Documentation Required for an Involuntary Transfer or Discharge

Jeannine LeCompte; Compliance Research Specialist

Along-term care facility seeking to implement an involuntary transfer or discharge of a resident must fulfill a state-specified list of requirements,including an extensive set of documentation justifying its actions.

Primarily, 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 healthcare institution or provider.

The documentation in the resident’s medical record must include:

– The basis for the transfer;

– If the transfer is being made for reasons of inability to meet the resident’s specific requirements, the documentation must state what those needs are, and the service available at the receiving facility to meet the need(s);

– Any documentation from the resident’s physician stating the need for the transfer. This must include:

The contact information for the responsible practitioner and resident representative;
All Advance Directive information;
All special instructions or precautions for ongoing care, as appropriate;
The resident’s comprehensive care plan goals;
Any other necessary information, such as a copy of the resident’s discharge summary.

-Additionally, for any transfer made due to the facility’s inability to meet the resident’s needs, the documentation 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.

When a discharge is made to protect the safety of individuals in the facility due to the clinical or behavioral status of the resident, or when the health of individuals in the facility would otherwise be endangered by the affected resident’s presence, a detailed and specific list of reasons and supporting documentation must be provided.

In the case of criminal activity, proof of the event and any supplemental evidence must be entered into the resident’s record, and relevant authorities must be informed of all the details as soon as possible.

Noncompliance can lead to legal exposure for the facility—from both the affected resident if their rights are infringed upon, and from other residents if they suffer any losses, injuries, or worse, as a result of the facility’s failure to act decisively once the danger becomes known.

When a patient is discharged for nonpayment, the facility must show that the resident or their representative has not submitted the necessary paperwork for third party (including Medicare/Medicaid) payment; or that the third party payor denied the claim and the resident refused to pay.

Nonpayment as reason for discharge is a potential minefield, and a later article in this series will study the issue in detail.