isn’t provided by the facility, but in these circumstances, it should be evident how the facility attempted to accommodate the need. Don’t forget – if you are indicating that you provide a service type in your facility per your Facility Assessment, the expectation is that you can take care of any resident with that need. Likewise, spelling out limitations that the facility has for potential needs which could not be handled in the facility may also be a wise move.

Other areas of concern which a surveyor would need to review include when a resident is discharged:

• Based on the improved health status and the facility’s services are no longer needed. However, the medical record shows a lack of improvement or an actual decline.
• Based on failure to pay, however, there is no documented evidence that the facility offered to assist the resident with applying for Medicaid, offered the resident the option to pay privately or that the resident refused to pay or have the stay paid by Medicare or Medicaid.
• Based on the resident endangering the safety or health of other individuals in the facility, but there is no documentation regarding the endangerment.

This last bullet is one that’s a common one that facilities may attempt to use to discharge a behavioral resident. It would be important to ensure that there is sufficient documentation of how the resident’s behaviors are impacting the safety of other residents in particular. Unfortunately, a resident with aggressive behaviors directed towards staff but who does not present with issues towards his or her peers is potentially not going to fall into that category. Documentation should indicate what potential safety issue there is for other residents, what behavioral interventions and safety precautions have been attempted for this resident and the outcome.

There’s so much more to this regulation, but we’ll wait until next week to discuss further. Check back soon for Part 2.

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