The Centers for Medicare & Medicaid Services (“CMS”) has given surveyors new rules and updates to allow surveyors to assess and cite violations of the regulations on resident discharge and transfer.
On November 18, 2024, the Quality, Safety & Oversight Group at CMS issued a memorandum entitled “REVISED: Revised Long-Term Care (LTC) Surveyor Guidance: Significant revisions to enhance quality and oversight of the LTC survey process” (“New Surveyor Guidance Memo”).
The New Surveyor Guidance Memo consolidates existing F-Tags, enhances surveyor oversight and reinforces protections against inappropriate discharges.
Key Changes to Discharge and Transfer Surveyor Guidance
Consolidation of F-Tags
CMS has streamlined the existing framework by eliminating:
- F-Tag 622 Transfer and Discharge Requirements (cited 379 times in 2024)
- F-Tag 623 Notice Requirements Before Transfer/Discharge (cited 1,221 times in 2024)
- F-Tag 624 Preparation for Safe/Orderly Transfer/Discharge (cited 142 times in 2024)
- F-Tag 625 Notice of Bed Hold Policy Before/Upon Transfer (cited 840 times in 2024)
- F-Tag 626 Permitting Residents to Return to Facility (cited 155 times in 2024)
- F-Tag 660 Discharge Planning Process (cited 260 times in 2024)
- F-Tag 661 Discharge Summary (cited 278 times in 2024)
These have been replaced with two new F-Tags:
- F-Tag 627 – Inappropriate Transfers and Discharges
- F-Tag 628 – Transfer and Discharge Process
CMS intends that the consolidation will simplify compliance while reinforcing safeguards that prevent residents from being discharged without due process.
F-Tag 627 – Inappropriate Transfers and Discharges
F-Tag 627 replaces F-Tags 622 through 626, creating a single standard to address improper discharges. It mandates that facilities implement policies to ensure residents can return following hospitalization or therapeutic leave unless there is a documented medical or safety justification.
The New Surveyor Guidance Memo instructs surveyors to use guidance for F-Tag 627 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:
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- 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;
- Discharge based on the 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;
- 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;
- Discharge based on failure to pay, but 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;
- Discharge occurred 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 caregiver’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 their ability to care for themself.
CMS emphasized that 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.
CMS also notes that when a resident leaves returning to the community, that as appropriate, facilities should follow their policies or state law as related to discharges which are “Against Medical Advice.” It notes that 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 that does not meet their health and/or safety needs, and the resident agrees (this would constitute noncompliance).
The New Surveyor Guidance Memo states that violations of the requirements at F-Tag 627, 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. 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.
F-Tag 628 – Transfer and Discharge Process
F-Tag 628 details the procedural requirements for all resident transfers and discharges. The intent of this tag is to ensure the facility adheres to all of the applicable components of the process for transferring or discharging a resident which include documentation and information conveyed to the receiving provider, the notice of transfer or discharge, notice of bed-hold policy and completing the discharge summary. Key provisions include:
- Clear Documentation Requirements: Nursing homes must provide thorough documentation justifying the need for a transfer or discharge. This includes a physician’s order and a detailed explanation of why the facility can no longer meet the resident’s needs.
- Advance Notice: Residents and their representatives must receive a written notice at least 30 days before a non-emergency discharge, except in cases of immediate threats to health and safety.
- Receiving Facility Communication: Before transfer, the discharging facility must ensure that the receiving facility has the necessary medical and personal information to provide proper care.
- Enhanced Surveyor Oversight: Surveyors are required to review documentation for compliance and interview residents and families to ensure proper procedures are followed.
Surveyor Guidance Enhancements
CMS has directed surveyors to take a more proactive role in identifying and addressing inappropriate discharges. The updated surveyor guidance includes the following:
- Offsite Preparation: Surveyors must contact state ombudsmen before inspections to determine if there have been complaints related to improper discharges.
- Resident and Family Interviews: Surveyors are required to speak with residents and their families to gather firsthand accounts of discharge procedures and any potential violations.
- Comprehensive Documentation Review: Any discharge that does not meet the stringent criteria outlined in F-Tag 627 and F-Tag 628 will be flagged for potential enforcement action.
Effective Date
The New Surveyor Guidance is effective March 24, 2025.
Practical Takeaways
With these changes, recommended actions include:
- Policy Review and Revision. Update discharge and transfer policies to align with F-Tag 627 and F-Tag 628 requirements. Ensure all staff understand the new documentation and communication expectations.
- Staff Training. Conduct mandatory training sessions for administrators, social workers and nursing staff on proper discharge and transfer procedures. Educate staff on non-pharmacological interventions to reduce unnecessary discharges due to behavioral concerns.
- Resident and Family Communication. Establish clear communication channels to inform residents and families of their rights regarding discharges. Provide written materials explaining the new CMS guidelines and how they protect residents from inappropriate discharges.
- Strengthened Documentation Protocols. Implement standardized forms for discharge planning to ensure thorough and consistent documentation. Require interdisciplinary team reviews before finalizing any discharge decision.
If you have questions or would like additional information about this topic, please contact:
- Sean Fahey at (317) 977-1472 or sfahey@hallrender.com;
- Brian Jent at (317) 977-1402 or bjent@hallrender.com;
- Todd Selby at (317) 977-1440 or tselby@hallrender.com; or
- Your primary Hall Render contact.
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