F627
(Rev. 229; Issued: 04-25-25; Effective: 04-25-25; Implementation: 04-28-25)
§483.15(c) Transfer and discharge-
§483.15(c)(1) Facility requirements-
(i) The facility must permit each resident to remain in the facility, and not
transfer or discharge the resident from the facility unless—
(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.
(ii) The facility may not transfer or discharge the resident while the appeal is
pending, pursuant to § 431.230 of this chapter, when a resident exercises his
or her right to appeal a transfer or discharge notice from the facility
pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or
transfer would endanger the health or safety of the resident or other
individuals in the facility. The facility must document the danger that failure
to transfer or discharge would pose.
§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances
specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must
ensure that the transfer or discharge is documented in the resident’s medical record
and appropriate information is communicated to the receiving health care
institution or provider.
(i) Documentation in the resident’s medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, 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).
(ii) The documentation required by paragraph (c)(2)(i) of this section must be
made by—
(A) The resident’s physician when transfer or discharge is necessary under
paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph
(c)(1)(i)(C) or (D) of this section.
§483.15(c)(7) Orientation for transfer or discharge.
A facility must provide and document sufficient preparation and orientation to
residents to ensure safe and orderly transfer or discharge from the facility. This
orientation must be provided in a form and manner that the resident can
understand.
§483.15(e)(1) Permitting residents to return to facility.
A facility must establish and follow a written policy on permitting residents to
return to the facility after they are hospitalized or placed on therapeutic leave. The
policy must provide for the following.
(i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold
period under the State plan, returns to the facility to their previous room if
available or immediately upon the first availability of a bed in a semi-private
room if the resident—
(A) Requires the services provided by the facility; and
(B) Is eligible for Medicare skilled nursing facility services or Medicaid
nursing facility services.
(ii) If the facility that determines that a resident who was transferred with an
expectation of returning to the facility, cannot return to the facility, the
facility must comply with the requirements of paragraph (c) as they apply to
discharges.
§483.15(e)(2) Readmission to a composite distinct part. When the facility to which a
resident returns is a composite distinct part (as defined in § 483.5), 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.
§483.21(c)(1) Discharge Planning Process
The facility must develop and implement an effective discharge planning process
that focuses on the resident’s discharge goals, the preparation of residents to be
active partners and effectively transition them to post-discharge care, and the
reduction of factors leading to preventable readmissions. The facility’s discharge
planning process must be consistent with the discharge rights set forth at 483.15(b)
as applicable and—
(i) Ensure that the discharge needs of each resident are identified and result in
the development of a discharge plan for each resident.
(ii) Include regular re-evaluation of residents to identify changes that require
modification of the discharge plan. The discharge plan must be updated, as
needed, to reflect these changes.
(iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the
ongoing process of developing the discharge plan.
(iv) Consider caregiver/support person availability and the resident’s or
caregiver’s/support person(s) capacity and capability to perform required
care, as part of the identification of discharge needs.
(v) Involve the resident and resident representative in the development of the
discharge plan and inform the resident and resident representative of the
final plan.
(vi) Address the resident’s goals of care and treatment preferences.
(vii) Document that a resident has been asked about their interest in receiving
information regarding returning to the community.
(A) If the resident indicates an interest in returning to the community, the
facility must document any referrals to local contact agencies or other
appropriate entities made for this purpose.
(B) Facilities must update a resident’s comprehensive care plan and
discharge plan, as appropriate, in response to information received from
referrals to local contact agencies or other appropriate entities.
(C) If discharge to the community is determined to not be feasible, the facility
must document who made the determination and why.
(viii) For residents who are transferred to another SNF or who are discharged to
a HHA, IRF, or LTCH, assist residents and their resident representatives in
selecting a post-acute care provider by using data that includes, but is not
limited to SNF, HHA, IRF, or LTCH standardized patient assessment data,
data on quality measures, and data on resource use to the extent the data is
available. The facility must ensure that the post-acute care standardized
patient assessment data, data on quality measures, and data on resource use
is relevant and applicable to the resident’s goals of care and treatment
preferences.
(ix) Document, complete on a timely basis based on the resident’s needs, and
include in the clinical record, the evaluation of the resident’s discharge needs
and discharge plan. The results of the evaluation must be discussed with the
resident or resident’s representative. All relevant resident information must
be incorporated into the discharge plan to facilitate its implementation and
to avoid unnecessary delays in the resident’s discharge or transfer.
§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary
that includes, but is not limited to, the following: . . .
(iv) A post-discharge plan of care that is developed with the participation of the
resident and, with the resident’s consent, the resident representative(s),
which will assist the resident to adjust to his or her new living environment.
The post-discharge plan of care must indicate where the individual plans to
reside, any arrangements that have been made for the resident’s follow up
care and any post-discharge medical and non-medical services.
INTENT
• These regulations and guidance address inappropriate discharges and:
o Specify the limited conditions under which a skilled nursing facility or
nursing facility may transfer or discharge a resident, the documentation that
must be included in the medical record, and who is responsible for making the
documentation.
o Ensure policies are developed and implemented which allow residents to
return to the facility following hospitalization or therapeutic leave.
o Ensure a facility does not transfer or discharge a resident in an unsafe
manner, such as a location that does not meet the resident’s needs, does not
provide needed support and resources, or does not meet the resident’s
preferences and, therefore, should not have occurred.
o Ensure the discharge planning process addresses each resident’s discharge
goals and needs, including caregiver support and referrals to local contact
agencies, as appropriate, and involves the resident and if applicable, the
resident representative and the interdisciplinary team in developing the
discharge plan.
