Admission, Transfer and

Discharge Rights

Description of Federal Requirements  [TOP]

The rules regarding transfer or discharge (a) establish the conditions under which a resident may be transferred involuntarily, including that the facility is closing, the resident has improved so that he/she no longer needs the care, the facility is unable to provide the resident with the necessary care, the resident is a danger to self or others, and the resident has failed to pay for care or (if supported by third parties, including Medicaid) has failed to have the care paid for.  The federal rule establishes expectations for documentation regarding transfers (including the reason), and written notice to the residents of at least 30 days, unless the reason for transfer is related to urgent medical needs of the resident or health and safety of others.   The written notice must include the reasons for the transfer/discharge, the effective date, the location of discharge or transfer, the right of appeal, and notification of how to reach the long-term care ombudsman and/or the appropriate Protection and Advocacy agency in the case of individuals with developmental disabilities or persons who are mentally ill.  Further, the facility “must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility.”

Another section (b) of this regulation refers to bed holds and the resident’s right to return to the nursing home after being discharged for hospitals or therapeutic leaves.  These policies are determined in part by the State’s policy about how long payment will be made to hold a bed for a resident after discharge.  In any case, the facility needs to clearly disclose to the resident and family in writing the amount of time the bed will be held, and its policies for readmission after that time expires.

Under a provision for “equal access to quality care (c) , the policies that the facility develops for transfer, discharge, and provision of all the services covered in the State Medicaid Plan must be identical for all residents regardless of the resident’s  source of payment.  The regulation also States that facilities are not obliged to provide any services that are not under the State plan.  The facility may charge privately paying residents any amount they chose for the services included in the State plan and other services, but are subject to requirements for disclosure in the Resident Rights regulation (483.10).

Under 483.10 (Resident Rights) some general rights are enunciate that overlap with this regulation on admission, discharge, and transfer rights, especially as regards written notice about Medicaid and Medicare coverage. 

Comparison of State Requirements  [TOP]
 

Using the sections on Comparisons of State Regulations a Each narrative highlights how States differ from Federal regulations on a specific topic.  a Italics are used for signed NHRegsPlus comments on the relevance of these variations for resident autonomy, quality      of life, or culture change.  a Examples are illustrative not comprehensive; always check specific State language.  a See a table with links to each State’s regulatory language at the bottom of the page.

The large majority of States have some provisions in excess of Federal regulations relating to admission, transfer, and discharge rights.  The exceptions are Connecticut, District of Columbia, Florida, North Carolina, Ohio, Utah, and Virginia). 

Admissions  [TOP]

Admission requirements going beyond federal rules include:  iteration of the State’s requirements for preadmission screenings; establishing reasons for denial of admission; waiting list rules, including preferences on wait lists; admission agreements; and requirements for special State approval for residents below a specified age.  Seven states (Illinois, Indiana, Maine, Massachusetts, Montana, Oregon, and Texas) require all potential nursing home residents (not just those on Medicaid) to undergo a preadmission screening. to determine that nursing home placement is indeed an appropriate option for each resident.  Admission rules occasionally concern times of day or week when admissions must be allowed or are prohibited.  Also, in keeping with current efforts of many States to divert residents from entering a nursing home, some States mandate counseling on options.  Examples follow. 

