F627

🚨 Attention Nursing Home Administrators! 🚨

➡️ Starting April 28, 2025, surveyors will be using new guidelines to determine if resident transfers and discharges are compliant. To streamline the process and improve clarity, CMS is updating its regulations. This means some old tags are being removed, specifically F622 – F626, and F660 – F661. Regulatory requirements §483.15(e)(1)-(2) have been relocated to a new tag, F627.

You know we've already tackled the updates to F620 (Admission Agreements), and now it's time to unpack the new F627 Tag, Transfer and Discharge.

This update consolidates and clarifies crucial regulations, ensuring residents are protected from unlawful transfers. Key takeaways:

🏠 Residents have the right to remain in the facility unless specific exceptions are met.

📝 Your facility assessment must accurately reflect your capabilities and match your admitting practices.

🚫 Improper discharges violate resident rights!

Please note: This is a long post to try to cover key elements on this new tag that will be incorporated into survey practices on April 28, 2025.

Key Requirements of Regulation F627 – Transfer and Discharge

This regulation covers several crucial aspects of resident transfer and discharge, aiming to protect resident rights and ensure a safe and well-planned transition.

📌 Permitted Transfer/Discharge Reasons: The facility must allow residents to remain unless specific conditions are met. These conditions include:

*Resident welfare and inability to meet needs within the facility.

*Resident's health has sufficiently improved.

*Safety of individuals in the facility is endangered due to the resident's clinical or behavioral status.

*Health of individuals in the facility would otherwise be endangered.

*Non-payment for services after appropriate notice.

*Facility closure.

⚖️ Appeal Rights: Facilities cannot transfer or discharge a resident while an appeal is pending, unless failing to do so would endanger the health or safety of the resident or other individuals. Documentation of this danger is mandatory.

📝 Documentation: All transfers and discharges must be thoroughly documented in the resident's medical record, and that documentation must clearly support the discharge/transfer. (See documentation section below.)

🗣️ Resident Orientation: Facilities must provide sufficient preparation and orientation to residents before transfer or discharge in a manner they understand.

↩️ Return Policy and Return to Facility:

*The facility must have a written policy on allowing residents to return after hospitalization or therapeutic leave.

*Residents eligible for Medicare/Medicaid have priority for their previous room (if available) or a semi-private room upon availability if they require the facility's services.

*When the facility to which a resident returns is a composite distinct part, the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there.

🗺️ Discharge Planning Process: A comprehensive and effective discharge planning process is required, focusing on:

*Identifying discharge needs and developing a discharge plan.

*Regularly re-evaluating and updating the discharge plan.

*Involving the interdisciplinary team.

*Considering caregiver/support person availability and capability.

*Involving the resident and representative in the planning process.

*Addressing the resident’s goals of care and treatment preferences.

*Documenting the resident’s interest in returning to the community.

*Assisting residents in selecting a post-acute care provider by using data relevant and applicable.

*Documenting the evaluation of discharge needs and the discharge plan. This plan must address the resident's discharge goals, transition to post-discharge care, and reducing factors leading to preventable readmissions.

📄 Discharge Summary: A comprehensive discharge summary is required when a resident is anticipated to be discharged. (See further notes under documentation section below.)

⚠️ Not Permitting Residents to Return - Administrator Highlights:

*Policy Alignment: Ensure facility policy explicitly addresses the process for not permitting a resident to return after a transfer (hospitalization/therapeutic leave), treating it as a discharge.

*Clear Rationale: Policies should mandate a clear, documented rationale for why the facility can no longer meet the resident's needs, especially when those needs were previously met.

*Documentation Compliance: Policy must ensure documentation aligns with §483.15(c)(2)(i)(B) when denying return based on unmet needs.

*Notification Procedures: Policies should specify procedures for notifying the resident, representative, and LTC ombudsman in writing of the discharge, including appeal rights.

*Appeal Process Adherence: Facility policy must outline the process for allowing the resident to return to their room (or an available bed) during an appeal, unless documented evidence exists that their return would endanger health/safety.

*Thorough Evaluation: Policies must require a thorough evaluation of the resident's current condition and the facility's capabilities before making a decision to deny return, with comprehensive documentation to support the decision.

*Consistent Application: Policy should address the need to ensure consistency in denying return based on unmet needs, reviewing recent admissions to determine if residents with similar care needs are being admitted or allowed to remain in the facility.

*Therapeutic Leave Considerations: Policies must explicitly state that exceeding the therapeutic leave timeframe does not automatically constitute a discharge. The facility must attempt contact and determine the resident’s intent to return. Only if the resident or representative communicates the resident does not intend to return is it appropriate to initiate discharge processes.

Compliance Probes for the Administrator:

Use the following questions to audit your facility's compliance with F627, paying close attention to the discharge process:

Policies and Procedures:

📜 Does the facility have a written policy and procedure that aligns with all aspects of F627, including specific protocols for each permissible transfer/discharge reason? This policy should explicitly address discharge planning requirements.

👥 Are policies and procedures readily available to all staff, residents, and families?

🧑‍🏫 Are staff trained on the transfer and discharge process, including documentation requirements, resident rights, and the specifics of the discharge planning process and discharge summary requirements?