DEFINITIONS
“Bed-hold”: Holding or reserving a resident’s bed while the resident is absent from the
facility for therapeutic leave or hospitalization.
“Composite Distinct Part”: A composite distinct part is a distinct part consisting of two
or more noncontiguous components that are not located within the same campus, as that
term is defined in §413.65(a)(2). The definition and additional requirements specific to
SNF/NF composite distinct parts are found at §483.5.
“Campus”: Campus is defined in §413.65(a)(2) and means the physical area
immediately adjacent to the provider’s main buildings, other areas and structures that
are not strictly contiguous to the main buildings but are located within 250 yards of the
main buildings, and any other areas determined on an individual case basis, by the
CMS regional office, to be part of the provider’s campus.
“Discharge Planning”: A process that generally begins on admission and involves
identifying each resident’s discharge goals and needs, developing and implementing
interventions to address them, and continuously evaluating them throughout the
resident’s stay to ensure a successful discharge.
“Distinct Part”: A distinct part SNF or NF is physically distinguishable from the larger
institution or institutional complex that houses it, meets the requirements of paragraph
(2) of this definition at §483.5, and meets the applicable statutory requirements for SNFs
or NFs in sections 1819 or 1919 of the Act, respectively. A distinct part SNF or NF may
be comprised of one or more buildings or designated parts of buildings (that is, wings,
wards, or floors) that are: In the same physical area immediately adjacent to the
institution's main buildings; other areas and structures that are not strictly contiguous to
the main buildings but are located within close proximity of the main buildings; and any
other areas that CMS determines on an individual basis, to be part of the institution's
campus. A distinct part must include all of the beds within the designated area, and
cannot consist of a random collection of individual rooms or beds that are scattered
throughout the physical plant. The term “distinct part” also includes a composite distinct
part that meets the additional requirements specified in the definition of “composite
distinct part” of §483.5 described above. Requirements specific to distinct part SNFs or
NFs are found at §483.5.
“Home Health Agency (HHA)”: a public agency or private organization (or a
subdivision of either) which is primarily engaged in providing skilled nursing services
and other therapeutic services in the patient’s home and meets the requirements of
sections 1861(o) and 1891 of the Social Security Act.
“Inpatient Rehabilitation Facility (IRF)”: are freestanding rehabilitation hospitals or
rehabilitation units in acute care hospitals that serve an inpatient population requiring
intensive services for treatment.
“Local Contact Agency”: refers to each State’s designated community contact agencies
that can provide individuals with information about community living options and
available supports and services. These local contact agencies may be a single entry point
agency, such as an Aging and Disability Resource Center (ADRC), an Area Agency on
Aging (AAA), a Center for Independent Living (CIL), or other state designated entities.
“Long Term Care Hospital (LTCH)”: are certified as acute-care hospitals, but focus on
patients who, on average, stay more than 25 days. Many of the patients in LTCHs are
transferred there from an intensive or critical care unit. LTCHs specialize in treating
patients who may have more than one serious condition, but who may improve with time
and care, and return home.
“Patient Assessment Data”: standardized, publicly available information derived from
a post-acute care provider’s patient/resident assessment instrument, e.g., Minimum Data
Set (MDS), Outcome and Assessment Information Set (OASIS).
“Therapeutic Leave”: Resident absences for purposes other than required
hospitalization.
“Transfer and Discharge”: Includes movement of a resident to a bed outside of the
certified facility whether that bed is in the same physical plant or not. Transfer and
discharge does not refer to movement of a resident to a bed within the same certified
facility. (See §483.5). Specifically, transfer refers to the movement of a resident from a
bed in one facility to a bed in another facility when the resident expects to return to the
original facility. Discharge refers to the movement of a resident from a bed in one
certified facility to a bed in another facility or other location in the community, when
return to the original facility is not expected.
GUIDANCE
Investigating noncompliance with the transfer and discharge requirements begins when
conducting offsite preparation. The team coordinator (TC) should contact the local
ombudsman and inquire if there are specific residents from whom the ombudsman has
received complaints related to inappropriate discharges for review (see Investigative
Procedure section below). The TC should also be sure to review complaints and survey
history of the facility for indications of noncompliance with the requirements for transfer
and/or discharge.
§483.15(c)(1)(i)-(ii) Transfer and Discharge Requirements Use guidance at this Ftag to
determine if noncompliance exists when evidence suggests a facility should not have
transferred or discharged a resident at the time of discharge, or at all. These
circumstances may include, but are not limited to, the following:
• When evidence in the medical record does not support the basis for discharge,
such as:
o Discharge based on an inability to meet the resident’s needs, but there is no
evidence of facility attempts to meet the resident’s needs, or no evidence of an
assessment at the time of discharge indicating what needs cannot be met;
o Discharge based on improvement of resident’s health such that the services
provided by the facility are no longer needed, but documentation shows the
resident’s health did not improve or actually declined;
o Discharge based on the endangerment of the safety or health of individuals in
the facility, but there is no documentation in the resident’s medical record
that supports this discharge;
o Discharge based on failure to pay, however there is no evidence that the
facility offered the resident to pay privately or apply for Medical Assistance or
that the resident refused to pay or have paid under Medicare or Medicaid;
o Discharge occurs even though the resident appealed the discharge, the appeal
is pending, and there is no documentation to support the failure to discharge
would endanger the health and safety of individuals in the facility.
