Can a nursing home make a resident leave?

Only for a reason listed in 42 CFR 483.15(c)(1). The reasons are unmet needs that the move is necessary to address, health that has improved so the resident no longer needs the facility's services, danger to the safety or health of people in the facility, nonpayment after reasonable and appropriate notice as the regulation defines it, and the facility closing. The home has to document the basis in the medical record.

How much notice does a nursing home have to give?

At least 30 days before the transfer or discharge, in writing, to the resident and the resident's representative, with a copy to the state long-term care ombudsman. Notice may be given as soon as practicable, instead of 30 days ahead, if safety or health in the facility is endangered, the resident's health has improved enough for a faster move, urgent medical needs require an immediate move, or the resident has lived there fewer than 30 days.

What has to be on the discharge notice?

The reason, the effective date, the destination, how to appeal and who receives the appeal, and how to reach the state long-term care ombudsman. For nursing facility residents with an intellectual, developmental, or mental disability, or a related disability, the notice also has to include the protection and advocacy agency. If those facts change before the move, the home has to update the recipients.

Does a hospital transfer mean the resident has lost the bed?

Not by itself. Before a transfer to a hospital or a therapeutic leave, the nursing facility has to give written information about the state's bed-hold policy, if there is one, and about the right to return. Federal rules do not set one national number of bed-hold days. If the facility later decides a resident who was expected to return cannot return, it has to follow the discharge rules, including notice.

Can the resident appeal, and can the move wait?

42 CFR 431.220(a)(2) requires the state Medicaid agency to give a hearing to a resident who believes a skilled nursing facility or nursing facility has erroneously determined that the resident must be transferred or discharged. Section 483.15(c)(1)(ii) says the facility may not carry out the transfer or discharge while that kind of appeal is pending unless failing to move the resident would endanger health or safety, and the facility must document the danger. The notice has to name the office that receives the appeal. Use the deadline that office gives you.

Is a room change a discharge?

42 CFR 483.5 says transfer and discharge means movement to a bed outside the certified facility, including a bed in the same building that is outside the certification. It does not mean movement to another bed inside the same certified facility. A move outside the certified facility is a transfer or discharge and needs the notice.

Nursing home transfer and discharge rights

The starting point is the right to remain

Section 483.15(c)(1) says the facility must permit each resident to remain in the facility, and must not transfer or discharge the resident, unless one of six conditions is met. The conditions are the regulation's list, not a general right for the home to decide that a resident no longer fits. The same section says the facility has to use identical transfer and discharge policies for residents regardless of who pays, consistent with the equal-access rule in 42 CFR 483.10(a)(2). A Medicaid stay and a private-pay stay are not supposed to be moved under different house rules.

42 CFR 483.5 defines transfer and discharge to include movement of a resident to a bed outside the certified facility, whether or not that bed is in the same physical plant. It does not include movement to a bed inside the same certified facility. A room change down the hall, inside the certified home, is not by itself a transfer or discharge under that definition. A move to a bed that is outside the certification, including a bed in another part of the same building that is not part of the certified facility, is. Composite distinct parts, which are a specific certification arrangement defined in section 483.5, have extra limits on room changes in section 483.15(c)(9). Those limits are about location inside that kind of provider. They are not a second set of discharge reasons.

The six reasons a home may move a resident

The facility may transfer or discharge a resident only when one of these is true:

The transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility.
The resident's health has improved enough that the resident no longer needs the services the facility provides.
The safety of people in the facility is endangered because of the resident's clinical or behavioral status.
The health of people in the facility would otherwise be endangered.
The resident has failed, after reasonable and appropriate notice, to pay for the stay, or to have it paid under Medicare or Medicaid.
The facility ceases to operate.

Nonpayment has its own sentence in the regulation, because families and homes often use the word for different situations. Nonpayment applies if the resident does not submit the paperwork needed for a third party to pay, or if a third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay. For a resident who becomes eligible for Medicaid after admission, the facility may charge only the amounts Medicaid allows. A bill the resident is disputing, or a Medicaid application that is still pending, is a facts question for the notice and for any appeal. The regulation does not treat every unpaid invoice as automatic grounds. It requires failure to pay after reasonable and appropriate notice, within the definition above.

