Successful Discharge Strategies for SNF Behavior and Non-Payment Issues
Introduction to Involuntary Discharge
Resident behavior and non-payment for a stay impacts the entire operations of
skilled nursing facilities and presents potentially dangerous and difficult environments for
operators along with potentially significant economic considerations.
Facilities are
allowed to involuntarily discharge a resident in narrow situations and, if allowed, must
initiate the discharge and provide proper notice as required by federal law.
In
considering the risks and regulatory analysis, as well as practical considerations, also
refer to the Surveyor Guidelines.
I.
Discharge Requirements:1 The facility must permit each resident to remain in the
facility, and not transfer or discharge the resident from the facility unless—
(i)
The transfer or discharge is necessary for the resident’s welfare and the
resident’s needs cannot be met in the facility;
(ii)
The transfer or discharge is appropriate because the resident’s health has
improved sufficiently so the resident no longer needs the services provided
by the facility;
(iii) The safety of individuals in the facility is endangered;
(iv) The health of individuals in the facility would otherwise be endangered;
(v)
The resident has failed, after reasonable and appropriate notice, to pay for
(or to have paid under Medicare or Medicaid) a stay at the facility. For a
resident who becomes eligible for Medicaid after admission to a nursing
facility, the nursing facility may charge a resident only allowable charges
under Medicaid; or
(vi)
The facility ceases to operate.
1
42 C.F.R. §483.12(a)(1)(2) (2011).
1 II.
Documentation:2 If a facility discharges the resident pursuant to §483.12(a)(2)(i)–
(v) supra, “the resident’s clinical record must be documented.” Documentation
must be made by–
(i)
The resident’s physician when transfer or discharge is necessary
under paragraph (a)(2)(i) or paragraph (a)(2)(ii) of this section; and
(ii)
A physician when transfer or discharge is necessary under paragraph
(a)(2)(iv) of this section.
III. Notice Before Transfer:3 Before a facility transfers or discharges a resident, the
facility must-(i)
Notify the resident and, if known, a family member or legal representative
of the resident of the transfer or discharge and the reasons for the move in
writing and in a language and manner they understand;
(ii)
Record the reasons in the resident’s clinical record; and
(iii) Include in the notice the items described in paragraph (a)(6) of this section.
IV. Timing of Notice:4
(i)
Except when specified in paragraph (a)(5)(ii) of this section, the notice of
transfer or discharge required under paragraph (a)(4) of this section must be
made by the facility at least 30 days before the resident is transferred or
discharged.
(ii)
Notice may be made as soon as practicable before transfer or discharge
when—
(A) The safety of the individuals in the facility would be endangered
under paragraph (a)(2)(iii) of this section;
(B) The health of individuals in the facility would be endangered, under
(a)(2)(iv) of this section;
2
Id. at §483.12(a)(3). Conversion from a private pay rate to payment at the Medicaid
rate does not constitute non-payment. See Surveyor Guidelines, practical considerations.
3
Id. at §483.12(a)(4)(i)–(ii); Id. at §483.13 (1992).
4
Id. at §483.12(a)(5)(i)–(ii).
2 (C) The resident’s health improves sufficiently to allow a more
immediate transfer or discharge, under paragraph (a)(2)(ii) of this
section;
(D) An immediate transfer or discharge is required by the resident’s
urgent medical needs, under paragraph (a)(2)(i) of this section; or
(E) A resident has not resided in the facility for 30 days.
V.
Contents of the Notice:5 Written notice specified in paragraph (a)(4) must include:
(i)
The reason for transfer or discharge;
(ii)
The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement that the resident has the right to appeal the action to the State;
(v)
Name, address and telephone number of the State long term care
ombudsman;
(vi) For nursing facility residents with developmental disabilities, the mailing
address and telephone number of the agency responsible for the protection
and advocacy of developmentally disabled individuals established under
Part C of the Developmental Disabilities Assistance and Bill of Rights Act;
(vii) For nursing facility residents who are mentally ill, the mailing address and
telephone number of the agency responsible for the protection and advocacy
of mentally ill individuals established under the Protection and Advocacy
for Mentally Ill Individuals Act.
VI.
Orientation for Discharge:6 “A facility must provide sufficient preparation and
orientation to residents to ensure safe and orderly transfer or discharge from the
facility.”
VII.
Appeals:7 Each State must provide a system for:
(1) A resident of a SNF or a NF to appeal a notice from the SNF or NF of intent
to discharge or transfer the resident
5
Id. at (a)(6).
Id. at §483.12(a)(7).
7
Id. at §483.204 (1993); see also Id. at 483.206 (1993).
6
3 (2) The State must provide an appeals system that meets the requirements of this
subpart, § 483.12 of this part, and part 431 subpart E of this chapter.
VIII.
Discharge Summary and Post-Discharge Plan of Care:
8
When the facility
anticipates discharge a resident must have a discharge summary that includes:
(1) A recapitulation of the resident’s stay;
(2) A final summary of the resident’s status to include items in [42 C.F.R.
§483.20(b)(2)], at the time of the discharge that is available for release to
authorized persons and agencies, with the consent of the resident or legal
representative; and
(3) A post-discharge plan of care that is developed with the participation of the
resident and his or her family, which will assist the resident to adjust to his
or her new living environment.
8
Id. at §483.20(l) (2010).
4 State-by-State Comparison
In addition to the federal requirements, each facility must follow state statutes and
administrative regulations regarding involuntary discharge procedures. Some states have
adopted the federal regulations in whole as state law, while others have supplanted the
federal requirements by including state regulations that govern how a resident may
contest an involuntary discharge through an appeal process. Below is a state-by-state
comparison of discharge requirements meant to act as a general summary in order to
evaluate and contrast the varying state requirements. Since many states have developed
detailed and varied discharge summary and post-discharge plan of care requirements, we
have provided a general citation to such provisions, rather than an in-depth exploration of
each state’s procedures. State discharge categories that are not addressed by federal law
are attended to as “Miscellaneous.” The chart contains citations to state law provisions as
a mere overview of the requirements and is not meant to present the totality of the law.
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
ALABAMA9
See federal “Discharge Requirements” (i)(iii)(iv)
See federal “Discharge Requirements” (v)
When federal “Discharge Requirements” (iii) or (iv), any physician
can make documentation
See federal “Notice Before Transfer”
See federal “Timing of Notice”
See federal “Contents of Notice”
Not addressed
ALASKA10
Not addressed
Not addressed
Date of discharge and final diagnosis in medical record, which must
be completed within 30 days of discharge and signed by attending
physician or other practitioner responsible for treatment
9
Ala. Admin. Code r. 420-5-10-.06 (1996).
Alaska Admin. Code tit. 7, § 12.670 (2006); Id. at 12.770(c)(1)(L) (2007); Id. at (e).