• When evidence in the medical record shows a resident was not permitted to return
following hospitalization or therapeutic leave, and there is no valid basis for
discharge.
• There is no evidence that the facility considered the care giver’s availability,
capacity, and/or capability to perform needed care to the resident following
discharge.
• The post-discharge plan of care did not address resident limitations in ability to
care for themself.
These regulations describe the requirements that must be met in order for a facility to
transfer or discharge a resident, thus protecting nursing home residents from transfers
and discharges which should not have occurred, and thus violate federal regulations.
§483.15(c)(1)(i)(A), (C) or (D) - Discharge when Needs Cannot be Met, or when
Safety or Health of Individuals is Endangered
Facilities are required to determine their capacity and capability to care for the residents
they admit. Therefore, facilities should not admit residents whose needs they cannot
meet based on the Facility Assessment requirements at §483.70(e) (see also F838,
Facility Assessment). For residents the facility has admitted, §483.15(c)(1)(i) provides
that “The facility must permit each resident to remain in the facility, and not transfer or
discharge the resident from the facility unless….” This means that once admitted,
residents have a right to remain in the facility unless the discharge or transfer meets one
of the specified exceptions in §§483.15(c)(1)(i)(A)-(F). Discharging a resident is a
violation of this right unless the facility can demonstrate that one of the limited
circumstances listed in the regulation is met.
Surveyors must ensure that for discharges related to circumstances at §483.15(c)(1)(i)(A),
(C), or (D) above, the facility has fully evaluated the resident, and does not base the
discharge on the resident’s status at the time of transfer to an acute care facility Without
an assessment of the resident’s status and needs at the time of proposed return to the
facility, 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.
In situations where a resident’s choice to refuse care or treatment 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
(See F656, §483.21(b)(1)(ii), Comprehensive Care Plans.) The facility must be able to
demonstrate that the resident or, if applicable, resident representative, received
information regarding the risks of refusal of treatment, (§483.10(c)(5) and (6), F552 and
F578) 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, and see also §§483.20 Resident Assessment and 483.35 Nursing
Services).
If unable to resolve situations where a resident’s refusal for care poses a risk to the
resident’s or others’ health or safety, the facility administration, nursing and medical
director may wish to convene an ethics meeting, which includes legal consultation, in
order to determine if the facility can meet the resident’s needs, or if the resident should
be transferred or discharged.
§483.15(c)(1)(i)(E) Nonpayment as Basis for Discharge
Non-payment for a stay in the facility occurs when the resident has failed, after
reasonable and appropriate notice, to pay for a stay at the facility and also may apply:
• When the resident has not submitted the necessary paperwork for third party
(including Medicare/Medicaid) payment; or
• After the third party payor (including Medicare or Medicaid) denied the claim and
the resident refused to pay for his/her stay.
It is the responsibility of the facility to notify the resident of their change in payment
status, and the facility should ensure the resident has the necessary assistance to
submit any third party paperwork. In situations where a resident representative has
failed to pay, the facility may discharge the resident for nonpayment; however, if
there is evidence of exploitation or misappropriation of the resident’s funds by the
representative, the facility should take steps to notify the appropriate authorities on
the resident’s behalf, before discharging the resident.
In situations where a resident’s Medicare coverage may be ending, the facility must
comply with the requirements at §483.10(g)(17) and (18), F582. If the resident
continues to need long-term care services, the facility, under the requirements above,
should offer the resident the ability to remain, which may include:
• Offering the resident the option to remain in the facility by paying privately for a
bed;
• Providing the Medicaid-eligible resident with necessary assistance to apply for
Medicaid coverage in accordance with §483.10(g)(13), F579, with an explanation
that:
o if denied Medicaid coverage, the resident would be responsible for payment
for all days after Medicare payment ended; and
o if found eligible, and no Medicaid bed became available in the facility or
the facility participated only in Medicare (SNF only), the resident would
be discharged to another facility with available Medicaid beds if the
resident wants to have the stay paid by Medicaid.
The resident cannot be discharged for nonpayment while a determination on the
resident’s Medicaid eligibility is pending.
NOTE: Surveyors should be aware of a facility’s Medicare and Medicaid
certification status and/or the presence of a distinct part as this can affect whether a
resident’s discharge for non-payment is justified and is a relevant part of the
investigation.
For a resident who becomes eligible for Medicaid after admission to a facility, the
facility may charge a resident only allowable charges under Medicaid. Additionally,
conversion from a private pay rate to payment at the Medicaid rate does not
constitute non-payment.
In certain cases, residents are admitted for short-term, skilled rehabilitation under Medicare,
but, following completion of the rehabilitation program, they communicate that they are not
ready to leave the facility. In these situations, if the facility proceeds with discharge, the
survey team should investigate to determine if the discharge violates these requirements, is
inappropriate, and should not have occurred. Additionally, these situations may require
further investigation to ensure that discrimination based on payment source has not occurred in accordance with §483.10(a)(2) (F550).