• Two states (Minnesota and New Jersey) require people who are denied admission to a facility be informed of the reason for non-admission.  New Jersey statute mandates this notification and reasons for non-admittance in writing to the resident or representative within 14 days of the denial. 
• New Mexico and Wisconsin regulations state that admissions may not be limited to weekdays but rather occur seven days a week.  Additionally, New Jersey prohibits transfers between 5:00 p.m. and 8:00 a. m. except in the event of an emergency or with consent from the residents or their representatives.
• New Jersey and Washington regulations delineate the procedure for maintaining a waiting list for admissions.  New Jersey grants preference to residents of a continuum of care community when a bed is available, whereas Washington statutes allow preference to be given to residents of a boarding home, independent living, or other continuum of care facility owned by the same entity as the nursing facility.
• Seven States require that potential residents under specific ages be approved by the State.  Such approval is required for residents are under age 14 in Tennessee, under age 16 in Iowa and Kansas, under age 18 in Illinois, Indiana, and Wisconsin, and under age 22 in Massachusetts.
• Five States (California, Kansas, Michigan, Minnesota, and Mississippi) require admissions agreements between facilities and residents or their representative.  In California, the admission agreement requires the use of a specific agreement form as the only allowable admission agreement.  This form includes an explicit statement in 12-point type of the inability to waive a resident’s right to sue for a violation of the resident bill of rights as a condition of admission.  [NHRegsComments: These California policies grew out of a study of admissions agreements conducted by a California legal advocacy in the late 1980’s led by Donna Ambrogio.  This study reviewed hundreds of distinct admission agreements, found that most were illegal, and recommended a standard protocol for such agreements. ] The admissions agreement in Kansas, Michigan, Minnesota, and Mississippi involves a contract for financial payment for services rendered by the nursing facility.  The Kansas agreement must indicate the statement of financial responsibility in black type with no less than 12-point type. 
• Vermont requires that all residents admitted to a facility receive Options Counseling.  [NHRegsComments.  Such policies are consistent with State efforts to ensure that older people consider community options before entering a nursing home and that even those who are admitted receive the opportunity to learn about community options and perhaps plan for a discharge.]

Transfers  [TOP]

More than half of the States  (Alaska, Arkansas, Delaware, Georgia, Hawaii, Idaho, Illinois, Indiana, Kansas, Kentucky, Maine, Maryland, Massachusetts, Nevada, New Jersey, New Mexico, New York, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Texas, Vermont, West Virginia, Wisconsin, and Wyoming) mandate a transfer agreement between the nursing facility and at least one hospital.  The language usually states that such agreements are to facilitate timely resident transfers and exchange appropriate medical information.  Maryland requires that the transfer agreement designates responsibility for ensuring safe transportation and care during transfer, securing residents’ belongings, and prompt readmission to the skilled nursing facility.

Variations are found regarding requirements for transfer and discharge notification.  Colorado mandates the notice of involuntary transfer be mailed to the Ombudsman at the same time it is provided to the resident.  Indiana also requires a copy of notice for involuntary transfer/discharge be sent to the long-term care ombudsman program in addition to the person or agency responsible for resident’s placement in the facility, resident’s physician, and the regional office of the division of disability, aging and rehabilitative services if the person has a developmental disability.  The notice in Maine must include a statement of the right for a resident to represent his or herself, choose a lawyer, family member, friend or other spokesperson speak on their behalf.  Maryland requires that the notice of transfer or discharge must include a statement regarding the right a resident to consult an attorney.  In Missouri, the notice must be given to the resident, his/her representative, and at least one family member; when no family member is known to the facility, a copy of the notice must be sent to the state Ombudsman’s office.  The state and ombudsman must be informed five business days prior to a non-emergency involuntary transfer in Tennessee.  Texas statute mandates that facilities must “immediately” call the state Division of Human Services to report an involuntary transfer or discharge and submit physician documentation except when transfer is to a hospital. 

Timing for notification of involuntary transfer and discharge also varies by state.  The federal regulations indicate that notice must be given 30 days in advance of an involuntary transfer or discharge.  The following states vary from the federal mandate, and in most of these less notice is required than the Federal regulations state:

• Arkansas and Oklahoma require 10 days notice prior to involuntary transfer or discharge,
• Mississippi requires two weeks notice. 
• In Louisiana, 15 days is allowable f the reason for the transfer is non-payment. 
• Illinois requires 21 days notice before involuntary transfer or discharge.
• Illinois requires 21 days notice. 
• Maryland actually requires 60 days notice if the facility is part of a continuum of care community.
•  Nebraska only requires five days notice if the resident is transferring to a less restrictive setting and ten days for overdue payments of five days ore more. 