10
5 Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Not addressed
Not addressed
Not addressed
Not addressed
ARIZONA11
(1) Behavior is threat to health or safety of the resident or other
individuals at facility
(2) Facility unable to meet the needs of the resident
Administrator may discharge if 30 days’ notice and right to appeal
Document in medical records: (1) Reason and date of discharge; (2)
30 day written notice; (3) If “Behavior,” by a physician and actions
taken by a staff member to protect other individuals in facility
Given to resident or representative
30 day written notice, except emergency
Explains resident’s right to appeal discharge
Not addressed
ARKANSAS12
(1) Presents a danger to the safety or health of other residents
(2) Resident’s welfare or welfare of other residents
Non-payment for stay
Record notice in medical record
Resident, responsible party and agency, and attending physician
30 days written notice. Transfer for welfare of other residents may
be affected immediately if documented in medical record
(1) Decision to and reasons for discharge and available alternatives
(2) Inform of right to appeal to Director within 7 calendar days
(1) Facility must assist in filing written objection
(2) Hearing held within 14 days after filing and decision made
within 7 days of hearing
CALIFORNIA13
Welfare of (1) patient or (2) other patients
Non-payment of stay
Document in health record
Not addressed
Reasonable advance notice to ensure orderly discharge
Not addressed
Not addressed
COLORADO14
(1) Necessary for resident’s welfare. Facilities participating in MA
11
Ariz. Admin. Code §R9-10-909 (2003).
318 Ark. Code R. § 7 (2006); 3000 Ark. Code R.§§ 3013, 3016, 3017 (2006).
13
Cal. Code Regs. tit. 22, § 72527 (2007).
14
6.1011-1. Colo. Code Regs. §§ 12.1, 12.6 (2013).
12
6 Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
program must demonstrate that needs cannot be met
(2) Necessary to preserve welfare of other residents
(3) Facilities participating in MA must provide assessment and
reasonable intervention prior to determining need for discharge
(1) See federal “Discharge Requirements” (v)
(2) Consequences of non-payment prior to initiating discharge
(1) Reason for, and if “Behavior,” the assessment and intervention
in clinical record; (2) If “Behavior (1),” by resident’s physician; (3)
If “Behavior (2),” any physician
(1) See federal “Notice Before Transfer”
(2) If facility is in MA program, copy of notice sent to State or
Local LTC Ombudsman at same time it is sent to resident
At least 30 days before discharge except as soon as practicable
when staff determines there is an emergency because safety or
health of residents is endangered
(1) Reason for and effective date of discharge; (2) Location to
which resident discharged; (3) Grievance procedure; (4) Required
statement: 6.1011-1. Colo. Code Reg. § 12.6 (2013)
Cannot be involuntarily discharged until expiration of the notice
period, the time for any further administrative appeals has expired,
or grievance or appeal has been resolved
CONNECTICUT15
(1) Welfare of patient cannot be met in the facility
(2) Health or safety of individuals in facility endangered
(1) If self-pay (also known an private pay) discharge for nonpayment or arrearage of more than 15 days of per diem rate
(2) If facility does not participate in Medicaid, may discharge selfpay resident who has intentionally transferred assets so as to
avoid costs under the contract or a non-resident self-pay patient
who has intentionally transferred assets in a sum which will
render unable to pay costs for 42 months of facility care
(1) Basis for discharge in medical record by a physician; (2) If
welfare, health or safety of patient, by patient's physician
Patient and guardian or conservator, if any, or legally liable relative
or other responsible party
30 to 60 days prior to discharge, except as many days as practicable
where “Behavior (2)” or has not resided in facility for 30 days
(1) See federal “Contents of the Notice”
(2) Date appeal must be initiated in order to stay discharge
(1) Written request to Commissioner of Social Services within 60
calendar days after facility issues notice, except if §19a-535(h)
(2) Discharge stayed if initiate appeal within 20 days of date
resident receives notice unless demonstrates good cause
15
Conn. Gen. Stat. Ann. §19a-535 (2011); Id. at Sec. 19a-504c-1. (1989); Conn.
Agencies Regs. §19-13-D 8t(p) (2007).
7 Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
(3) Hearing convened between 10 and 30 days from request receipt
(4) Written decision within 30 days after hearing or within 60 days
after date of hearing request, whichever occurs sooner
(5) If emergency, hearing held within 15 business days after request
receipt; decision issued within 30 days of hearing record close
(6) Except in an emergency, commissioner’s receipt of a request for
a hearing in response to an improper notice within 10 days stays
discharge until decision issued
(7) Copy of decision must be sent to facility, resident, guardian,
legally liable relative or other responsible party
(8) If discharge upheld, facility may not discharge prior to 15 days
from date resident, etc. receives decision. If not proper, may be
readmitted
(9) Superior Court may consider an appeal from decision
DELAWARE16
Welfare of (1) resident/patient or (2) other patients
Non-payment of justified charges
Not addressed
30 days advanced notice, unless emergency, then no notice
Not addressed
Reasons for discharge
Opportunity for a partial hearing to challenge action
DISTRICT OF COLUMBIA17
(1) Essential to meet resident’s documented health-care needs or to
be in accordance with prescribed level of care; (2) Essential to
safeguard residents from physical or emotional injury
(1) See federal “Discharge Requirements” (v)
(2) Right to redeem up to discharge date, and if full payment made,
may remain in the facility
(1) Must discuss reasons with resident and answer any questions
about discharge or written notice they received. Summarize
contents of discussion and names of individuals involved in
writing and make part of resident’s clinical record
(2) Copies of written notice placed in clinical record and
transmitted to Mayor’s designee and, if resident’s care is paid in
whole or part through Medicaid, DHS and LTC Ombudsman
Notice to resident and representative
Oral and written notice 21 calendar days before discharge, unless
LTC Ombudsman determines that emergency or other compelling
circumstances necessitate a more immediate discharge
(1) Specific reason, stated in detail and not in conclusory language
(2) Proposed effective date
(3) See D.C. Code § 44-1003.02 (d)(3) for required statement
16
17
Del. Code Ann. tit. 16, §1121(18) (West 2009).
D.C. Code § 44-1003 (2010).
8 Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
(4) Hearing request form, a postage paid envelope pre-addressed to
the appropriate District official or agency
(5) Name, address, and phone number of person charged with the
responsibility of supervising the discharge
(6) Name, address, and phone number of LTC Ombudsman
program and local legal services organization
(7) Location to which the resident will be transferred
(1) If resident requests a hearing under § 44-1003.03(a), facility
staff must prepare resident for possibility of having to move on
5-day notice should the decision not be in resident’s favor
(2) Resident, representative, or LTC Ombudsman may contest
discharge by mailing a written hearing request to the Mayor and
notifying the administrator or facility staff of request within 7
calendar days after receiving notice of discharge
(3) A timely request stays discharge unless the LTC Ombudsman
determines that emergency necessitate immediate discharge
(4) Mayor must hold a hearing at facility within 5 calendar days of
receiving request and render a decision within 7 calendar days
(5) If proper discharge, cannot discharge before 22nd calendar day
following resident’s notice receipt or the 5th calendar day after
notice of decision, whichever is later, unless an emergency
FLORIDA18
(1) Health or safety of other residents or facility employees would
be endangered
(2) Resident’s welfare and needs cannot be met in the facility
See federal “Discharge Requirements” (v)
(1) If “Behavior (1),” resident’s physician or medical director
documents in medical records
(2) If “Behavior (2),” see federal “Documentation” (i)
Signed by nursing home administrator and copy to legal guardian or
representative and local ombudsman within 5 business days after
resident signs the notice
30 days notice, except as soon as practicable when “Behavior (1)”
(1) Means to request local LTC ombudsman to review notice and
request information about initiating a fair hearing with Office of
Appeals Hearings; (2) Reason for, effective date, and location to
which discharged; (3) Right to and procedure for filing an appeal
(1) If requests hearing within 10 days of notice, discharge stayed
pending a hearing decision. If not, facility may discharge after
30 days from date resident received notice
(2) Failure of nursing home administrator to forward request for
review to local ombudsman within 24 hours after submitted
request tolls 30-day advance notice until request forwarded
(3) Resident or legal representative may request a hearing within 90
18
Fla. Stat. §400.022 (2007); Id. at §400.0255 (2011).