NOTE: Situations in which residents sign out of the facility, or leave Against Medical
Advice (AMA) should be thoroughly investigated to determine if the resident or
resident representative was forced, pressured, or intimidated into leaving AMA.
Additionally, the discharge would require further investigation to determine compliance
with the requirements at 483.15(c), including the requirement to provide a notice at
F628. See additional guidance at Abuse, Neglect and Exploitation at F600.
NOTE: Residents who are sent to the acute care setting for routine treatment/planned
procedures must also be allowed to return to the facility (See F626, Permitting Residents
to Return to Facility).
§483.15(c)(1)(ii) Discharge pending appeal
When a resident chooses to appeal his or her discharge from the facility, the facility may
not discharge the resident while the appeal is pending.
If the resident, or if applicable, their representative, appeals his or her discharge while in
a hospital, facilities must allow the resident to return pending their appeal, unless there
is evidence that the facility cannot meet the resident’s needs, or the resident’s return
would pose a danger to the health or safety of the resident or others in the facility. If
there are concerns related to a facility’s determination that it cannot meet a resident’s
needs, surveyors should assess whether the facility has admitted residents with similar
needs. A facility’s determination to not permit a resident to return while an appeal of the
resident’s discharge is pending must not be based on the resident’s condition when
originally transferred to the hospital.
Successful Appeals on Discharges
For residents who have appealed their discharge and obtained a favorable ruling from
the hearing, the resident or their representative may choose to report the discharge as a
complaint to the State Survey Agency based on the favorable appeal ruling. However,
the State Survey Agency cannot take a survey action, such as citing noncompliance
exclusively based on the ruling of the hearing. Rather, the State Survey Agency must
triage the complaint and conduct a survey in accordance with the timelines specified in
Section 5079.9 of Chapter 5 of the State Operations Manual. During the survey,
surveyors must investigate compliance with the applicable regulations, such as the
discharge requirements in this F-tag. Surveyors should also consider compliance with
§483.70(b), Compliance with Federal, State, and local laws and professional standards
at F836. If noncompliance is found, cite the appropriate tag and level of scope and
severity. Also, if the resident’s discharge location is to a setting that does not meet their
health or safety needs, the facility’s plan of correction should state that the facility will
either, 1) Re-admit the resident until a safe and compliant discharge can be done, or 2)
Coordinate a transfer of the resident to another setting where they will be safe. See the
Deficiency Categorization section towards the end of this guidance for more
information.
§483.15(c)(2) Required Documentation in the Resident’s Medical Record
To demonstrate that any of the circumstances permissible for a facility to transfer or
discharge as specified in the regulations have occurred, the medical record must show
documentation of the basis for transfer or discharge.
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;and
• 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.
NOTE: Documentation of the transfer or discharge may be completed by a nonphysician
practitioner (NPP) in accordance with State law.
§483.15(d)(1) – (e)(1)-(2) Bed Hold and Permitting Residents to Return
Facilities must develop and implement policies for bed-hold and permitting residents to
return following hospitalization or therapeutic leave. These policies apply to all
residents, regardless of their payment source. The facility policies must provide that
residents who seek to return to the facility within the bed-hold period defined in the
State plan are allowed to return to their previous room, if available. Additionally,
residents who seek to return to the facility after the expiration of the bed-hold period or
when state law does not provide for bed-holds are allowed to return to their previous
room if available or immediately to the first available bed in a semi-private room
provided that the resident:
• Still requires the services provided by the facility; and
• Is eligible for Medicare skilled nursing facility or Medicaid nursing facility
services.
The policies must also provide that if the facility determines that a resident cannot
return, the facility must comply with the requirements at 42 CFR 483.15(c).
Medicaid-eligible residents must be permitted to return to the first available bed even if
the residents have outstanding Medicaid balances.
Emergency Transfers to Acute Care
When residents are sent emergently to an acute care setting, these scenarios are
considered transfers, NOT discharges, because the resident’s return is generally
expected.
Residents who are sent emergently to an acute care setting, such as a hospital, must be
permitted to return to the facility. In a situation where the facility discharges the resident
while he or she is in the hospital following emergency transfer, the facility must have
evidence that the resident’s status at the time the resident seeks to return to the facility
(not at the time the resident was transferred for acute care) meets one of the criteria at
§483.15(c)(1)(i)(A) through (D). Additionally, the resident has the right to return to the
facility pending an appeal of the discharge unless the return would endanger the health
or safety of the resident or other individuals in the facility. The facility must document
the danger that the failure to transfer or discharge would pose. (§483.15(c)(1)(ii)).
A facility may have concerns about permitting a resident to return to the facility after a
hospital stay due to the resident’s clinical or behavioral condition at the time of transfer.
The facility must not evaluate the resident based on his or her condition when originally
transferred to the hospital. If the facility determines it will not be permitting the resident
to return, the medical record should show evidence that the facility made efforts to:
• Determine if the resident still requires the services of the facility and is eligible
for Medicare skilled nursing facility or Medicaid nursing facility services.
• Ascertain an accurate status of the resident’s condition—this can be accomplished
via communication between hospital and nursing home staff and/or through visits
by nursing home staff to the hospital.
