Discharge Planning: How to Plan and Conduct a Smooth Resident Discharge

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Discharge PlanningHow to Plan and Conduct a
Smooth Resident Discharge

• Presented by Peter M. Mellette, Esq.

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BASES FOR DISCHARGE

• Necessary for residents welfare
• Resident needs cannot be met in facility
• Resident no longer needs the services of the
  facility
• Safety of individuals in facility is endangered
• Health of individuals in facility is endangered
• Resident has failed, after reasonable and
  appropriate notice, to pay for a stay at the
  facility
• Facility ceases to operate
• 42 CFR 483.12(a)(2) and Va. Code Section
  32.1-138(A)(4)

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FACILITYS VOLUNTARY WITHDRAWAL FROM
MEDICARE/MEDICAID

• The Nursing Home Resident Protection Amendments
  of 1999 (42 U.S.C. 1396r(c)(2)(F)) state that a
  facilitys voluntary withdrawal from
  participating in a State Medicare/Medicaid plan
  is not an acceptable basis for transfer or
  discharge of residents who were living in the
  facility prior to the withdrawal.

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ACTIONS NEEDED BEFORE A DISCHARGE

• Give notice to resident (in writing if time
  permits) and to responsible party.
• Document reasons for transfer in clinical record.
• Identify discharge location.
• Physician must review above information and
  approve transfer
• 42 CFR 483.12(a)(6) and Va. Code Section
  32.1-138.1

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WRITTEN NOTICE
Must be given to resident and legal
representative with reasons for the
discharge. Contents

• Reasons
• Effective date
• Location

• Appeal Rights
• Ombudsman info
• VOPA info

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30-DAY NOTICE RULE

• Notice must be given 30 days prior to
  non-emergency transfer/discharge, however,
  exceptions to the 30-day notice rule include
• Safety risk
• Health risk
• Improved health
• Urgent medical needs
• Did not reside for more than 30 days

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OTHER REQUIREMENTS

• Facility must provide orientation for
  transfer/discharge.
• Notice of bed-hold policy, if any, including
  first availability rule for Medicaid
  beneficiaries.
• Seek to obtain informed consent for the
  transfer/discharge from the resident of a
  responsible party.
• Provide for consultation with patient, family,
  responsible party and patients attending
  physician (exception for emergencies).

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INVOLUNTARY TRANSFER/DISCHARGE

• In the case of involuntary transfer, the facility
  must ensure that there is
• Notation in the patients record by attending
  physician or medical director approving the
  transfer/discharge after consideration of effects
  of transfer/discharge
• Appropriate actions to minimize effects of the
  transfer/discharge
• A current assessment of care needs and the kind
  of service the patient needs upon
  transfer/discharge.

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HEARING PROCESS RIGHT TO APPEAL

• Regardless of payor, resident and/or the
  residents family member, responsible party, or
  legal representative had the right to appeal the
  nursing facilitys decision to transfer or
  discharge him or her through an administrative
  law hearing conducted by DMAS.

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HEARING PROCESSHOW TO REQUEST AN APPEAL

• The transfer/discharge notice must include
  information about how to request a hearing before
  DMAS and the residents rights to use legal
  counsel or other spokesmen at the hearing.

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HEARING PROCESSNOTICE OF APPEAL RIGHTS

• A resident must be given notice of the right to
  appeal 10 days before the discharge/transfer is
  to take place
• Note Best practice is to include in 30-day notice

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REFUSAL TO RE-ADMIT RESIDENTSINTENT TO RETURN

• If a resident has been transferred to a hospital
  or other facility and the resident has manifested
  the intent to return, the nursing facility had a
  duty to re-admit the resident except in certain
  situations.

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APPROPRIATE REASONS TO REFUSE RE-ADMITTANCE

• The residents documented medical needs are
  greater than the nursing facility can provide.
• The resident has an infectious disease that
  cannot be managed in the nursing facility.
• Nursing facility cannot accommodate the
  residents mental condition and needs without
  endangering the health and safety of other
  residents.