9 Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
days after resident’s receipt of discharge notice
(4) Office of Appeals Hearings conducts hearing within 90 days of
request and must notify facility of a resident’s request
(5) Aggrieved party may appeal to the district court of appeals
(6) Representative of local LTC ombudsman council may be
present at all hearings
GEORGIA19
(1) In an emergency where resident or other residents subject to
imminent and substantial danger that only immediate discharge will
relieve, facility may involuntarily transfer to another health facility;
(2) Resident’s physician determines that failure to transfer resident
will result in injury or illness to the resident or others
Non-payment of allowable fees has occurred
If “Behavior (1)” person in charge documents reasons in resident’s
file and immediately informs resident and guardian of resident’s
choice regarding transfer and place where resident to be transferred
Written notice to resident, representative, and resident’s physician
At least 30 days before proposed discharge
(1) Reasons for, effective date, and location to which discharged;
(2) Notice of right to a hearing, and of right to representation by
legal counsel. If resident so desires, facility must also send a copy
of such notice to community or state ombudsman
(1) Oral or written complaint to administrator if believe discharge
rights violated; (2) Facility must provide appeal rights, name and
phone number of community or state ombudsman
HAWAII20
See federal “Discharge Requirements” (i)(iii)(iv)
See federal “Discharge Requirements” (v)
(1) Written documentation of reason for discharge and efforts made
to mitigate any stress that may arise and that resident understood
reason, or that duly authorized healthcare decision maker and
family notified; (2) Complete summary including current status and
care, final diagnosis, and prognosis
Except in case of an emergency, resident or legal guardian, family,
or surrogate and attending physician must be informed in advance
Not addressed
Not addressed
Not addressed
IDAHO21
Welfare of (1) resident or (2) other patients or residents
See federal “Discharge Requirements (v)”
Discharge is documented in medical record
19
Ga. Comp. R. & Regs. 111-8-50-.11 (2013).
Haw. Code. R. § 11-94.1-36 (2011); Id. at § 11-94.1-22 (2011). 21
Idaho Admin. Code r. 16.03.02.203 (2013).
20
10 Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Patient given reasonable advance notice to ensure orderly discharge
Not addressed
Not addressed
Governed by Idaho Admin. Code r. 16.05.03 (2006)
ILLINOIS22
(1) Medical reasons; Physical safety of (2) resident, (3) other
residents, (4) facility staff or facility visitor. Notify Department
(1) Late or non-payment. If payment not received within 45 days
after bill, may request resident and responsible party for
payment within 30 days. If not then paid, send discharge notice
to resident, responsible party by registered or certified mail
(2) Notice must state that responsible party has right to pay bill
amount in full up to date of discharge and then may remain
Discharge information completed within 48 hours after discharge.
Staff must record date, time, condition, to whom released, planned
destination and place a copy of notice in medical record. If physical
safety of other residents endangered, document in medical record
Written notice sent to Department, resident, representative, and, if
care is paid for through Title XIX, to the Department of Public Aid
21 days notice, except as soon as practicable when discharge
because of resident’s health care needs, “Behavior (3) or (4),” or
identified offender in provisional admission period
(1) Reason and effective date of discharge
(2) See Ill. Admin. Code tit. 77, § 300.3300 for required statement
(3) Hearing request form and a postage paid, preaddressed envelope
to the Department of Public Health
(4) Name, address, and phone number discharge supervisor
(1) Resident, guardian or if a minor, parent may file a request for a
hearing with Department within 10 days of receipt of notice
(2) Hearing held at facility within 10 days after request is filed and
decision within 14 days after filing of hearing request
(3) If discharge proper, resident not discharged before 34th day of
notice receipt or 10th day after receipt of discharge decision,
whichever is later, unless “Timing of Notice” exception occurs
(4) Within 10 days following discharge, facility or resident may
send a written challenge Department for a hearing. Hearing will
be held within 30 days of receipt of the request
a. If facility prevails, it may file a claim against the State for
payments loss less expenses saved as a result of discharge
b. If resident prevails, resident may file a claim against State
for any excess expenses directly caused by discharge
c. Hearing request stays discharge pending hearing or appeal
22
Ill. Admin. Code tit. 77, § 300.3300 (2011); Id. at §300.1810(k) (1999). 11 Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
of the decision, unless “Timing of Notice” exception
INDIANA23
See federal “Discharge Requirements” (i)(iii)(iv)
See federal “Discharge Requirements” (v)
See federal “Documentation.” Notice in clinical record
(1) Resident, legal representative or interested family of and
reasons for discharge in writing and in a language and manner
that the resident understands
(2) Local LTC ombudsman program and person or agency
responsible for placement, maintenance, and care in the facility
(3) In resident developmentally disabled, regional office of division
of disability, aging, and rehabilitative services
(4) Resident’s physician when federal “Discharge Requirements”
(iii)(iv)(v)
See federal “Timing of Notice”
(1) Reason, effective date, and location to which discharged; (2)
See 410 Ind. Admin. Code 16.2-5-1.2 for required statement; (3)
Division’s director, address, phone number, and operation hours;
(4) Hearing request form; (5) Name, address, and phone number of
division and local LTC ombudsman; (6) Mailing address and phone
number of protection and advocacy services commission for
residents with developmental disabilities or who are mentally ill
(1) If resident appeals, facility may not discharge within 34 days
after resident receives initial notice, unless an emergency
(2) May file hearing request within 10 days of receipt of notice
(3) Department will hold informal hearing at facility within 23 days
from date resident received notice and issue decision within 30
days from date resident received notice
(4) If discharge appropriate, cannot discharge within 34 days after
receipt of initial notice unless emergency
(5) Both parties have the right to administrative or judicial review
IOWA24
(1) Uncontrollable residents discharged in accordance with contract
arrangements and requirements of Iowa Code 135C; (2) Medical
reasons, resident’s of other residents’ welfare (defined as social,
emotional, or physical well-being).
May remain in facility if makes full payment up to discharge date
Copy of notice and discharge notes in record
Personally deliver copy of notice to resident. Copy to department,
responsible party, physician, person or agency responsible for
placement, maintenance, and care in facility, and department on
23
410 Ind. Admin. Code 16.2-3.1-12 (West 2013); Id. at 16.2-5-1.2 (West 2013); Id. at
16.2-3.1-36 (West 2013).
24
Iowa Admin. Code r. 481-58.40 (2013); Id. at 58.12 (2013) Id. at 58.16 (8) (2013); Id.
at 58.15(2)(h)(3) (2013).
12 Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
aging LTC ombudsman
(1) 30 day written notice unless emergency discharge to protect
health, safety, or well-being of other residents and staff; (2) For
emergency “Behavior” written notice to resident prior to or within
48 hours following discharge
(1) Reason and effective date of proposed discharge; (2) See Iowa
Admin. Code r. 481- 58.40 (d), (l) for required statement and postdischarge conversation with resident; (3) See Iowa Admin. Code r.