When the home uses any of the six reasons, it has to document the transfer or discharge in the resident's medical record and send appropriate information to the provider who will receive the resident. The record has to include the basis for the move. If the reason is that the resident's needs cannot be met, the record also has to name the specific needs the facility cannot meet, what the facility tried, and the service available at the receiving facility that will meet those needs. The resident's physician has to make that documentation when the reason is unmet needs or improvement in health. A physician has to make it when the reason is that someone's safety or health in the facility is endangered.

The information sent to the next provider has to include, at a minimum, contact information for the practitioner responsible for the resident, contact information for the resident's representative, advance-directive information, special instructions or precautions for ongoing care, the goals of the comprehensive care plan, and whatever else is needed for a safe transition, including a discharge summary when 42 CFR 483.21(c)(2) applies. A notice that names a town, and nothing about the care that has to travel with the resident, is not that package.

What the written notice has to contain, and when it has to arrive

Before the facility transfers or discharges a resident, it has to notify the resident and the resident's representative of the move and the reasons, in writing, and in a language and manner they understand. It has to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. It has to record the reasons in the medical record. Except for the shorter clocks below, and except for the separate closure notice, the notice has to be made at least 30 days before the resident is transferred or discharged.

Notice may be made as soon as practicable before the move, rather than 30 days before, in five situations. The safety of people in the facility would be endangered. The health of people in the facility would be endangered. The resident's health has improved enough to allow a more immediate move. An immediate transfer or discharge is required by the resident's urgent medical needs. Or the resident has not lived in the facility for 30 days. "As soon as practicable" is the regulation's phrase. It is not a permission to skip the notice.

The written notice has to include all of the following:

The reason for the transfer or discharge.
The effective date.
The location to which the resident is being transferred or discharged.
A statement of the resident's appeal rights, including the name, mailing address, email address, and telephone number of the office that receives the appeal, and information on how to get an appeal form and help completing it.
The name, mailing address, email address, and telephone number of the Office of the State Long-Term Care Ombudsman.
For a nursing facility resident with an intellectual or developmental disability, or a related disability, the contact information for the protection and advocacy agency established under the Developmental Disabilities Assistance and Bill of Rights Act.
For a nursing facility resident with a mental disorder or a related disability, the contact information for the protection and advocacy agency established under the Protection and Advocacy for Mentally Ill Individuals Act.

If any of that information changes before the move happens, the facility has to update the people who received the notice as soon as practicable after the new information is available. A notice that leaves the destination blank, or that names an appeal office without a way to reach it, is missing a required item. The location matters because the resident and the representative have to be able to tell whether the proposed place can meet the needs the home says it cannot meet.

The facility also has to provide and document enough preparation and orientation to make the transfer or discharge safe and orderly. That orientation has to be in a form and manner the resident can understand. Orientation is part of the move. It is not a substitute for the written notice, and the written notice is not a substitute for it.

Appealing the notice

42 CFR 431.220(a)(2) says the state Medicaid agency must grant a hearing to any resident who requests one because the resident believes a skilled nursing facility or nursing facility has erroneously determined that he or she must be transferred or discharged. The office named on the notice is the place the notice tells you to send that request. The federal rule does not set one national deadline for the request. It tells the home to put the receiving office's contact information, and instructions for getting the form, on the notice. Use those instructions, and ask that office for the date your request has to arrive. The long-term care ombudsman can help a resident understand the notice. The ombudsman is not the hearing office.

Section 483.15(c)(1)(ii) limits what the home may do while an appeal is pending. It says the facility may not transfer or discharge the resident while the appeal is pending, under 42 CFR 431.230, when the resident appeals a transfer or discharge notice under the paragraph the discharge rule cites, 42 CFR 431.220(a)(3), unless failing to move the resident would endanger the health or safety of the resident or of other people in the facility. The facility has to document that danger. In the current text of section 431.220, the hearing for a resident who believes the facility has erroneously required a transfer or discharge is paragraph (a)(2). Paragraph (a)(3) is a different hearing, about the state's preadmission screening and resident review determination. The notice in your hand, and the state office named on it, are the practical path. Ask that office which provision it is applying to a request filed from a nursing home discharge notice. Do not guess the paragraph number from memory and miss the deadline printed on the form.