Resident Assessment and Care Planning (Detailed Discharge Focus):

✅ Is a comprehensive assessment of discharge needs conducted for each resident upon admission and regularly reviewed/updated? This should include, but not be limited to, assessment of medical, functional, cognitive, psychosocial, and environmental factors impacting discharge.

🤝 Does the care planning process actively involve the resident and their representative in identifying discharge goals and preferences? Document specific goals, preferences, and any discussions about returning to the community. This also means addressing any concerns the resident and/or their representative may have.

🧑‍⚕️ Is the interdisciplinary team (IDT) actively involved in discharge planning, with documented evidence of their contributions? The documentation should show how each discipline contributed to the overall plan, including input on medication reconciliation, dietary needs, therapy recommendations, and social support services.

👩‍⚕️ Are caregiver/support person availability and capability adequately addressed in the discharge plan? Document the specific support the caregiver can provide, any training needed for the caregiver, and contingency plans if the caregiver is unable to provide the necessary support.

🏡 Is there a process to document the resident’s interest in returning to the community and provide referrals to appropriate agencies? Document the specific agencies contacted, the information provided to the resident, and the outcome of the referral. If discharge to the community is determined to not be feasible, who made the determination and why?

📊 How does the facility ensure compliance with the requirements of §483.21(c)(1)(viii) to use data to assist residents in selecting a post-acute care provider? *Specifically, how does the facility identify and use "relevant and applicable" data (SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use) that directly relates to the resident's individual goals of care and treatment preferences? Provide examples of data sources utilized and how this data is presented to residents and their representatives in an understandable format.

📝 Discharge planning probes:

*Are potential barriers to a safe and successful discharge identified and addressed proactively?

*Is information provided about the availability of the Long-Term Care Ombudsman Program?

*Are strategies implemented to minimize the risk of preventable readmissions, such as medication reconciliation, follow-up appointments, and education on self-management?

*How does the facility track and analyze readmission rates to identify areas for improvement in the discharge planning process?

*Are care plans updated in response to information received from referrals to local contact agencies or other appropriate entities?

AMA (Against Medical Advice) Discharges:

🏃 If a resident leaves the facility AMA, is there documentation of:

*The resident's decision to leave AMA, clearly stating they understand the risks and potential consequences.

*Attempts made by staff to dissuade the resident from leaving, including explanations of potential health risks.

*The resident's cognitive status at the time of departure (e.g., alert and oriented).

*Documentation of the time of resident departure.

*Notification of the resident's physician and other applicable persons, such as APS, if indicated regarding the AMA discharge.

*Witness signatures from staff present during the AMA discharge process.

*A discharge note summarizing the resident's stay and current medical status.

*A copy of the AMA form signed by the resident (if they are willing to sign). If the resident refuses to sign, this must be documented.

Resident Rights and Education:

📢 Are residents informed of their right to appeal a transfer or discharge decision?

❓ Is the appeals process clearly explained to residents and their representatives?

📚 Does the facility provide adequate preparation and orientation to residents before transfer or discharge, tailored to their understanding and cognitive abilities?

Non-Payment Issues:

💰 Does the facility have a clear and documented process for addressing non-payment issues, including providing appropriate notice to residents and families?

🆘 Is there documentation of attempts to assist residents in obtaining third-party payment (Medicare/Medicaid) before initiating a transfer/discharge due to non-payment?

🧾 Does the facility offer the resident the option to pay privately for their stay? If so, is this documented, including the cost of private pay, and the resident's response (acceptance or refusal)? If the resident refuses to pay privately, this refusal must be clearly documented.

Documentation:

🖋️ All transfers and discharges must be thoroughly documented in the resident's medical record, and that documentation must clearly support the discharge/transfer. Documentation should be timely, accurate, and complete.

✅ Does the documentation include the specific reason for the transfer/discharge, as per F627 (c)(1)(i)(A) through (F)? Be explicit and avoid vague language.

🏥 When applicable, is there documentation of the facility's attempts to meet the resident's needs within the facility before considering transfer? Include specific interventions, dates, staff involved, and the resident's response.

📞 Is there documentation of communication with the receiving facility/provider, including pertinent resident information? This should include a comprehensive summary of the resident's medical history, current medications, functional status, and any specific care needs. Include evidence of communication.

⚠️For transfers due to resident behavior or safety concerns, is there thorough documentation supporting the need for the transfer and attempts to manage the behavior within the facility? This should include Behavior Plans, data collection, interventions attempted, and the resident's response to those interventions. Document how the safety of other residents/staff was impacted.

📃 Are discharge summaries completed in a timely manner and contain all required information as outlined in §483.21(c)(2)? Verify that the discharge summary includes:

*A recapitulation of the resident's stay.

*A final summary of the resident's status at discharge.

*A post-discharge plan of care developed with the resident and representative, including:

-Where the resident will reside.

-Arrangements for follow-up care (medical and non-medical).

-Specific medical and non-medical services required.

-Contact information for post-discharge providers.

*Medication Reconciliation.

*The resident’s involvement with selecting their post-acute care provider.

🏡 Is documentation present showing residents have been asked about their interest in returning to the community?

By diligently addressing these compliance probes, administrators can ensure their facility meets the requirements of F627, protects resident rights, and promotes safe and effective transitions of care. Regular audits and ongoing training are essential to maintaining compliance and providing high-quality care. Special attention should be paid to the comprehensiveness and resident-centeredness of the discharge planning process and the completeness of the discharge summary.

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