481- 58.40 (n) for required “Behavior” statement
(1) Request for a hearing stays the discharge; (2) Notice of date,
time, and place of hearing sent by certified mail or delivered in
person to licensee, resident, responsible party, and department on
aging LTC ombudsman 5 full business days after request receipt
(2) Request for review made within 15 days of issuance of proposed
decision and mailed or delivered by either party to Director,
Department of Inspections and Appeals, Lucas State Office
Building, Des Moines, IA 50319-0083. Failure to do so precludes
judicial review unless department reviews upon own motion
KANSAS25
See federal “Discharge Requirements” (i)(iii)(iv)
See federal “Discharge Requirements” (v)
Record reason in clinical record. If
federal “Discharge
Requirements” (i), by resident’s physician. If federal “Discharge
Requirements” (iii) or (iv), by any physician.
See federal “Notice Before Discharge” (i)
30 days unless safety of other individuals in home endangered or
resident’s urgent medical needs require transfer to another facility
(1) Reason for and effective date of discharge; (2) Addresses and
phone numbers of department on aging complaint program and state
LTC ombudsman, and if required, developmentally disabled or
mentally ill, advocacy and protection organizations
Not addressed
KENTUCKY26
See federal “Discharge Requirements” (i)(iii)(iv); For NFs, health
or safety of individuals in facility must be immediately endangered
See federal “Discharge Requirements” (v)
Reasons in clinical record; by a physician if health of individuals
would otherwise be endangered
(1) Notify resident and, if known, a family member or legal
representative, in writing, of and reasons for discharge in a
language and manner they understand
(2) For SNFs, patient, next of kin, or responsible person, and
25
Kan. Admin. Regs. § 26-39-102 (2009); Id. at §26-39-103 (2009).
902 Ky. Admin. Regs. 20:300 (1991); 902 Ky. Admin. Regs. 20:026 (2011); 900 Ky.
Admin. Regs. 2:050 (2010).
26
13 Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
attending physician must be consulted in advance of discharge
30 days, except as soon as practicable if “Behavior” or has not
resided in facility for 30 days
(1) Reason for and effective date of discharge
(2) Location to which resident is discharged
(3) Statement that resident has right to appeal to the cabinet
(4) Name, address, phone number of state LTC ombudsman
(5) For NF residents with developmental disabilities, or who are
mentally ill, the mailing address and phone number of Department
of Kentucky Protection and Advocacy
Resident, or person acting on resident’s behalf, may request cabinet
review and must do so in writing within 15 days of receipt of notice
LOUISIANA27
See federal “Discharge Requirements” (i)(iii)(iv)
See federal “Discharge Requirements” (v)
Not addressed
Not addressed
30 days notice; if emergency, as soon as practicable. If nonpayment
and facility does not participate in MA reimbursement, 15 days
Not addressed
Resident, legal representative or interested family member can
appeal to Department of Health and Hospitals, which will provide a
fair hearing in all such appeal
MAINE28
See federal “Discharge Requirements” (i)(iii)(iv)
See federal “Discharge Requirements” (v)
See federal “Documentation”
See federal “Discharge Before Notice”
See federal “Timing of Notice”
(1) See federal “Contents of Notice;” (2) Provide lists of licensed
providers of care and services prior to discharge for whom home
health care is needed; (3) Right to self-represent or by legal counsel,
a relative, friend or other spokesman
Right to appeal to Administrative Hearings Unit of the Department
MARYLAND29
(1) Necessary for resident’s welfare and needs cannot be met; (2)
Resident’s presence endangers health or safety of other individuals
in nursing facility
See federal “Discharge Requirements (v)
(1) Notice and circumstances surrounding the discharge, including
interventions initiated by facility before proposing discharge and
27
La. Admin Code. tit. 48, pt. I, § 9733 (1993).
10-144 Me. Code. R. § 10. Q (2013); Id. at §10.D (2013).
29
Md. Code Regs. 10.07.09.10 (2010); Id. at 10.07.09.11 (2013); Id. at 10.07.09.13
(2010). 28
14 Discharge Notice
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Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
reasons necessary in clinical record; (2) For “ Behavior (1),” by
resident’s physician; (3) For “Behavior (2),” by a physician
Except in emergency situations such as a hospitalization, or not
resided in facility for 30 days, notify resident, representative, or
interested family member, State LTC Ombudsman, and Department
30 days, except as soon as possible in an emergency, then ASAP
(1) Reason and effective date; (2) Statement that can request, within
30 calendar days of notice receipt, a hearing to the Administrative
Hearings Office; (3) Name, address, and phone number of State’s
Office on Aging and local aging LTC ombudsman; (4) Right to
consult with a lawyer; (5) Name, address, and phone number of
Legal Aid Bureau, Older American Act Senior Legal Assistance
Programs; (6) If developmentally disabled or mentally ill, mailing
address and phone number of agency for protection and advocacy
(1) Except in emergency or not resided in facility at least 30 days,
after a request for a hearing, discharge stayed until a final decision
is issued; (2) When non-payment and resident resides in facility
pending decision, facility may establish an escrow account
MASSACHUSETTS30
(1) If in opinion of facility or Department, resident poses a danger
to self or health and welfare of other residents or staff, the attending
physician, physician-PA or physician-NP team, and the Department
must be notified and arrangements made for transfer to a facility
providing more appropriate care; (2) Needs can no longer be met
due to change in physical or mental condition
Yes, discharge report and forms sent to Department
Physician, PA or NP’s order and copy of notice in clinical record
Notice to next of kin or sponsor
At least 30 days before discharge date, may vary with level of care
and whether able to set up receiving facility during emergency
(1) Explanation for, including discharge plans and procedures
(2) Statement of right to object, which will be noted in record
Not addressed
MICHIGAN31
(1) Medical reasons
(2) Welfare of patient, other patients or nursing home employees
(1) Non-payment of stay; (2) Maintain a record of efforts to collect
payment; (3) If redeems up to discharge date, may remain in facility
Reasonable advanced notice actions in medical record
Facility administrator and employees must discuss reasons with
patient or guardian. Notice to department of consumer and industry
services, patient, next of kin, representative or legal guardian, and
30
105 Mass. Code Regs. 150.003(G) (1994).
Mich. Comp. Laws Ann. § 333.21773 (West 2001); Id. at § 333.20201(3)(e) (2011); Id.
at § 333.21774 (2013); Id. at 333.21776 (2013); Mich. Admin. Code r. 325.20116 (2013).