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BEHAVIORAL ISSUESRESIDENT VISITATION RIGHTS

• A resident had the right and the nursing facility
  must provide immediate access to family members
  and other visitors.
• The resident can deny or withdraw consent to
  visitation by family members at any time
• Visitation of others is limited by reasonable
  restrictions and the residents right to deny or
  withdraw consent at any time.
• 42 CFR 483.10(j)(1)(vii-viii)

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RESIDENT-TO-RESIDENT ABUSE

• Residents who are abusive to other residents must
  be monitored and must have a care plan that
  addresses the abusive behavior.
• Those residents subject to abuse must be
  protected from further injury.
• Residents whose behavior is a safety or health
  danger to another resident can be transferred or
  discharged.

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ABUSIVE OR VIOLENT VISITORS

• Likewise, a nursing facility has a duty to
  respond to family member or visitor behavior when
  that behavior rises to a violent or abusive level
  and poses a foreseeable, ongoing danger to
  residents or staff.

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SEX OFFENDERS LIVING IN LONG TERM CARE FACILITIES

• A recent GAO report noted that over 650 sex
  offenders are currently residing in nursing
  facilities and state laws regarding whether the
  convicted offender must notify the nursing
  facility of the prior conviction vary between
  states.

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SEX OFFENDERS LIVING IN LONG TERM CARE FACILITIES
(cont.)

• Nursing facilities may subject a resident to
  supervision or separation based on the residents
  prior convictions if the resident presents a
  current safety or health concern.
• Whether a nursing facility can discharge a
  convicted sex offender for the prior conviction
  may depend on whether the individual currently
  poses a safety and/or health risk to other
  individuals in the facility.
• Unless the convicted sex offender poses an
  immediate health and/or safety danger, he or she
  probably cannot be discharged without 30-day
  notice.

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CONDUCTING SMOOTH AND ORDERLY RESIDENT DISCHARGES

• Ensure the notice is properly given to resident,
  family members, responsible party and legal
  representative to give residents and family time
  to prepare for the transfer or discharge.
• Involve the resident and family members in
  planning the discharge or transfer, e.g. give the
  resident a tour of the destination before the
  relocation date to minimize transfer trauma.

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CONDUCTING SMOOTH AND OREDERLY RESIDENT
DISCHARGES (cont.)

• Ensure that nursing facility had obtained
  approval for the discharge from the providers
  medical director and the residents attending
  physician.
• Ensure that reasons for the discharge/transfer
  have been well documented in the residents
  clinical record.

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WHEN DISCHARGE IS NECESSARY

• DISRUPTIVE FAMILY MEMBERS

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HEALTH/SAFETY DISCHARGE BASES

• Threat to the Residents Physical/Emotional
  Well-Being from Other Residents
• Noise level complaints.
• Threat to the Residents Physical Well-Being from
  Bed to Chair Transfer Techniques
• Resident/daughter insistence on unsafe lifting
  technique.
• General Threat to the Resident from Nursing
  Facility Environment.
• Resident was depressed/suicidal while in facility.

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HEALTH/SAFETY DISCHARGE BASES (cont.)

• Daughters Threat to the Health and Safety of
  Others in the Nursing Facility
• Frequent threats and physical harm to provider
  staff.
• Residents Threat to the Health and Safety of
  Others in the Nursing Facility
• Refusal of medication and verbal abuse of staff
  and other residents.
• Evidence that Resident No Longer Required Skilled
  Nursing or Nursing Facility Level Care
• Frequent trips with daughter outside the nursing
  facility.

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WHEN IS A DISCHARGE SUBJECT TO APPEAL?

• THE RESIDENT WHO DIDNT GET IN

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OTHER FACILITY PROVIDES CARE TO THE INDIVIDUAL

• Individual argued that the second facility she
  resided in was able to provide her care,
  therefore either of the providers facilities
  could have cared for her.
• Argument undercut by court
• DMAS approved Medicaid reimbursement for subacute
  care, indicating that level of care the
  individual actually required.
• The second facility only admitted the individual
  after she agreed to terminate a threatened
  lawsuit.

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INDIVIDUAL DID NOT APPLY TO PROVIDERS FACILITIES

• After individual was discharged from the first
  provider, she did not apply to either of the
  providers facilities.
• She also indicated that the second facility she
  resided in was her first choice.

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CONCLUSION AND MORAL

• Hard to lose if you dont admit.
• A comprehensive admissions policy is facilitys
  best defense.
• Remember that decertification of beds and refusal
  to readmit following a hospitalization may not
  work as a substitute to discharge.

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QUESTIONS?