Capturing Required Transfer/Discharge Documentation

Capturing Required Transfer/Discharge Documentation

Significant emphasis is placed on the need for comprehensive documentation to support that resident transfers/discharges are justified and in compliance with the regulations outlined in the April 28, 2025 update to Appendix PP of the State Operations Manual.

Regulatory Overview

Section (c)(1)(i) of F627 in Appendix PP lists the reasons that must exist for the facility to transfer/discharge a resident. These reasons include:

(A) The transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility;

(B) 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;

(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;

(D) The health of individuals in the facility would otherwise be endangered;

(E) 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. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or

(F) The facility ceases to operate.

Key Areas of Focus for Facility Transfer-Discharge Documentation

(A) The basis for the transfer per paragraph (c)(1)(i) of this section in F627. In other words which of the 6 areas listed above (A-F) apply to the resident transfer/discharge.

(B) In the case of paragraph (c)(1)(i)(A) of this section of F627, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).

For circumstances where the discharge or transfer is necessary for the resident’s welfare and the facility cannot meet the resident’s needs or the resident’s health has improved sufficiently so that the resident no longer needs the care of the facility, the resident’s physician must document information about the basis for the transfer or discharge. Additionally, if the facility determines it cannot meet the resident’s needs, the documentation made by the resident’s physician must include:

• The specific resident needs the facility could not meet
• The facility efforts to meet those needs
• The specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the current facility

In situations where the facility determines a resident’s clinical or behavioral status endangers the safety or health of individuals in the facility, documentation regarding the reason for the transfer or discharge must be provided by a physician, not necessarily the attending physician.

The facility must be able to demonstrate by their documentation that one of the limited circumstances listed in the regulation (as outlined above) is met to support not only the reason for transfer/discharge, but also for refusal by the facility to allow the resident to return after a hospitalization. To do this, the facility must have sufficient documentation to prove that an assessment of the resident’s status and needs at the time of proposed return to the facility was conducted. Without this there can be no determination of (A), the resident’s needs cannot be met, or (C) and (D), that the safety or health of individuals would be endangered.

Deficiency Example

In this case example, a facility failed to prove that an assessment was completed for a resident to determine if they could be allowed back to the facility following a hospitalization. The facility was cited at a “G” actual harm. The 2567 stated:

Based on record review, Medical Director, Hospital Case Manager, Resident’s Legal Guardian, and staff interviews, the facility failed to allow a resident to return to the first available bed at the facility after being sent to the hospital for a medical and psychiatric evaluation. The resident had gotten into bed with another resident believing her to be his wife. The resident remained in the hospital for over a month despite being cleared to return to the nursing home after 3 days. A reasonable person would expect once they were medically cleared from the hospital to be allowed back into their home and not being allowed back into their home could cause them to experience altered mental condition, fear, anxiety, and depressed mood. This deficient practice was evidenced for 1 of 3 residents reviewed for transfer and discharge.

The deficiency was cited based on the lack of documented evidence that the facility performed an assessment to determine if the resident continued to demonstrate the behaviors that posed a risk to the safety of others in the facility, or analysis of whether there were interventions that could be put in place to prevent this recurrence. The hospital documentation indicated the facility “refused to take the resident back” and the complaint survey visit resulted in the actual harm deficiency.

Summary

Appendix PP indicates that if the situation involves a resident’s choice to refuse care or treatment and this poses a risk to the resident’s or others’ health or safety, the comprehensive care plan must identify the care or service being declined, the risk the declination poses to the resident, and efforts by the interdisciplinary team to educate the resident and the representative, as appropriate. The facility must be able to demonstrate that the resident or, if applicable, resident representative, received information regarding the risks of refusal of treatment, and that staff conducted the appropriate assessment to determine if care plan revisions would allow the facility to meet the resident needs or protect the health and safety of others.

As with many other aspects of healthcare services, thorough and detailed documentation is critical to justifying and supporting that the requirements for transfer and discharge are met. Staff should understand the importance of documentation compliance.

Next Steps: Contact Proactive to schedule compliance support including QA monitoring of documentation and to schedule a mock survey. Access these helpful resources in the Proactive Solutions Center:

• Appendix PP 2025 Revisions Package with 68 separate resources including updated policies, staff training outlines and QAPI audit tools
• Proactive’s comprehensive Survey Ready Toolkit with 66 separate resources to guide preparation for the annual survey

Written By:

Janine Lehman, RN, RAC-CT, CLNC

Director of Clinical Services

Proactive LTC Consulting