• Find out from the hospital the treatments, medications, and services the facility
would need to provide to meet the resident’s needs upon returning to the facility.
If the facility is unable to provide the treatments, medications, and services
needed, the facility may not be able to meet the resident’s needs. For example, a
resident now requires ventilator care or dialysis, and the nursing home is unable to
provide this same level of care.
• Work with the hospital to ensure the resident’s condition and needs are within the
nursing home’s scope of care, based on its facility assessment, prior to hospital
discharge. For example, the nursing home could ask the hospital to:
o Attempt reducing a resident’s psychotropic medication prior to discharge and
monitor symptoms so that the nursing home can determine whether it will be
able to meet the resident’s needs uponreturn;
o Convert IV medications to oral medications and ensure that the
oral medications adequately address the resident’sneeds.
§483.15(e)(1)(ii) Not Permitting Residents to Return
Not permitting a resident to return following hospitalization or therapeutic leave
constitutes a discharge and requires a facility to meet the requirements as outlined in
§483.15(c)(1)(ii).
Because the facility was able to care for the resident prior to the hospitalization or
therapeutic leave, documentation related to the basis for discharge must clearly show
why the facility can no longer care for the resident.
If the facility does not permit a resident’s return to the facility (i.e., discharges the
resident) based on inability to meet the resident’s needs, documentation must be in
accordance with requirements at §483.15(c)(2)(i)(B). The facility must notify the
resident, his or her representative, and the LTC ombudsman in writing of the discharge,
including notification of appeal rights. (§483.15(c)(3) and (5)(iv)) If the resident chooses
to appeal the discharge, the facility must allow the resident to return to his or her room
or an available bed in the nursing home during the appeal process, unless there is
documented evidence that the resident’s return would endanger the health or safety of
the resident or other individuals in the facility.
If concerns arise regarding facility failure to permit a resident to return, review the
medical record for evidence of whether a notice of transfer and discharge and notice
of bed-hold were provided. Determine the basis for discharge and how the facility
evaluated the resident. The surveyor may have to obtain hospital records for further
investigation. Review any other documentation necessary to ascertain the extent to
which the facility made efforts to enable the resident to return.
In cases where a facility did not allow a resident to return due to lack of an available bed,
the surveyor should review facility admissions beginning with when the resident was
ready to return to determine whether the facility held the resident’s bed in accordance
with its bed-hold policies, or, if the resident’s stay outside of the facility exceeded the
bed-hold period, whether there was an available bed at the time the resident sought return
to the facility. If there was not an available bed at the time the resident sought return to
the facility, the surveyor should determine whether or not the resident was allowed to
return to the first available bed in a semi-private room.
When a facility alleges they cannot meet the resident’s needs and does not allow a
resident to return, the surveyor should 1) investigate why the resident’s needs cannot be
met; and 2) review facility admissions to determine if residents with similar care needs
have been admitted or permitted to remain, which could indicate the facility has the
capability to meet the needs of the resident who is not being allowed to return and
demonstrates noncompliance with this requirement.
Additionally, facilities must not treat situations where a resident goes on therapeutic
leave and returns later than agreed upon, as a discharge. The resident must be permitted
to return and be appropriately assessed for any ill-effects from being away from the
facility longer than expected, and provide any needed medications or treatments which
were not administered because they were out of the building. If a resident has not
returned from therapeutic leave as expected, the medical record should show evidence
that the facility attempted to contact the resident and resident representative. The facility
must not discharge the resident unless it has ascertained from the resident or resident
representative that the he or she does not wish to return.
NOTE: In reviewing complaints for discharges that do not honor a resident’s right to
return following a hospitalization or therapeutic leave, surveyors would review both
transfer and discharge requirements because the situation begins as a transfer and then
changes to a discharge when the facility decides it will not permit the resident to return.
Composite Distinct Part
If a facility does not have a composite distinct part, §483.15(e)(2) does not apply. When a
resident is returning to a composite distinct part, he/she must be allowed to return to an
available bed in the particular location of the composite distinct part in which he/she
resided previously, or the next available bed in that location.
NOTE: If there are concerns as to whether or not a facility is appropriately certified
as a distinct or composite distinct part, consult with the CMS Location for
clarification.
§483.15(c)(7) Preparation for Transfer or Discharge
Sufficient preparation and orientation means the facility informs the resident where he
or she is going, and takes steps under its control to minimize anxiety. Examples of
preparation and orientation may include explaining to a resident why they are going to
the emergency room or other location or leaving the facility; working with family or
resident’s representative to assure that the resident’s possessions (as needed or requested
by the resident) are not left behind or lost; and ensuring that staff handle transfers and
discharges in a manner that minimizes anxiety or depression and recognizes
characteristic resident reactions identified by the resident’s assessment and care plan.
The facility must orient and prepare the resident regarding his or her transfer or
discharge in a form and manner that the resident can understand. The form and manner
of this orientation and preparation must take into consideration factors that may affect
the resident’s ability to understand, such as educational level, language and/or
communication barriers, and physical and mental impairments. The facility must also
document this orientation in the medical record, including the resident’s understanding
of the transfer or discharge.