31
15 Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
person or agency responsible for placement, maintenance, and care
30 days, unless discharge mandated by patient’s health care needs
or physical safety of other patients and nursing home employees
(1) Reason and effective date; (2) Hearing request form, with a
postage paid, preaddressed envelope to the department; (3) Name,
address, and phone number of department official; (4) Required
statement of Mich. Comp. Laws Ann. § 333.21773 (3)(c)
(1) Hearing request to department within 10 days of notice receipt
stays discharge until decision; (2) Informal hearing at facility not
sooner than 7 days after request filed; (3) Written decision within
14 days after request filed is final and not subject to further
administrative appeal; (4) If discharge allowed, patient not required
to leave before 34th day after notice receipt or 10th day after receipt
of department’s decision, whichever is later
MINNESOTA32
Adopts federal “Discharge Requirements” Minn. R. 4658.0015
Adopts federal “Discharge Requirements” Minn. R. 4658.0015
Discharge summary, including service termination notice and
related documentation in medical record
Written notice and its justifications to resident
No later than 30 days before discharge; however may be shortened
by situations outside facilities control, such as other resident’s
welfare or non-payment, as documented in medical record
Statement that right to contest discharge and the address and phone
number of the area nursing home ombudsman
(1) Request hearing in writing no later than 30 days after receiving
written notice will stay discharge; (2) Hearing held within 14 days
after request received; (3) Right to request or receive help from
LTC Ombudsman or Office of Health Facility Complaints
MISSISSIPPI33
Medical reasons; Welfare of resident or other residents
Nonpayment (except as prohibited by 3rd party payment sources)
Copy of notice and discharge summary in medical records. Must be
completed within 60 days following discharge and retained 5 years
from date of discharge, or if minor, until 21 years old, plus 3 years
Written notice to resident
2 weeks advance notice
Date and reason of discharge
Not addressed
32
Minn. Stat. §144A.135 (2007); Id. at §144.651, subd. 29 (2013); Minn. R. 4658.0465
(2007).
33
15-16-1:45 Miss. Code R. §17.2 (2012); Id. at §25.1 (2012).
16 Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
MISSOURI34
(1) See federal “Discharge Requirements” (except for “Discharge
Requirements (i)” discharge where appropriate because of
resident’s welfare and needs cannot be met by the facility)
(2) Welfare of other residents
See federal “Discharge Requirements”
(1) See federal “Documentation;” (2) Facility administrator or DON
must document reason in clinical record prior to date resident
receives notice or prior to time facility decides to discharge
(1) See federal “Notice Before Discharge” (i). If no family, copy
sent to regional coordinator at Ombudsman’s office
(2) May require notice to responsible agency
See federal “Timing of Notice”
(1) Reason for, effective date, and location to which discharged
(2) Right to appeal to director of Division of Aging or designated
hearing official within 30 days of receipt of the notice and
address to send hearing request
(3) Filing an appeal will allow stay in facility until the hearing held
(4) Name, address and phone number of regional LTC ombudsman
office. For residents with developmental disabilities or who are
mentally ill, the mailing address and phone number of the
Missouri Protection and Advocacy Agency
(5) If emergency, advise of right to request expedited hearing
(1) Legal guardian, attorney-in-fact or other individual may file
appeal on resident’s behalf
(2) Written notice of hearing must contain date and time of hearing
and mailed at least 10 days before hearing to facility, resident or
legally authorized representative, and to all parties in interest,
including any family members who received discharge notice
(3) May be a conference call or in person at any location deemed
reasonably appropriate to accommodate resident’s needs
(4) May obtain legal counsel, self-represent, or use a relative/ friend
(5) If decision upheld, resident has 10 days after decision received
to relocate; facility must assist in making suitable arrangements
(6) If discharge inappropriate, may remain in facility. If already
discharged, facility must notify resident, representative, or any
other responsible party who will assure that resident made
aware of decision and that may return to the facility
MONTANA35
See federal “Discharge Requirements;” an appropriate nursing
facility bed is available within 25 mile radius of swing-bed hospital
See federal “Discharge Requirements” (v)
See federal “Documentation;” Reason in clinical record
34
35
Mo. Code Regs. Ann. tit. 19, § 30-82.050 (1995); Id. at § 30-88.010 (2008).
Mont. Code. Ann. § 50-5-1104 (1997); Mont. Admin. R. 37.40.420–21(2004).
17 Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
See federal “Notice Before Discharge”
See federal “Timing of Notice”
(1) See federal “Contents of Notice”
(2) Method by which may obtain a hearing and that can self
represent or by legal counsel, relative, friend or other spokesperson
Requests for notice forms may be made to Department of Public
Health and Human Services, Senior and Long Term Care Division,
111 N. Sanders, P.O. Box 4210, Helena, MT 59604-4210
NEBRASKA36
(1) For medical reasons based on resident’s needs, as determined
and documented by a physician
(2) Safety of resident, other residents or facility employees
Non-payment of stay, except as prohibited by federal and state law
Not addressed
Written notice to resident or designee
30 days in advance. 10 days if resident 5+ days in payment arrears.
No notice if emergency “Behavior” discharge
(1) Reason and effective date of discharge
(2) See 175 Neb. Admin. Code §12-006.05 for required statement
Not addressed
NEVADA37
(1) Facility can no longer provide for patient’s needs and discharge
is necessary for the patient’s welfare; (2) Health or safety of other
persons in facility is endangered if patient remains in facility
Charges for services not paid after notice of those charges
(1) Reasons in medical record; (2) If “Behavior (1),” resident’s
physician; (3) If “Behavior (2),” by a physician
See federal “Notice Before Transfer”
Federal “Timing of Notice”
See federal “Contents of Notice”
Not addressed
NEW HAMPSHIRE38
(1) Medical reasons, patient’s welfare or that of other patients;
(2) Health or safety of other individuals in the facility
See federal “Discharge Requirements”
(1) Basis for discharge in clinical records. Consult patient’s
physician or APRN prior to discharge for welfare of other patients;
(2) If “Behavior (2),” documented by any physician or ARPN in
clinical record; (3) When “Non-payment,” make and document
36
175 Neb. Admin. Code §12-006.05 (2013); Id. at § 12-006.16G2 (2013); Id. at §§ 12006.09C2–C3 (2013).
37
Nev. Admin. Code §449.74429 (1999); Id. at § 449.74431 (1999).
38
N.H. Rev. Stat. Ann. § 151:21 (2009); Id. at §151:26 (2009); N.H. Code Admin. R.