Five states (Illinois, Indiana, Iowa, Michigan, and Nebraska) require the use of 12-point type for a statement regarding the right to appeal within the written notice of involuntary transfer or discharge.  Illinois also requires that a hearing request form with self-addressed stamped envelop to the state Department of Human Services accompany the notice.

States also vary with regard to bed holds after a transfer.  For example:

• In California, residents or representatives must decide whether to hold their bed within 24 hours of notification of transfer.  Then, the bed must be held for up to seven days. 
• In Iowa, the decision must be made to hold the bed within 48 hours of transfer notification.
• Rhode Island requires a bed hold decision within 24 hours of notice. 
• Illinois, New Hampshire, and Vermont statutes indicate that beds must be held for at least 10 days. 
• In Wisconsin, the period for a bed hold is up to 15 days.

In its section on transfers to other facilities, Vermont also embeds language related to internal transfers.  The State requires facilities to be financially liable for any charges associated with internal transfers to other rooms within the facility, including charges for disconnecting and reconnecting telephones and television cables.

Discharges and Involuntary Transfers  [TOP]

Some states (Arizona, Delaware, Illinois, Indiana, Iowa, Maryland, Michigan, Missouri, Montana, New Hampshire, New York, Oklahoma, Oregon, Vermont, Washington, and Wisconsin) outline the specific process for appeals made for involuntary transfers and discharges.  These protocols are highly detailed.

Some states are detailed in requirements related to planning for involuntary transfers and discharges.  

• Maine mandates that residents discharged in need of home health care or another nursing facility must be given a list of all licensed providers with contact information that serve the area in which the resident resides.  Direct or indirect financial interests in these providers must also be disclosed to the resident.
• In New Jersey, transfer policies must include provisions for transfer transportation and security for the resident and personal belongings during transfer. 
• Oklahoma statutes indicate that an involuntary transfer can occur after the interdisciplinary team has conducted a comprehensive assessment and alternative measures to involuntary transfer/discharge have been unsuccessful. 
• Wisconsin statutes require a planning conference at least 14 days prior to involuntary transfer or discharge to discuss the reason for relocation, assess the effect of the relocation on the resident, and to develop alternative plans.  This conference must include the resident, guardian, physician, any others designated by the resident and if any, appropriate county agency.  Voluntary transfers also require a planning conference at least 7 days prior to transfer or discharge. 
• In West Virginia, facilities are required to assist residents or their representatives in finding an alternative placement in the case of an involuntary discharge.  Additionally, residents cannot be transferred to a community setting against their will.  Residents must be fully informed of all of their options as well as the right to refuse discharge. [NHRegsComments:  This provision, while respectful of residents’ rights seems to run counter to the general trend to help residents learn about community options.  This language seems to anticipate that transition counseling, which in some States is done by relocation specialists rather than nursing home personnel, will lead to discharges to the community against the residents’ will.]
• In Oregon all residents and their representatives transferring or discharging must receive a copy of “Leaving the Nursing Facility.”  Also the facility must notify the county authority, usually the Area Agency on Aging, responsible for long-term care assessment and allocation under the Medicaid waivers. 
• In Georgia, If one spouse is being transferred, the other spouse must be notified and transferred to that same place if he/she requests.  Spouses must be transferred on the same day "pending availability of accommodations" and be allowed to be in the same room if they wish. 