§483.21(c)(1) Discharge Planning
Discharge planning is the process of creating an individualized discharge care plan,
which is part of the comprehensive care plan. It involves the interdisciplinary team (as
defined in §483.21(b)(2)(ii) working with the resident and resident representative, if
applicable, to develop interventions to meet the resident’s discharge goals and needs to
ensure a smooth and safe transition from the facility to the post-discharge setting.
Discharge planning begins at admission and is based on the resident’s assessment and
goals for care, desire to be discharged, and the resident’s capacity for discharge. It also
includes identifying changes in the resident’s condition, which may impact the discharge
plan, warranting revisions to interventions. A well-executed discharge planning process,
without avoidable complications, maximizes each resident’s potential to improve, to the
extent possible, based on his or her clinical condition. An inadequate discharge planning
process may complicate the resident’s recovery, lead to admission to a hospital, or even
result in the resident’s death.
The discharge care plan is part of the comprehensive care plan and must:
• Be developed by the interdisciplinary team and involve direct communication
with the resident and if applicable, the resident representative;
• Address the resident’s goals for care and treatment preferences;
• Identify needs that must be addressed before the resident can be discharged, such
as resident education, rehabilitation, and caregiver support and education;
• Be re-evaluated regularly and updated when the resident’s needs or goals change;
• Document the resident’s interest in, and any referrals made to the local contact
agency; and
• Identify post-discharge needs such as nursing and therapy services, medical
equipment or modifications to the home, or ADL assistance.
Resident Discharge to the Community
Section Q of the Minimum Data Set (MDS) requires that individuals be periodically
assessed for their interest in being transitioned to community living, unless the resident
indicates otherwise. See: https://www.cms.gov/medicare/quality/nursing-homeimprovement/
resident-assessment-instrument-manual .
For residents who want to be discharged to the community, the nursing home must
determine if appropriate and adequate supports are in place, including capacity and
capability of the resident’s caregivers at home. Family members, significant others or the
resident’s representative should be involved in this determination, with the resident’s
permission, unless the resident is unable to participate in the discharge planning process.
Each situation is unique to the resident, his/her family, and/or guardian/legally authorized
representative. A referral to the Local Contact Agency (LCA) may be appropriate for
many individuals, who could be transitioned to a community setting of their choice. The
nursing home staff is responsible for making referrals to the LCA, if appropriate, under
the process that the State has established. Nursing home staff should also make the
resident and if applicable, the resident representative aware that the local ombudsman is
available to provide information and assist with any transitions from the nursing home.
For residents who have been in the facility for a longer time, it is still important to
inquire, as appropriate, whether the resident would like to talk with LCA experts about
returning to the community. New or improved community resources and supports may
have become available since the resident was first admitted which may now enable the
resident to return to a community setting.
If the resident is unable to communicate his or her preference or is unable to participate in
discharge planning, the information should be obtained from the resident’s representative.
Discharge planning must include procedures for:
• Documentation of referrals to local contact agencies, the local ombudsman, or
other appropriate entities made for this purpose;
• Documentation of the response to referrals; and
• For residents for whom discharge to the community has been determined to not be
feasible, the medical record must contain information about who made that
decision and the rationale for that decision.
Discharge planning must identify the discharge destination, and ensure it meets the
resident’s health and safety needs, as well as preferences. If a resident wishes to be
discharged to a setting that does not appear to meet his or her post-discharge needs, or
appears unsafe, the facility must treat this situation similarly to refusal of care, and must:
• Discuss with the resident, (and/or his or her representative, if applicable) and
document the implications and/or risks of being discharged to a location that is
not equipped to meet his/her needs and attempt to ascertain why the resident is
choosing that location;
• Document that other, more suitable, options of locations that are equipped to meet
the needs of the resident were presented and discussed;
• Document that despite being offered other options that could meet the resident’s
needs, the resident refused those other more appropriate settings;
• Determine if a referral to Adult Protective Services or other state entity charged
with investigating abuse and neglect is necessary. The referral should be made at
the time of discharge.
As appropriate, facilities should follow their policies, or state law as related to discharges
which are Against Medical Advice (AMA). Note: These situations only apply when a resident
expresses their wishes to be discharged earlier than outlined in the care plan. These
situations do not apply if a facility offers to discharge a resident to a location which does
not meet their health and/or safety needs, and the resident agrees (this would constitute
noncompliance).
§483.21(c)(1)(viii) Residents who will be discharged to another SNF/NF, HHA, IRF,
or LTCH
If a resident will be discharged to another SNF, an IRF, LTCH, or HHA, the facility must
assist the resident in choosing an appropriate post-acute care provider that will meet the
resident’s needs, goals, and preferences. Assisting the resident means the facility must
compile available data on other appropriate post-acute care options to present to the
resident. Information the facility must gather about potential receiving providers
includes, but is not limited to:
• Publicly available standardized quality information, as reflected in specific quality
measures, such as the CMS Nursing Home Compare, Home Health Compare,
Inpatient Rehabilitation Facility (IRF) Compare, and Long-Term Care Hospital
(LTCH) Compare websites, and
• Resource use data, which may include, number of residents/patients who are
discharged to the community, and rates of potentially preventable hospital
readmissions.
The listing of potential providers and data compiled must be relevant to the resident’s
needs, and be aligned with the resident’s goals of care and treatment preferences.
