Documentation Key for SNFs as CMS Targets Improper Discharges

Better record-keeping could help skilled nursing facilities protect themselves from litigation or penalties as regulators looks to cut down on improper discharges.

The Centers for Medicare and Medicaid Services (CMS) last month announced a new initiative aimed at blunting the growing trend of illegal “dumping,” or eviction, of SNF residents. Common reasons for discharges often include payment concerns; behavioral, mental, and emotional problems; or resident distress.

Though SNF-initiatived discharges are sometimes seen as necessary, last-ditch moves, they don’t come without risk. Involuntary discharges can sometimes prompt highly public lawsuits, as was the case when a California SNF evicted an 83-year-old resident last March.


To help tackle the growing trend, CMS said it’s considering a range of fixes, including surveyor and provider training, intake and triage training, and civil money penalty (CMP)-funded projects. But regulators are possibly seeing the issue in the wrong light, according to Steve Miller, president of Bridgemark Healthcare, a skilled nursing owner and operator group with 13 SNFs in Illinois and Missouri.

“At the end of the day, why do nursing homes involuntarily discharge residents anyway? Not out of malice or ill intent,” Miller told Skilled Nursing News. “It is almost always because they cannot get paid for their services, or because they cannot safely manage that resident’s needs.”

Instead of cracking the whip harder, he added, CMS should work with SNFs to find a solution.


“Regulators (including ombudsmen) should be much more supportive of nursing homes’ involuntary discharge efforts for non-payment; and should be much more focused on helping a resident find suitable short-term care when behaviors are unmanageable in the SNF setting,” Miller said.

Involuntary discharges are rare for Ecumen, said Shelley Matthes, director of quality improvement. The Minnesota-based senior care provider follows specific guidelines for involuntary discharges and pre-screens its residents before they’re admitted to one of its SNFs.

The need to relocate a resident is often based on mental health issues outside of Alzheimer’s and can be necessary to maintain the safety of the other residents — but only as a last resort, she explained.

“Sometimes, SNFs become an only option for younger (under 65) people with mental illness, and this puts us in a difficult spot with so many vulnerable adults in the communities,” Matthes told SNN. “We’ve spent years training on this and really do our best to manage and accommodate for these kinds of situations — exhausting every resource available — but I think every community has their limits.”

Documentation could be key

Many long-term care providers throughout the country are grappling with the same issues as Miller, according to Matt Murer, who chairs law firm Polsinelli’s national health care practice. And although SNFs can’t keep regulators from coming through the door, they can prepare for their arrival through meticulous documentation.

One example might be if a SNF seeks to discharge a resident over disruptive or violent behavior. A SNF is likely on much firmer ground, as far as regulation enforcement is concerned, if it can document what led to the discharge, Murer said.

“Providers need to know that CMS is going to be looking for you to provide clear documentation…that proves this behavior was present,” Murer told SNN. “They’re going to want it, especially if you’re articulating some judgement about their condition.”

In a behavior-related case, that proof would likely include the written testimony of an attending physician or medical director who can attest to a resident’s state of being — but SNFs should make sure that takes place before, not after, a resident is discharged, he said.

“CMS is going to have a skeptical eye if you have a discharge notice and then a week later, you have something on it from your medical director,” Murer said.

Another piece of advice is to make sure that SNF-initiated discharge really needs to happen. Sometimes, there are steps SNFs can take to solve the problem before a discharge is necessary. And if all else fails, SNF providers should be prepared to show those steps they took, Murer said.

Written by Tim Regan

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