Four states include provisions for resident-requested discharge.  The statutes in Michigan simply delineate a resident’s right to discharge one’s self from the nursing home.  North Dakota regulations explicitly state that residents have the right to be discharged upon written request after notification of the consequences of this decision delineated by the attending physician.  Illinois also includes provisions for the right of the resident to request discharge in writing to the administrator, physician, or nurse.  In New Jersey, residents may discharge themselves upon signing a waiver.  [NHRegsComments:  Although a resident’s right to leave a nursing home would appear to be self evident if he or she is not adjudicated as incompetent, many residents are unaware that they do have that option and perhaps frontline staff are also unaware; therefore the clarifications seem helpful,  they

Some States have counseling requirements prior to involuntary transfers or discharges. Some of these requirements apply to the receiving facility as well as the facility from which the resident is transferring. 

• Illinois mandates that involuntary transfers must be discussed with the resident, his/her representative, and the person or agency responsible for care.  This discussion must be documented in record and counseling must be offered prior to the move),
• Iowa mandates counseling before and after a transfer by a licensed psychologist, psychiatrist, social worker, or a person of resident’s choosing.  The receiving facility must immediately establish and implement a plan to reduce the possible adverse effects of the involuntary transfer or discharge.  Michigan also requires counseling before and after and involuntary transfer.  .
• When an involuntary transfer is proposed in Tennessee, the facility must consider the potential traumatic effect on the resident, distance from the proposed facility to resident’s family and friends, the ability of the receiving facility to meet the resident’s medical needs, and compliance with state and federal regulations.  The transferring facility must also provide counseling to resident, representative, and family to resolve issues prior to transfer.  . [NHRegsComments, The references to the distance of the proposed facility and the facility’s compliance with regulations are unique to Tennessee.]
• Wisconsin regulations mandate that residents be afforded the opportunity to visit the potential new facility at least once and the person’s visit must include a meeting with administration unless medically contraindicated or waived by resident. [NHRegsComments.  It would be interesting to study how strictly this regulation is applied, including whether residents are informed about their entitlement to visit possible receiving facilities, and how often this right is waived.  On the face of it, this sounds like a good protection for residents.]

Oregon has by far the most detailed regulations on admission, transfer, and discharge rights.  The regulations contain particularly elaborate discussion of how to help prepare the resident for transfer, and they give the resident the ultimate right to stay if transfer would be deemed harmful.  In Oregon, the facility shall not involuntarily transfer a resident for medical or welfare reasons under the various reasons outlined in its regulations if the risk of physical or emotional trauma significantly outweighs the risk to the resident and/or to other residents if no transfer were to occur, and the facility shall not involuntarily transfer a resident for any other reasons if the transfer presents a substantial risk of morbidity or mortality to the resident.  A section called “Considerations for Involuntary Transfer” includes many resident-centered components, and safeguards.  Prior to issuing a notice for an involuntary transfer, in order to determine the appropriateness of transfer, the facility shall consider the following: (1) the availability of alternatives to transfer; (2) the resident's ties to family and community; (3) the relationships the resident has developed with other residents and facility staff; (4) the duration of the resident's stay at the facility; (5) the medical needs of the resident and the availability of medical services; (6) the age of the resident and degree of physical and cognitive impairment; (7) the availability of a receiving facility that would accept the resident and provide service consistent with the resident's need for care. (8) the consistency of the receiving facility's services with the activities and routine with which the resident is familiar, and the receiving facility's ability to provide the resident with similar access to personal items significant to the resident and enjoyed by the resident at the transferring facility; (9) the probability that the transfer would result in improved or worsened mental, physical, or social functioning, or in reduced dependency of the resident. (10) the type and amount of preparation for the move, including but not limited to: (a) solicitation of the resident's friends and/or family in preparing the resident for the move; (b) Visitation by the resident to (prior to actual transfer) or familiarity of the resident with the place to which the resident is to be transferred; and (11) on-site consultation by an individual with specific expertise in mental health services if the basis for considering transfer is behavioral, e.g., gero-psychiatric consultation.  [NHRegComments:  These considerations built into State rules on discharge seem particularly resident-centered and also contain practical ideas about how to consider whether a move would be difficult for a resident and assist him/her to make transfers positive.]