To ensure resident involvement, facilities are expected to present provider information to
the resident and resident representative, if applicable, in an accessible and understandable
format. For example, the facility should provide the aforementioned quality data on other
post-acute care providers that meet the resident’s needs, goals, and preferences, and are
within the resident’s desired geographic area. Facilities must then assist residents and/or
resident representative as they seek to understand the data and use it to help them choose
a post-acute care provider, or other setting for discharge, that is best suited to their goals,
preferences, needs and circumstances. For residents who are discharged to another
SNF/NF, a HHA, IRF, or LTCH the facility must provide evidence that the resident and
if applicable, the resident representative was given provider information that includes
standardized patient assessment data, and information on quality measures and resource
use (where that data is available).
Post-Discharge Plan of Care
The post-discharge plan of care details the arrangements that facility staff have made to
address the resident’s needs after discharge, and includes instructions given to the
resident and his or her representative, if applicable. The post-discharge plan of care must
be developed with the participation of the Interdisciplinary team and the resident and,
with the resident’s consent, the resident’s representative. At the resident’s request, a
representative of the local contact agency may also be included in the development of the
post-discharge plan of care. The post-discharge plan of care should show what
arrangements have been made regarding:
• Where the resident will live after leaving the facility;
• Follow-up care the resident will receive from other providers, and that provider’s
contact information;
• Needed medical and non-medical services (including medical equipment);
• Community care and support services, if needed; and
• When and how to contact the continuing care provider.
Instructions to residents discharged to home
For residents discharged to their home, the medical record should contain documentation
that written discharge instructions were given to the resident and if applicable, the
resident representative. These instructions must be discussed with the resident and
resident representative and conveyed in a language and manner they will understand.
INVESTIGATIVE PROTOCOL
Use the Critical Element (CE) Pathways for 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 requirements on when a facility
can transfer or discharge a resident and ensuring the transfer or discharge meets the
resident’s health and/or safety needs.
Summary of Investigative Procedure
Use Offsite Preparation information from the Ombudsman to identify residents or
resident representatives (for residents already discharged) who may have concerns with
inappropriate discharges. For any residents with concerns, briefly review the most
recent comprehensive assessment, comprehensive care plan (specifically the discharge
care plan), progress notes, and orders to:
• Identify the basis for the transfer or discharge,
• Determine whether the facility has identified and addressed the resident’s goals
and discharge needs;
Determine if the resident was appropriately oriented, prepared, and understood the
information provided to him or her.
During this review, identify the extent to which the facility has developed and
implemented interventions in accordance with the resident’s needs, goals for care and
professional standards of practice. This information will guide observations and
interviews to be made in order to corroborate concerns identified.
Deficiency Categorization
In addition to actual or potential physical harm, always consider whether psychosocial
harm has occurred when determining severity level (See Psychosocial Outcome Severity
Guide, https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html, select the Survey
Resources download and select the Psychosocial Outcome Severity Guide from the list of
resources.
Violations of the requirements at F627, Inappropriate Discharges, would generally be
cited at the severity level of Harm (Level 3) or Immediate Jeopardy (Level 4) when using
the reasonable person approach in considering psychosocial outcomes as well as the
likelihood for serious physical harm resulting from an unsafe discharge. See State
Operations Manual Appendix Q and the Psychosocial Outcome Severity Guide located in
the Survey Resources zip file located at https://www.cms.gov/medicare/providerenrollment-
and-certification/guidanceforlawsandregulations/nursing-homes). for
additional information about psychosocial/mental harm and using the reasonable person
concept.
NOTE: For citations at any level of scope and severity, if the discharged resident’s
health and/or safety is threatened in the setting they are currently located, the facility’s
plan of correction should state that the facility will either, 1) Re-admit the resident until a
safe and compliant discharge can be done, or 2) Coordinate a transfer of the resident to
another setting where they will be safe. The facility should not be determined in
substantial compliance until one of these two items is complete (and all other
noncompliance has been corrected). If the resident’s needs are being met in their current
location, the plan of correction should include specifics on how the facility will prevent
inappropriate noncompliant discharges in the future.
Additionally, for situations in which residents’ discharge locations did not meet their
health and/or safety needs, enforcement should be implemented immediately. For
example, a discretionary denial of payment for new admissions should be imposed to go
into effect within 2 or 15 days (as appropriate), and remain in effect until a return to
substantial compliance as evidenced by either, 1) the resident is readmitted and not
discharged unless a safe and compliant discharge is done, or 2) the facility coordinates a
discharge to another setting where their needs will be met.
Examples of Severity Level 4 Non-compliance: Immediate Jeopardy to Resident
Health or Safety include, but are not limited to:
• A facility discharged a resident on the basis that the resident’s health had
improved so that the resident no longer needed the services provided by the
facility, however, the resident and her family disagreed and filed an appeal. The
facility did not allow the resident to remain in the facility while the appeal was
pending and dropped her off at her daughter’s home. The resident’s daughter
previously stated she could not care for her mother at her home where needed
medical equipment and wound care was not available, thus creating an
inappropriate discharge for this resident, which did not meet her health needs.
• A facility discharged a resident based on the facility’s inability to meet the
resident’s needs. However, upon complaint investigation, it was determined by
interview and record review that, while the resident was depressed and had
challenging behaviors requiring staff attention, he did not have needs which could
not be met in that facility, and there was evidence that the facility was caring for
other residents with similar behaviors. The resident was discharged to an unsafe
setting, or in a manner, that placed the resident at risk for serious harm (e.g., the
resident still has medical needs, but they cannot be supported in the setting they
were discharged to).