Ann. He-E 802.16–.18 (2011)
18 Discharge Notice
Timing of Notice
Notice Contents
Appeals
reasonable efforts to resolve payment prior to discharge with
resident, family, or legal representative; (4) Document delivery of
notice to the resident by requesting resident’s signature on a dated
statement of receipt; recording date of delivery to resident in
resident’s record and whether and when notice mailed to family
members or legal representative
(1) Patient, personal representative, legal guardian, family member,
if known, in accordance with resident’s instructions/ limitations
LTC ombudsman, and the federally designated protection and
advocacy agency for individuals with disabilities
(2) When notice delivered to resident, facility staff must orally(a)
communicate all information contained in the written notice, or, if
hearing-impaired or cannot communicate orally due to a disability,
consult DEAS to make accommodations; (b) Offer to contact a
family member, legal representative, state LTC ombudsman, or any
organizations identified in notice; (c) Document date and time of
notice and offer of assistance in resident’s record; (d) Provide
written material describing discharge rights
At least 30 days notice from date resident received notice except
when facility has explored other reasonable alternatives, and
documented these in resident’s record, but discharge is necessary
because resident’s health care needs, “Behavior (2),” or has not
resided in facility for 30 days
(1) Basis for, effective date, and location to which discharged
(2) Required statement in N.H. Rev. Stat. Ann. § 151:26(II)(a)(5)
(3) Statement that right to make written request of a hearing within
90 days of receipt of notice and that may self-represent or use
legal counsel, a relative, a friend or another advocate
(4) Statement that if request filed within 20 days, resident remains
in facility and that MA payments to facility continue until final
decision is made
(5) If less than 30 days notice allowed, right to an expedited hearing
within 10 calendar days of the notice discharge
(6) Name, mailing address, phone number of state LTC
ombudsman and statutory responsibilities of that office
(7) 60+ years, the name, address and phone number of the provider
of legal services under Title VII of the Older Americans Act
(8) For residents with developmental disabilities or who are
mentally ill, the mailing address and phone number of agency
responsible for the protection and advocacy of such persons
(1) Expedited hearing held within 5 working days of the request for
hearing and decision issued within 3 working days of hearing;
Decision issued within 15 working days in all other cases
(2) Request for a hearing must be submitted in writing, with a copy
of discharge notice to DHS
(3) Resident, legal representative certified facility, the department,
19 Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Miscellaneous
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
a family member or a friend may request such hearing
(4) When feasible, all hearings conducted at resident’s facility and
resident has right to certain medical records
(5) If discharge upheld, resident will be relocated
NEW JERSEY39
(1) Emergency; (2) Medical reasons; Protect welfare of (3) resident
or (4) others
See federal “Discharge Requirements”
Reason recorded in medical records
Written notice to resident and next of kin or guardian
30 days, except in case of emergency with notification of resident’s
physician or advance NP and next of kin or guardian
Name, address, and phone number of the New Jersey Office of the
Ombudsman for the Institutionalized Elderly
Not addressed
No resident can be discharged between 5:00 P.M. and 8:00 A.M.,
except in an emergency or with consent of responsible person
NEW MEXICO40
Welfare of (1) resident or (2) other residents; (3) Health and safety
of others
Nonpayment, after 7 days’ notice and opportunity to pay deficiency
Reasons other than failure to pay documented by a physician
Resident, physician and guardian, relative, or responsible person
At least 30 days unless continued presence of resident endangers
the health, safety, or welfare of the resident or other residents
(1) Right to appeal; (2) Name and address of ombudsman; (3) Time
and place of planning conference and any person of resident’s
choice may attend; (4) Procedure for submitting a complaint
Not addressed
NEW YORK41
Interdisciplinary care team, with resident or representative,
determines that (1) necessary for resident's welfare and needs
cannot be met after reasonable attempts at accommodation in the
facility or (2) health or safety of individuals in facility would
otherwise be endangered, risk to others more than theoretical and all
reasonable alternatives to discharge have been explored and failed
to safely address the problem
See federal “Discharge Requirements.” Only allowed if charge not
in dispute, appeal of denial of benefits is not pending, or funds are
actually available and resident refuses to cooperate in obtaining
funds for payment
39
N.J. Admin. Code § 8:39-4.1 (2011); Id. at 8:39-5.4 (2011). Note: Sunsets in Feb.
2014, expected to be renewed
40
N.M. Code R. §7.9.2.22(K) (2013); Id. at § 7.9.2.38 (2013).
41
N.Y. Comp. Codes R. & Regs. tit. 10, § 415.3 (1997).
20 Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
See federal “Documentation”
See federal “Notice Before Discharge”
(1) See federal “Timing of Notice”
(2) Except in medical emergency, consult resident immediately if
competent, and notify resident’s physician and representative
within 24 hours when there is a “Behavior” discharge decision
(1) Statement that right to appeal and phone number of State
Department of Health; (2) Name, address and phone number of
LTC ombudsman; (3) For residents who are mentally ill or
developmentally disabled, the mailing address and phone number of
the Commission on Quality of Care for the Mentally Disabled; (4)
Statement that if resident appeals within 15 days of being notified
of discharge may remain in facility pending appeal determination.
(Does not apply if “Behavior” discharge requiring less than 30 days
notice)
(1) Post-transfer appeal determination within 30 days of transfer if
did not request an appeal determination prior to transfer and
may return to first available bed if resident wins the appeal
(2) Department reviews, renders decision within 15 days of request
(3) If discharge inappropriate, facility must readmit to first bed
NORTH CAROLINA42
(1) Medical reasons; Welfare of (2) patient or (3) other patients
See federal “Discharge Requirements”
Medical order for discharge obtained for all patients except when
discharged for “Non-payment”
Patient or legal representative
At least 5 days advance notice, unless attending physician orders
immediate transfer, and reasons documented in medical record
Not addressed
Not addressed
NORTH DAKOTA43
Not addressed
Not addressed
Condition on discharge in record
Not addressed
Not addressed
Not addressed
Not addressed
OHIO44
See federal “Discharge Requirements”
See federal “Discharge Requirements,” Not considered non-
42
N.C Gen. Stat. § 131E-117 (1997); 10A N.C. Admin. Code 13D.2205 (2013).
N.D. Admin. Code 33-07-03.2-17 (1996).
44
Ohio Rev. Code Ann. § 3721.13 (West 2013).
43
21 Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
payment if resident applied for MA, unless application has been
denied and resident appealed denial, which was upheld
Not addressed
Not addressed
Not addressed
Not addressed
Not addressed
OKLAHOMA45
(1) Medical reasons; Safety of (2) resident or (3) other residents
30+ days of non-payment as documented by business records
For “Behavior,” document in clinical record that interdisciplinary
team performed a comprehensive assessment and alternative
measures unsuccessful or that resident is a danger to self or other
residents, and that facility not capable of managing that resident
Written notice to resident, legal representative and person who pays
for care charges, if different, and Department
30 days in advance of discharge date, except when mandated by
resident’s health needs. 10 day notice on rare occasions when
physical safety of other residents endangered after alternative to
redirect resident behavior have been exhausted
(1) Full explanation of reasons; (2) Notice date and date given to
resident and representative; (3) Date by which resident must leave;
(4) That representative or person responsible for payment may file
within 10 days of notice a written request for a hearing
(1) If timely, written request, Department must convene a hearing
within 10 working days of receipt. Request should state reason
for discharge and attach a copy of facility’s letter
(2) Cannot discharge during pending hearing unless emergency
(3) Required to readmit relocated resident to first available bed in a
semi-private room if discharge not proper
(4) Parties may be represented by counsel or self-represent
(5) Hearing held at Oklahoma State Department of Health building
(6) Written decision within 10 working days of close of record
(7) If ALJ finds improper discharge, Department must review,
investigate, and issue deficiencies as appropriate
(8) If discharge proper, facility has the right to discharge resident
(9) Facility’s failure to give proper notice results in discharge denial
OREGON46
(1) Facility unable to meet resident’s care needs and has identified
another environment available which can better meet needs
(2) Medical emergency of resident
(3) Division Administrator or State Fire Marshal states in writing
that safety of other persons in facility is endangered and justifies
45
46
Okla. Admin. Code § 310:675-7-4 (2009).
Or. Admin. R. 411-088-0000– 411-088-0080 (1993); Id. at 411-086-0160 (1993).
22 Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
transfer (Life or Safety Threat)
(4) Resident’s behavior creates a serious and immediate threat to
other residents or persons in facility and all reasonable
alternatives to transfer have been attempted and documented in
medical record (Behavior Problem)
(5) May not be transferred for Life of Safety Threat or Behavior
Problem if risk of physical or emotional trauma significantly
outweighs risk to other residents
(6) May discharge resident convicted of a sex-crime under Or.