Table Comparing States  [TOP]

Note: If the States in this table are not hyper-linked, their provisions do not appear to address the topic, and therefore, do not alter the Federal Regulatory scope.  The Table summarizes content on Administration by State (with a link to each State's specific language).  Link to a downloadable PDF document containing all State regulation on Admission, Transfer and Discharge at the bottom of the Table.

 

483.12 Admission, Transfer and Discharge Rights
State	Goes beyond Federal Regulations?	Subjects addressed:  How State differs from or expands on  Federal Regulations
Alabama	Yes	Ambulance requirements.
Alaska	Yes	Transfer agreement with a hospital for emergency care.
Arizona	Yes	State-mandated resident transfer and appeals process for those objecting to such a transfer.
Arkansas	Yes	Discharge and transfer notices.  Transfer agreement with at least one hospital.
California	Yes	Posted notice stating admission and discharge policies are available upon request.  Required use of California standard admission form.  Bed hold policies.
Colorado	Yes	Ombudsman and resident to be notified in writing of involuntary discharges.  Appeal rights for involuntary transfers, discharges, or moved to another room.
Connecticut	No	Connecticut does not include regulations on Admission, Transfer, and Discharge Rights.
Delaware	Yes	Transfer agreement with at least one hospital.  Hearing process to protest transfer or discharge.
District of Columbia	No	District of Columbia does not include regulations on Admission, Transfer, and Discharge Rights.
Florida	No	Florida does not include regulations on Admission, Transfer, and Discharge Rights.
Georgia	Yes	Requires a transfer agreement with at least one hospital.  Involuntary transfers of spouses who are both residents.
Hawaii	Yes	Requires a transfer agreement with at least one hospital.
Idaho	Yes	Requires a transfer agreement with at least one hospital.
Illinois	Yes	Requires a transfer agreement with at least one hospital.  Preadmission screening. Admission of residents under age 65.  Beds hold requirements.  Involuntary transfers notification and appeals; counseling procedures for planned involuntary discharge. Resident right to be discharged if he/she wishes.
Indiana	Yes	Requires a transfer agreement with at least one hospital.  Preadmission screening. Approval for admission of residents under age 18.  Notifications to ombudsman & others of involuntary transfers and discharges.  Appeals process.  Responsibilities of receiving and sending facility, including for resident’s belongings.
Iowa	Yes	Bed-hold notification; approval for admission of persons under age 16.  Involuntary transfer notification; counseling for those receiving involuntary transfer. Receiving facility duties for involuntary transfer.
Kansas	Yes	Requires a transfer agreement with at least one hospital.  No children under age 16 may be admitted. Admission agreement specifications.
Kentucky	Yes	Written transfer agreements with hospitals.
Louisiana	Yes	Advance notice of transfer.
Maine	Yes	Requires a transfer agreement with at least one hospital.  Referrals to home health on discharge & disclosure of conflict of interest.  Resident rights for representation & self-representation in appeal of transfers.  No admission until PASSAR mental health & DD screens completed.
Maryland	Yes	Requires a transfer agreement with at least one hospital. Content of transfer agreement.  Transfer and discharge notices, including for CCRCs.  Appeal and representation rights.
Massachusetts	Yes	Requires a transfer agreement with at least one hospital.  State approval for admissions of all residents under age 22.  The state medical review team must approve admissions of all residents under age 22.
Michigan	Yes	Financial agreements prior to admission. Process for involuntary transfer and discharge.  Counseling for residents before and after involuntary transfer or discharge.   Resident right to be discharged if he/she wishes.
Minnesota	Yes	Denial of admission.  Financial agreements at admission
Mississippi	Yes	Written financial admission agreements.  Notice before transfer or discharge.
Missouri	Yes	Written notice of transfer to resident, resident’s representative, and at least one family member or (if no family member) the State Ombudsman.  Appeals process for involuntary transfers or discharges.