• A facility failed to allow a resident requiring the facility’s services to return
following therapeutic leave to a family member’s home. Additionally, when the
facility refused to allow him to return, they took no steps to comply with the
discharge requirements for notice and appeal rights. This resulted in an
inappropriate discharge. The resident was found living on the street, without the
needed care and adequate food and shelter, and susceptible to serious injury.
• A facility failed to ensure that the post-discharge destination and continuing care
provider could meet the resident’s needs prior to the discharge of a resident with a
feeding tube to a residential group facility, resulting in discharge to an unsafe
setting. The surveyor discovered that within 24 hours of discharge, the resident
was transferred to the hospital for aspiration, was intubated for respiratory distress
and diagnosed with brain death. Review of medical records showed no
documentation of the resident’s tube feeding needs in the discharge plan, or
whether the nursing home informed the receiving facility of the presence of the
feeding tube and the need for aspiration precautions. It was also unclear whether
the nursing home had determined that the receiving facility had the ability to care
for a resident with a feeding tube prior to placement of the individual.
Examples of Severity Level 3 Noncompliance: Actual Harm that is not Immediate
Jeopardy include, but are not limited to:
• The facility failed to allow a resident to remain in the facility after his skilled
rehabilitation ended and while his application for Medical Assistance was
pending. The resident consequently was discharged to another facility that was
located further from the resident’s family, resulting in the resident expressing
persistent sadness and withdrawal from social activities.
• A facility discharged a resident after the resident attempted to hit a staff member
during morning care over several days. The facility discharged the resident
claiming the resident was a danger to others. Upon investigation of a complaint, it
was determined the facility had been failing to provide the resident with their
prescribed medication prior to morning care in accordance with the care plan.
Evidence also showed the resident had never attempted to hit staff when pain was
managed according to the care plan, therefore the resident was not actually a
danger to others. There was also no documentation of the facility’s attempts to
meet the resident’s needs or what services the new receiving facility had in order
to meet the resident’s needs. During an interview with the resident, the surveyor
found the resident was not happy in the new facility and was no longer
participating in activities or therapy, resulting in a significant decreased ability to
perform ADLs.
• Facility failed to allow a resident to return to an available bed in the same
location of the composite distinct part in which they resided previously. The new
location was not on the same campus where the resident previously resided, and
was farther from the resident’s family, resulting in the resident expressing
sustained and persistent sadness and withdrawal.
• After transfer to an acute care facility, a facility failed to allow a resident to
return to the facility where the resident had lived for several months saying they
could not meet the resident’s needs. Review of the resident’s records did not
show the resident had any new needs after hospitalization that could not be met
by the facility.. As a result, the resident was transferred from the hospital to a
different nursing home 40 minutes away, where he did not know anyone, and
where he developed increased anxiety and depression.
• The facility failed to develop and/or implement a discharge care plan for a
resident who had expressed a desire to return home as soon as possible once she
completed rehabilitation for a fractured hip. The medical record revealed the
therapist had discontinued the active treatment one week ago. The resident stated
and the medical record verified that the facility had not developed plans for her
care after her discharge and had not contacted any community providers to assist
in her discharge. She indicated that she has not slept well due to worrying about
returning to her home and paying the rent while in the facility. The resident’s
home was over an hour away. She stated she was depressed over having to remain
in the nursing home, and spent most of the day in her room as it was too far for
her friends to visit.
• A facility failed to develop discharge plans to meet the needs and goals of each
resident, resulting in significant psychosocial harm, when the facility determined
it would be closing, necessitating the discharge of all residents. The facility
notified residents and resident representatives it would assist with relocation.
Interviews with residents and observations showed residents were agitated,
fearful, and in tears over the impending move. Residents indicated they were not
asked their preferences and many would be relocated far away from family.
Residents also indicated they were not given opportunities to provide input into
the discharge planning process, specifically regarding discharge location. Record
review showed no evidence of interaction with residents or resident
representatives related to discharge planning. This was cross-referenced and cited
at F845, Facility Closure.
An example of Severity Level 2 Noncompliance: No Actual Harm with Potential for
More Than Minimal Harm that is Not Immediate Jeopardy includes, but is not
limited to:
• A facility transferred a resident to the hospital emergently due to a change in
condition. The facility failed to provide the hospital with contact information for
the practitioner responsible for the resident’s care leading to a delay in admitting
the resident.
• Facility failed to develop a discharge care plan that addressed all of the needs for
a resident being discharged home. Specifically, the care plan did not address the
resident’s need for an oxygen concentrator at home. After the resident was
discharged to his home, a family member had to contact the physician to obtain
the order and make arrangements for delivery of the equipment. Although there
was a delay in obtaining the oxygen concentrator, the resident did not experience
harm, however this four-hour delay had a potential for compromising the
residents’ ability to maintain his well-being.
An example of Severity Level 1 noncompliance: The failure to permit the resident to
remain in the facility, document the resident’s transfer or discharge, and
communicate necessary information to the receiving provider places the resident at
risk for more than minimal harm. Therefore, Severity Level 1 does not apply for
this regulatory requirement.