A hospital stay is not automatically a discharge

Before a nursing facility transfers a resident to a hospital, or the resident goes on therapeutic leave, the facility has to give the resident or the resident's representative written information that states the duration of the state bed-hold policy, if the state has one, during which the resident may return and resume residence. The notice also has to describe the state's reserve-bed payment policy, if any, the facility's own bed-hold policies, and the return rights in section 483.15(e). At the time of the transfer, the facility has to give another written notice that states how long that bed-hold lasts. Federal rules do not set a single number of bed-hold days for every state. They require the home to tell you the duration of the policy that applies.

The facility has to have a written policy on letting residents return after a hospitalization or therapeutic leave. If the hospitalization or leave runs longer than the bed-hold period under the state plan, a resident returns to the previous room if it is available, or immediately to the first available bed in a semi-private room, when two things are true: the resident still needs the services the facility provides, and the resident is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. If the facility decides that a resident who was transferred with an expectation of returning cannot return, it has to follow the discharge requirements in section 483.15(c). A hospital transfer does not, by itself, end the stay. A later decision that the resident cannot come back is a discharge, and it needs the discharge notice.

If the home is closing

When the facility is closing, the administrator has to give written notice before the closure to the state survey agency, the Office of the State Long-Term Care Ombudsman, the residents, and the resident representatives. The notice includes the plan for transfer and adequate relocation of the residents, as 42 CFR 483.70(k) requires. Closure is one of the six permitted reasons. It is also the one with this extra notice to the survey agency and a relocation plan. A closure notice that tells residents to be out, and does not describe where they will go, is missing the relocation piece the regulation names.

What to do with the paper in front of you

Read the reason against the six conditions, not against a house phrase such as "not a good fit." Check the effective date against the 30-day rule, and see whether the home is using one of the exceptions that allow notice as soon as practicable. Check that the destination is a real location, that the appeal office can be reached at the address and phone number printed on the notice, and that the ombudsman's contact information is on the page. Ask for the medical-record note that states the basis, and, when the reason is unmet need, the description of what the home tried and what the next facility offers. Ask for the orientation the regulation requires, in a form the resident understands.

If the situation is an eviction to a place you believe is unsafe, that allegation has a specific place in complaint triage. Chapter 5 of the State Operations Manual lists, among the nursing home intakes assigned an immediate-jeopardy priority, all intakes alleging eviction of a resident to an unsafe location. How to file that complaint, and the three-business-day clock that priority uses, is in the complaint guide. If surveyors later cite the home, the finding is written on Form CMS-2567 and may appear as a tag on the facility page. The inspection-report guide explains the form. The deficiency-tag guide explains how a tag and a scope-and-severity letter show up in the CMS file.

The facility pages reached from state and city lists and from search show inspections, staffing, and penalties. They do not show whether a particular resident was given a discharge notice. Compare will not show that either. The notice, the medical record, the ombudsman, and the state survey agency are the record for a move. The CMS star rating is a different record. The guide to choosing a home is about reading that rating record before a stay. This page is about the rules that apply once a resident is in the building.

Sources

42 CFR 483.15, admission, transfer, and discharge rights, including notice, appeal, orientation, bed hold, and return.
42 CFR 483.5, definition of transfer and discharge.
42 CFR 483.10(a)(2), equal access.
42 CFR 431.220 and 42 CFR 431.230, Medicaid hearings.
42 CFR 483.21(c)(2), discharge summary, and 42 CFR 483.70(k), facility closure.
State Operations Manual, Chapter 5, section 5075.1, immediate-jeopardy priority for an alleged eviction to an unsafe location.
Long-Term Care Ombudsman Program, Administration for Community Living.