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F625

§483.15(d) Notice of bed-hold policy and return

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies—

     (i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; 

    (ii)  The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any; 

     (iii) The nursing facility’s policies regarding bed-hold periods, which must be consistent with paragraph (e)(1 ) of this section, permitting a resident to return; and 

     (iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

INTENT

To ensure that residents are made aware of a facility’s bed-hold and reserve bed payment policy before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility.

DEFINITIONS

“Bed-hold”: Holding or reserving a resident’s bed while the resident is absent from the facility for therapeutic leave or hospitalization.

“Reserve Bed Payment”: Payments made by a State to the facility to hold a bed during a resident’s temporary absence from a nursing facility.

“Therapeutic Leave”:  Absences for purposes other than required hospitalization.

GUIDANCE

Notice of Bed-Hold Policy

All facilities must have policies that address holding a resident’s bed during periods of absence, such as during hospitalization or therapeutic leave. Additionally, facilities must provide written information about these policies to residents prior to and upon transfer for such absences. This information must be provided to all facility residents, regardless of their payment source.

These provisions require facilities to issue two notices related to bed-hold policies. The first notice could be given well in advance of any transfer, i.e., information provided in the admission packet. Reissuance of the first notice would be required if the bed-hold policy under the State plan or the facility’s policy were to change.

The second notice must be provided to the resident, and if applicable the resident’s representative, at the time of transfer, or in cases of emergency transfer, within 24 hours. It is expected that facilities will document multiple attempts to reach the resident’s representative in cases where the facility was unable to notify the representative. The notice must provide information to the resident that explains the duration of bed-hold, if any, and the reserve bed payment policy. It should also address permitting the return of residents to the next available bed.

When a resident residing in a skilled nursing facility under Medicare is hospitalized or takes therapeutic leave, Medicare will not pay to hold the bed. Facility policies may allow the resident to pay privately to hold his or her bed. While the provisions of this requirement specifically address bed-hold under Medicaid law, facilities must make all residents aware in writing of their policies related to holding beds during absences from the facility.

NOTE: Residents not covered by Medicare or Medicaid, may be permitted to privately provide reserve bed payments.

Medicaid law requires each state Medicaid plan to address bed-hold policies for hospitalization and periods of therapeutic leave.  State plans vary in payment for and duration of bed-holds. However, federal regulations do not require states to pay nursing facilities for holding beds while the resident is away from the facility. In general, the State plan sets the length of time, if any, that the state will pay the facility for holding a bed for a Medicaid-eligible resident. It is the responsibility of the survey team to know the bed-hold policies of their State Medicaid plan.

Additionally, §483.15 (e)(1) and F626 require facilities to permit residents to return to the facility immediately to the first available bed in a semi-private room.

As stated above, a participating facility must provide notice to its residents and if applicable, their representatives, of the facility’s bed-hold policies, as stipulated in each State’s plan. This notice must be provided prior to and upon transfer and must include information on how long a facility will hold the bed, how reserve bed payments will be made (if applicable), and the conditions upon which the resident would return to the facility.  These conditions are:

  • The resident requires the services which the facility provides; and
  • The resident is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services.

Bed-hold for days of absence in excess of the State’s bed-hold limit is considered a non-covered service which means that the resident could use his/her own income to pay for the bed-hold. However, if a resident does not elect to pay to hold his or her bed, the resident will be permitted to return to the next available bed, consistent with the requirements at §483.15(e).

The provision at §483.15(d)(1)(ii) references regulations for Medicaid Payments for Reserving Beds in Institutions (§447.40), which state “Absences for purposes other than required hospitalization (which cannot be anticipated and planned) are included in the patient’s plan of care.” This means that therapeutic leave of absence must be consistent with the resident’s goals for care, be assessed by the comprehensive assessment, and incorporated into the comprehensive care plan, and cannot be a means of involuntarily discharging the resident.

INVESTIGATIVE PROTOCOL

Use the Critical Element (CE) Pathways for Community Discharge, or Hospitalization, as appropriate, along with the above interpretive guidelines when determining if the facility meets the requirements for, or investigating concerns related to the facility requirements for bed-hold.

Summary of Investigative Procedure

If concerns arise regarding notice of bed-hold, review the medical record for evidence of whether a notice of bed-hold was provided both (1) prior to and (2) upon transfer. Look for documentation such as a copy of the dated notice(s), progress notes, transfer checklist(s), or other evidence that the notice was given. Additionally, ask to review facility policies on bed- hold. Review the facility’s admission packet to determine if notice of bed-hold is given at admission.  If not, determine how the facility notifies residents prior to transfer.

Ask the resident, or if applicable, the resident’s representative(s), whether they received the bed- hold notice and understand the facility’s bed-hold policy. If not, determine how the facility notifies residents of this information prior to transfer.