In Part 3 of our CMSCG “Ftag of the Week” for F627 Inappropriate Transfers, we’ll finish up reviewing the regulatory requirements for this tag. There’s a lot to review, in part because so many regulations were consolidated into F627 and F628 when the revised surveyor guidance went into effect in April. In Part 1 of this Ftag guidance series, we reviewed transfer and discharge requirements and the need to ensure your medical record supports the reason for transfer or discharge. Then, in Part 2, we reviewed the discharge planning process, particularly as it relates to ensuring a discharge is “appropriate” to avoid issues with this tag. Now we’ll review some other key parts to this regulation.
Orientation for Transfer or Discharge (Former F624)
This regulatory requirement is one of the ones which was relocated to F627, so it’s not a “new” requirement. Nursing homes must provide and document sufficient preparation and orientation, in a manner and form the resident can understand, to ensure a safe and orderly transfer or discharge. When we’re reviewing discharges during a medical record review or during a mock survey, we always look for that additional evidence of preparation for discharge – education, training, etc. – to ensure the resident and representative, if appropriate, know how to safely address all post-discharge needs.
Permitting Residents to Return to the Facility (Former F626)
Permitting residents to return to the facility is another existing requirement that lost its Ftag number and was moved to F627. This regulatory requirement requires nursing homes to develop and implement a policy which addresses permitting residents to return to the facility after they have been out of the facility on therapeutic leave or have been hospitalized. There are several requirements for the policy, so now’s a good time to review your organization’s protocol just to ensure you’ve hit all key points for compliance.
- A resident whose hospitalization or therapeutic leave exceeds the State bed hold period returns to the facility to his/her previous room, if available, or immediately upon the first availability of a bed in a semi-private room if the resident requires the services which are provided by the facility and is eligible for Medicare SNF or Medicaid NF services.
- For a resident who was transferred with the expectation of returning to the facility but cannot return to the facility, the facility must comply with the discharge requirements elsewhere in this regulation.
This section also addresses readmission to a composite distinct part. Don’t forget that if the facility is a composite distinct part, the resident must be permitted to return to an available bed in the particular location of the composite distinct part where he/she resided prior to the hospitalization/ therapeutic leave. If there is no bed available in that area at the time of readmission, then the resident must be offered the option to return to that location upon first availability of a bed.
Discharge Summary
The requirements for a discharge summary appear both here under F627 as well as F628. When a discharge is anticipated, the resident must have a discharge summary which includes the post-discharge plan of care. The post-discharge plan of care must be developed with the resident and/or representative and include:
- Where the individual plans to reside. Remember, part of the intent of this regulation is to ensure that a facility does not discharge any resident in an unsafe manner, including to a location that does not meet the individual’s needs or provide needed support and resources.
- Any arrangements that have been made for follow-up
- Any post-discharge services arranged (medical and non-medical)
On Survey
Here’s where you need to really pay attention. As part of the offsite preparation for survey, the survey team will begin investigating noncompliance with transfer and discharge regulations. The team leader will contact the LTC Ombudsman to find out if there are specific residents who have complained to the Ombudsman regarding inappropriate discharges. Any other complaints and the facility’s history which may indicate noncompliance with transfer or discharge requirements will also be reviewed off-site.
So, the surveyors will already be aware if they need to determine if noncompliance exists for these requirements. They’ll use the guidance at F627 to determine if a facility should not have initiated a transfer or discharge when it did (or even at all). We reviewed some of the potential issues for these concerns in an earlier part of this Ftag series, and the information includes common scenarios which may indicate noncompliance.
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A particular area of note is when surveyors are reviewing discharges where the facility has indicated at the time of discharge that the resident’s needs cannot be met by the facility or that the safety or health of individuals is endangered. When a surveyor reviews a discharge under these circumstances, he/she is looking for evidence that the facility has fully evaluated the resident and did not base the discharge on the resident’s status at the time of transfer to the acute care facility. SOM Appendix PP has been updated to specifically stated that if the facility did not assess the resident’s status and needs at the time of proposed return to the facility, then there can be no determination made that the resident’s needs cannot be met by the facility or that the health or safety of others would be endangered. There is specific guidance for providers in this section, including what’s expected if a resident’s choice to refuse care or treatment creates a health or safety risk, including if the facility is unable to resolve these situations.
F627 – A Negative Outcome for the Resident … and the Facility
F627 – A Negative Outcome for the Resident … and the Facility A final word of warning is appropriate here related to ensuring your transfers and discharges are appropriate and meet all regulatory expectations. Appendix PP now advises surveyors that issues identified at F627 would generally rise to a severity level of Harm or Immediate Jeopardy when the reasonable person approach is applied.
Not sure what the Psychosocial Outcome Severity Guide is? Get familiar – surveyors certainly are. Applying this guide can increase the severity of a non-compliant practice.
Surveyors are guided to use the Psychosocial Outcome Severity Guide when evaluating the potential for psychosocial harm under these circumstances. Also note that if it is determined that a resident’s discharge location did not meet his/her health and/or safety needs, enforcement should be implemented immediately.
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