Admin. R. 411-080-0020 if certain requirements are met
Cannot transfer if delinquent charges are paid or presents a
substantial risk of morbidity or mortality to resident
Keep in resident’s record the name, address, and phone number of
legal representative, if any, and of any person designated by
resident or legal representative to receive transfer notice
(1) Must consider certain factors prior to issuing discharge notice
including resident’s community ties and available alternatives
(2) Resident and all persons required to be listed in medical record
(3) Aging and People with Disabilities Division or Type B Area
Agency on Aging unless private pay and less than 30 day stay
(4) LTC Ombudsman if no one currently involved and designated
by the resident
(5) If still resides at the facility, notice must be served personally
(6) All other notices, including former residents, must be either
served personally or delivered by registered or certified mail
Written notice 30 days prior, unless Life or Safety Threat or
Behavior Problem, then less than 30 days allowed. Minimum 14
days prior written notice for Life or Safety Threat
Notice must be accompanied by a copy of Aging and People with
Disabilities Division’s brochure, “Leaving the Nursing Facility”
(1) Right to return or be readmitted if appeal request made within
180 days of transfer date, and still required nursing facility care
and is eligible by means of payment
(2) Facility must provide written notice, mailed (registered or
certified), or delivered in person within 5 days from the date of
request for return or readmission is denied
(3) Resident, agency designated to receive the notice, or person
acting on resident’s behalf, may request an informal conference
within 10 days of service or delivery of notice
(4) Facility employee who provides direct care and receives oral or
written desire for an informal conference from resident must
notify facility administrator, who then notifies the Division
(5) Cannot be transferred until disposition of request completed to
parties’ satisfaction or authorization by Hearings Officer
(6) Informal Conference held within 10 days after request received
(7) Division must give phone notice and send written notice of
23 Miscellaneous
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
conference time and place (generally facility) to facility and all
persons entitled to notice.
(8) If a resolution is met, it will be reduced to writing and no formal
hearing held. If facility wishes to proceed with transfer,
Division must ask if resident wishes to request a formal hearing.
(9) If requested, hearing held within 30 days of informal conference
(10) Division must provide all persons and entities listed in OAR
411-088-0070(3) and the licensee with hearing notice, which
must be served personally or by registered or certified mail.
(11) Findings and an order issued at conclusion of hearing
affirming facility’s decision, granting conditional approval, or
ordering facility to retain or readmit resident
(12) If transferred or refused right of return or readmission as a
result Life or Safety Threat, not entitled to a hearing prior to
transfer
“Transfer”: termination of an individual as facility resident
PENNSLYVANIA47
(1) Medical reason; Welfare of (2) resident or (3) other residents
See federal “Discharge Requirements,” reasonable effort to collect
Actions documented in record
Written notice to resident and responsible person
30 days unless emergency
Not addressed
Not addressed
RHODE ISLAND48
Welfare of other residents
See Federal “Discharge Requirements”
Medical records must be completed within 60 days with all clinical
information pertaining to stay and diagnosis at discharge made part
of medical record and signed by a physician
Reasonable advance notice for transfer to a health care facility
Not addressed
Not addressed
Not addressed
SOUTH CAROLINA49
(1) Medical reasons; Welfare of (2) resident or other residents
See Federal “Discharge Requirements”
Not addressed
Written notice to resident. Where other residents endangered, notify
a family member within 24 hours following transfer
At least 30 days, except when health, safety, or welfare of residents
47
28 Pa. Code § 201.25 (1999); Id. at § 201.29 (1999).
23-17- R.I. Code R. §§ 17.3–.5; 19.18; 21.5 (2013).
49
S.C. Code Ann. §44-81-40 (1994); S.C. Code Ann. Regs. §1013 (2012).
48
24 Notice Contents
Appeals
Miscellaneous
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
would be endangered, then practicable under the circumstances
Not addressed
Not addressed
If require care and/or supervision, must be discharged to a location
licensed and appropriate for resident’s needs and abilities
SOUTH DAKOTA50
Safety or health of individuals in the facility is endangered
Failed to pay for allowable billed services as agreed
Not addressed
(1) Written notice to resident and family member or client advocate
(2) Immediately inform resident, consult with resident’s physician,
and notify legal representative or interested family member
At least 30 days before discharge unless resident has not resided in
facility for 30 days
(1) Reason for, effective date, and location to which discharged
(2) Description of how to appeal discharge
Facility must have a policy that describes how to appeal
TENNESSEE51
(1) In general, no discharge without a written order from attending
physician or through other legal processes; (2) Medical reasons; (3)
Welfare of resident; (4) Welfare of other residents
Non-payment, except as prohibited by Medicaid
Medical records must be completed within 30 days after discharge
(1) Timely notice to next of kin and/or sponsor or authorized
representative, if any
(2) No involuntary discharge until nursing home has first informed
the department and the area LTC ombudsman.
No involuntary discharge can be made until 5 business days after
above agencies have been notified
Provide resident with brief description of significant findings and
events of resident’s nursing home stay, condition on discharge and
the recommendation and arrangement for future care, if any
When attending physician has ordered a discharged, but resident or
a representative opposes, nursing home must counsel with resident,
next of kin, sponsor and representative in an attempt to resolve the
dispute and cannot transfer until such counseling has been provided
TEXAS52
See federal “Discharge Requirements” (i)(iii)(iv)
See federal “Discharge Requirements” (v)
(1) See federal “Documentation”
50
S. D. Admin. R. 44:04:17:14 (1995); Id. at 44:04:17:04 (1995).
Tenn. Comp. R. & Regs. 1200-8-6-.05 (2007); Id. at 1200-8-6-.12 (2005); Id. at 12008-6-.06 (5)(i)(8)–(9) (2007).
52
40 Tex. Admin. Code. §19.502 (2013); Id. at §19.403 (2008); Id. at §19.408 (2006); Id.
at §19.803 (1995).
51
25 Discharge Notice
Timing of Notice
Notice Contents
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Miscellaneous
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
(2) Document and state discharge reasons in clinical record
(1) See federal “Discharge Before Notice”
(2) When immediate involuntary discharge because of “Behavior”
facility must immediately call state office LTC-R Customer
Service Section of the Texas DHS to report discharge intention
and submit required physician documents regarding discharge
See federal “Timing of Notice”
See federal “Contents of Notice”
(1) If appeals “Behavior” discharge within required 10 days from
notice, may remain in facility and have vendor payments and
eligibility continue until final determination. (Does not apply to
“Non-payment”)
(2) When discharge inappropriate, facility must readmit to the next
available bed. If discharge has not yet taken place, the facility
must allow resident to remain
(3) Resident notified in writing when discharge deemed appropriate
and any payments made on resident’s behalf past date of
discharge or decision, whichever is later, must be recouped
See 40 Tex. Admin. Code. §§19.502 (j) for discharge of spouse
UTAH53
(1) Medical reasons, for personal welfare or that of other residents
(2) See federal “Discharge Requirements”
See Federal “Discharge Requirements”
Document and record reasons in medical record. Made by a
physician if discharge because safety or health of individuals in
facility is endangered
See federal “Discharge Before Notice”
See federal “Timing of Notice”
(1) See federal “Contents of Notice”
(2) Name, address, and phone number of local LTC Ombudsman
Not addressed
VERMONT54
(1) See federal “Discharge requirements”
(2) Medical reasons, welfare of resident or other residents
(3) In addition, an discharge if ordered by a court
(1) See federal “Discharge Requirements”
(2) Right to redeem in full up to discharge date and then may
remain in facility
Circumstances and reasons documented in clinical record and made
by resident’s physician if discharge for resident’s welfare, health or
safety of individuals in facility endangered or “Non-payment”
See federal “Notice Before Discharge”
53
Utah Admin. Code. r. 432-150-12 (2011); Id. at 432-150-13(5) (2011); Id. at 432-15022 (2011); Id. at 432-150-25 (2011).
