News, Skilled Nursing Facility

CMS proposes initiative to address improper SNF discharges

According to a memo published by the Centers for Medicare & Medicaid Services (CMS) on December 22, 2017, post-acute care discharges that violate Federal regulations continue to be one of the most frequent nursing home complaints made to State Long Term Care Ombudsman Programs. The memo, addressed to state survey agency directors, announces CMS’ consideration of a variety of solutions to solve this problem, including training for surveyors and providers, intake and triage training, and state-wide civil monetary penalty- (CMP) funded projects to help prevent improper discharges.

Federal regulations currently state that a facility must allow each resident to remain at the facility unless any of the following is true:

  • The transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility;
  • 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;
  • The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
  • The health of individuals in the facility would otherwise be endangered;
  • 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
  • The facility ceases to operate.

In contrast to the increase in improper post-acute care discharges detailed in the news, CMS states that discharges due to a facility’s inability to care for a resident or meet his/her needs should be rare due to the requirement that facilities determine their capacity and capability to care for the residents they admit.

CMS notes that the most commonly reported reason for noncompliant discharges is due to behavioral, mental, and/or emotional expressions or indications of resident distress, with other noncompliant discharges being driven by payment concerns (such as when a Medicare or private pay resident shifts to Medicaid), or a resident’s hospital stay for health concerns unrelated to the behaviors that form the alleged basis for the discharge.

“Discharges which violate federal regulations are of great concern because in some cases they can be unsafe and/or traumatic for residents and their families. These discharges may result in residents being uprooted from familiar settings; termination of relationships with staff and other residents; and residents may even be relocated long distances away, resulting in fewer visits from family and friends and isolation of the resident. In some cases, residents have become homeless or remain in hospitals for months,” states the memo.

Currently, CMS seems to be leaning toward their CMP proposal to address improper discharges in SNFs. Other proposals include:

  • Projects designed to educate residents and their families on their rights in relation to facility initiated discharge;
  • Projects creating teams of health professionals who could provide immediate support to facilities around the state to reduce risk of harm to self or others when a resident is exhibiting expressions or indications of distress.
  • Projects designed to educate facility staff on best practices for engaging residents and families in collaborative strategies such as person-centered environments and care plans to reduce resident distress; and/or
  • Formation and support of a collaborative group focusing on nursing home issues such as resident placement or transitional care, residents expressing or indicating distress, or medically complex residents such as those with dementia or delirium.