Documentation To Support Transfer or Discharge for F622 & F623 Compliance

Documentation To Support Transfer or Discharge for F622 & F623 Compliance

The decision to transfer or discharge a resident from the nursing facility is not to be taken lightly. Recent updates to Appendix PP of the State Operations Manual are a reminder to providers that discharge or transfer is a serious measure—one that requires documented evidence that the facility has made diligent efforts to meet the resident’s needs before taking such action. Do you trust that your documentation will meet the standards for F622 and F623?

The Regulatory Framework: Appendix PP, F-Tag 622 and 623

Appendix PP outlines the regulatory requirements under F622 – Transfer and Discharge Requirements, and F623 – Notice Requirements Before Transfer/Discharge. These guidelines emphasize that facilities must:

• • Attempt to meet the resident’s needs in the facility before considering transfer or discharge.
  • Provide comprehensive documentation of the circumstances and interventions tried.
  • Show that the transfer or discharge is necessary for the resident’s welfare, the safety of others, or due to non-payment.

When is Transfer or Discharge Justified?

Key Principle: Least Restrictive Alternative

Before initiating a transfer or discharge, facilities must explore and implement less restrictive alternatives to address the behavior or condition in question. The facility must demonstrate that all reasonable options to accommodate the resident’s physical, behavioral, or psychosocial needs were exhausted.

Documentation Expectations

Appendix PP clarifies that facilities must:

1. Assess the Root Cause

• • Conduct a thorough interdisciplinary assessment to determine why the need arose, especially in cases involving behavior.

2. Care Plan Interventions

• • Implement and revise care plan interventions aimed at addressing the root cause.

3. Behavioral and Environmental Supports

• • Introduce behavioral supports, including mental health consultations, staff training, and environmental modifications.

4. Collaboration with Stakeholders

• • Involve the resident, family, physician, and behavioral health providers in efforts to address the issue.

5. Track and Document Outcomes

• • Maintain detailed records of incidents, interventions, outcomes, and reevaluations over time

What Should Be on the Discharge Notice?

The transfer/discharge notice must clearly outline:

• • The specific reason(s) for discharge (e.g., safety risk to others, facility cannot meet needs despite interventions).
  • Summary of all attempts made to meet the resident’s needs.
  • Date of discharge and receiving location.
  • Contact info for the Ombudsman and explanation of appeal rights.
  • Physician’s documentation supporting the discharge, if applicable.

Case Study Example 1

Resident Background:

Mrs. T is a 76-year-old female resident with moderate dementia. Over the past month, she has exhibited aggressive verbal outbursts and occasional physical aggression toward staff during care routines.

Facility Response & Documentation:

1. Assessment:

• • A behavioral health assessment revealed that Mrs. T’s aggression coincided with bathing activities and appeared to be linked to anxiety and confusion.

2. Interventions Implemented:

• • The care plan was modified to schedule baths at times of day when Mrs. T was most alert.
  • Staff were trained in dementia-sensitive communication and personal space cues.
  • A trial of anti-anxiety medication was prescribed and monitored by the attending physician.
  • Non-pharmacological approaches including the use of familiar music and consistent use of a female caregiver to reduce distress during bathing and personal care.

3. Ongoing Monitoring:

• • Behavioral logs were maintained daily, documenting each defined behavioral incident, the resident’s response, and the effectiveness of the intervention.

4. Stakeholder Involvement:

• • Weekly care plan meetings were held which included Mrs. T’s family and the facility’s consulting psychologist to adjust approaches based on her response.

5. Final Outcome:

• • After six weeks, behaviors decreased in frequency and intensity. Transfer was no longer considered necessary.

If behaviors had not improved, and it was determined that the facility could not meet Mrs. T’s needs without endangering others, the documentation above would form the required justification for a safe, lawful transfer under CMS rules.

Case Study Example 2

Resident Background:

Mr. R is a 72-year-old male with a history of schizophrenia and traumatic brain injury. Over the past two months, his behaviors escalated to frequent verbal threats and physical altercations with peers and staff, despite consistent behavioral interventions.

Facility Response & Documentation:

1. Assessment:

• • A psychiatric evaluation indicated worsening paranoia and command hallucinations that posed a safety risk to others.

2. Interventions Implemented:

• • Increased 1:1 supervision during peak behavioral episodes.
  • Initiated antipsychotic medication with psychiatric oversight.
  • Modified his environment to reduce stimuli and potential triggers.
  • Engaged behavior management consultant and held weekly interdisciplinary team (IDT) reviews.
  • Attempted room changes and peer adjustments to mitigate conflicts.

3. Ongoing Monitoring:

• • All incidents were logged in behavior tracking forms with time/date, staff involved, antecedents, interventions used, and outcome.

4. Stakeholder Involvement:

• • Family, physician, mental health provider, and facility leadership participated in all IDT meetings and signed off on attempts to maintain the resident safely.

5. Final Outcome:

• • Despite these efforts, Mr. R continued to exhibit dangerous behaviors. The IDT concluded the facility could no longer meet his needs safely. A specialized behavioral facility was identified as an appropriate alternative for admission. Documentation included copies of assessments, care plans, behavioral logs, IDT notes, and a completed discharge notice with the rationale.

Takeaway: Due Diligence is Mandatory

The 2025 CMS Appendix PP guidance makes it clear: documentation is not just paper compliance but is meant to justify a facility’s ethical care practices and legal compliance. Transfer or discharge should be a last resort, and must always be preceded by a robust, documented effort to accommodate the resident’s needs within the facility. Facilities that meet these standards not only protect themselves from regulatory citations but also uphold the dignity and rights of their residents.

Want to avoid F622/F623 tags on your next survey? Contact Proactive LTC Consulting to review your discharge protocols and documentation practices before CMS does.

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