Montana	Yes	Appeals process for involuntary transfers or discharges. Preadmission screening for all potential nursing home residents.
Nebraska	Yes	Times for written notice of transfer.  Appeal rights notice.
Nevada	Yes	Requires a transfer agreement with at least one hospital.
New Hampshire	Yes	Appeal process for transfers or discharges.  Mandated 10-day minimum a bed hold.
New Jersey	Yes	Requires a transfer agreement with at least one hospital.  Process for transfer, Limitations on discharges between 5 p.m. and 8 a.m.  Waiting list for admission.  Rights of CCRCs for preferential waiting list.  Giving reasons for admission refusal.  Resident’s rights to discharge themselves.
New Mexico	Yes	Resident admissions to be 7 days a week. Procedures for involuntary discharge of residents
New York	Yes	Requires a transfer agreement with at least one hospital.  Procedure for appealing resident transfers and discharges.
North Carolina	No	North Carolina does not include regulations on Admission, Transfer, and Discharge Rights.
North Dakota	Yes	A resident has the right to be discharged upon written request and notification by the attending physician of the consequences associated with such a decision,
Ohio	No	Ohio does not include regulations on Admission, Transfer, and Discharge Rights.
Oklahoma	Yes	Requires a transfer agreement with at least one hospital.  Reasons for involuntary transfer.  Notice of and appeal of involuntary transfers & discharge.
Oregon	Yes	Very detailed considerations for managing involuntary transfer and prohibitions in some circumstances.  Readmission rights for those transferred involuntarily,    Notifications of transfer.  Procedures for discharge and informing community agencies.  Rights of appeal of involuntary transfer.  Preadmission screening for all Medicaid eligible residents.  Private admission assessment for non-Medicaid eligible potential residents to assure they are informed about appropriate services and alternatives.
Pennsylvania	Yes	Requires a transfer agreement with at least one hospital.
Rhode Island	Yes	Requires a transfer agreement with at least one hospital.  Bed hold notices.
South Carolina	yes	Requires a transfer agreement with at least one hospital.
South Dakota	yes	Requires a transfer agreement with at least one hospital.
Tennessee	yes	Children under 14 may not be admitted except when approved by the state.  Considerations before proposing an involuntary transfer.  Counseling prior to involuntary transfer.  Notifications prior to a non-emergency involuntary transfer.
Texas	Yes	Requires a transfer agreement with at least one hospital. Notification of State regarding involuntary transfer except to hospital.  Submission of physician documentation when transferred to hospital. Preadmission screening for all new admissions of residents.
Utah	No	Utah does not include regulations on Admission, Transfer, and Discharge Rights
Vermont	Yes	Requires a transfer agreement with at least one hospital.  Bed holds.  Resident transfers mandated if there is a court order.  Process for involuntary transfers or discharges.  Facility responsibility for charges incurred due to relocations within the facility.  Mandatory options counseling for those being admitted to a facility.
Virginia	No	Virginia does not include regulations on Admission, Transfer, and Discharge Rights.
Washington	yes	Wait list for admission.  Circumstances when nursing homes can give admission preference.  Appeals process for involuntary transfers or discharges.
West Virginia	yes	Requires a transfer agreement with at least one hospital.  Facility to assist finding an appropriate alternative for involuntary transfers. Non-Medicaid residents must pay bed hold rate prior to readmission.  Residents must not be transferred to a community setting against their will and must be informed of all of their options, including the right to refuse discharge.
Wisconsin	Yes	Requires a transfer agreement with at least one hospital.  Process before discharge for involuntary transfers or discharges.  Process before discharges when transfer is voluntary. Includes counseling and at least one visit to potential alternative placements.    Appeals process for involuntary transfers.  The state must approve of admissions for persons under age 18.  Admissions occur 7 days a week.  Bed hold rules.
Wyoming	yes	Requires a transfer agreement with at least one hospital.

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