54
Vt. Stat. Ann. 33, § 7301 (2003); 13-110-005 Vt. Code. R. § 3.14 (2001).
26 Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
Non-Payment
Documentation
Discharge Notice
30 days before discharge except less than 30 days for emergency if:
(1) Resident’s attending physician documents emergency discharge
is necessary for resident’s welfare or health and safety of other
residents (then as soon as practicable) or
(2) Presents an immediate threat to health or safety of others
a. Permission from licensing agency to immediately discharge
b. Permission not necessary when immediate threat requires
police, mental health crisis personnel, or EMS intervention
and in whose professional judgment discharge must occur
immediately. Notify licensing agency next business day
(3) When ordered or permitted by a court
(1) See federal “Contents of Notice”
(2) How to appeal to state
(3) Statement that resident may remain in place pending the appeal
(1) Notify facility administrator or licensing agency director orally
or in writing of appeal within 10 business days of notice receipt
(2) Director issues decision within 8 business days of appeal receipt
(3) Decision sent to resident and facility and will state that decision
may be appealed to Human Services Board with information on
how to do so
(4) Either party has 10 business days to file a written request for an
appeal.
(5) Board will conduct a de novo evidentiary hearing
VIRGINIA55
Safeguard other patients from physical or emotional injury
See federal “Notice Before Discharge”
Except in an emergency involving patient's health or well being,
attending physician or facility’s medical director must make written
documentation of approval in record after considering and taking
appropriate actions to minimize discharge effects
Reasonable advance written notice given to the patient
At least 5 days prior to discharge
Not addressed
Not addressed
WASHINGTON56
See federal “Discharge Requirements” (i)(iii)(iv)
See federal “Discharge Requirements” (v)
Not addressed
(1) Resident, surrogate decision maker, if any, family and the
department in writing and language the resident understands
55
Va. Code Ann. § 32.1-138.1 (1993); 12 Va. Admin. Code § 5-371-150 (2011); Id. at §
5-371-10.
56
Wash. Rev. Code § 74.42.450 (2013); Wash. Admin. Code § 388-97-0120 (2008); Id.
at § 388-97-0080 (2008); Id. at § 388-97-0040 (2008); Id. at § 388-97-0140 (2008); Id. at
§ 388-97-0320(1)(d); Id. at § 388-97-0160 (2008).
27 Timing of Notice
Notice Contents
Appeals
Miscellaneous
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Behavior
(2) Immediate written notification of discharge date of medicaid
resident to department’s local home and community service
office
(3) Send a copy of notice to department’s designated local office
when discharge is because “Discharge” or “Non-payment”
See federal “Timing of Notice.” As soon as practicable when cannot
meet resident’s urgent medical needs or 15 days advance notice
when safety or health of other individuals endangered
(1) See federal “Contents of Notice”
(2) Attach a department-designated hearing request form to notice
(3) Inform that appeal request may be made up to 90 days from date
resident receives notice, discharge stayed when request received
by administrative hearings office, and that facility will assist
resident in requesting a hearing to appeal discharge decision
(1) Department must be notified of the appeal and may choose to
participate in the proceedings. In such case, it represent the
state’s interest in assuring that SNF and NF discharges comply
with the law and requirements necessary for federal funds
(2) If a MA certified facility’s discharge not upheld, and resident
has been relocated, resident has right to immediate readmission
to first available bed in a semi-private room if resident requires
and is eligible for the services provided by a NF or SNF
(3) If resident appeals a department discharge decision, cannot
discharge without resident’s consent until at least 30 days after a
final order is entered upholding the decision to discharge
See Wash. Admin. Code § 388-97-1040 for residents with dementia
WEST VIRGINIA57
See federal “Discharge Requirements” (i)(iii)(iv)
See federal “Discharge Requirements” (v)
Reason in clinical record and made by resident’s physician when
federal “Discharge Requirements (i)(iii)(iv)”
See federal “Notice Before Discharge”
See federal “Timing of Notice”
See federal “Contents of Notice”
Not addressed
WISCONSIN58
(1) Requires care other than that which facility licensed to provide
(2) Medical reasons as ordered by a physician
(3) Health, safety or welfare of resident or other residents
endangered
(4) Cannot discharge for above reasons unless alternative placement
arranged
57
W. Va. Code R. §64-13-4 (2007). Wis. Admin. Code HFS §132.53 (1991); Id. at HFS §132.31 (2009); Id. at HFS §
132.60 (2007).
58
28 (5) Medical emergency or disaster
Non-Payment
(1) Non-payment, following reasonable opportunity to pay
deficiency. Not required to arrange alternative placement
(2) May not discharge for non-payment if resident in need of
ongoing care and treatment and has not been accepted for such
by another facility or through community support services and
funding of care reduced or terminated because resident requires
a level or type of care not provided or facility is an institution
for mental diseases
Documentation
Discharge Notice
Not addressed
(1) Notice to and reasons for discharge to resident, resident’s
physician and, if known, family member or legal counsel,
guardian, or other responsible person
(2) Resident’s guardian and any other person designated in writing
by resident must be notified promptly of plan to discharge
At least 30 days notice unless resident’s continued presence
endangers the health, safety or welfare of resident or other residents
(1) Name, address, phone number of board on aging and LTC
(2) Statement that resident has the right to appeal decision
(3) If developmental disability or mental illness, mailing address
and phone number of the protection and advocacy agency
(1) Facility must post in a prominent place a notice that right to
appeal a discharge decision and name, address and phone
number of state board on aging and LTC or, if resident mentally
ill or developmentally disabled, the mailing address and phone
number of the protection and advocacy agency
(2) Copy given to resident upon discharge notice
(3) Resident must send a letter of appeal to regional office of
department’s bureau of quality assurance within 7 days after
receiving notice, with a copy to facility administrator, asking for
a review. Letter must indicate why discharge should not take
place. If done within 7 days, discharge stayed until resolution.
(4) Within 5 days after receiving a copy of written appeal, facility
must provide written justification to bureau for discharge
(5) Bureau must review and notify both parties in writing of
decision within 14 days after receiving written facility’s
justification for the discharge
(6) Either party may appeal bureau’s decision in writing to the
department of administration’s division of hearings and appeals
within 5 days of receipt
(7) Appeal procedures do not apply if resident’s continued presence
poses a danger to health, safety or welfare of other residents
Timing of Notice
Notice Contents
Appeals
29 WYOMING59
Behavior
Non-Payment
Documentation
Discharge Notice
Timing of Notice
Notice Contents
Appeals
Not addressed
Not addressed
Condition on discharge in medical record
Not addressed
Not addressed
Not addressed
Not addressed
59
048-020-011 Wyo. Code R. 10 (2000); Id. at 16 (2000).
30