Nursing home-initiated discharges require a closer look as “inappropriate discharges” may be on the rise, according to a report released by the Office of the Inspector General (OIG) and U.S. Department of Health and Human Services (HHS).
Overall, OIG isn’t aware of how many residents have experienced facility-initiated discharges from nursing homes, much less which were considered “inappropriate.”
An “inappropriate” facility-initiated discharge didn’t meet an acceptable reason under federal regulation; examples include the resident’s welfare and needs not being met, or the resident has failed to pay facility charges.
“That’s one of the big points of this report, the lack of data and a lack of transparency about these numbers has made it very difficult to understand where there might be problems. We want to make clear that every discharge is not inappropriate. However, we need to understand where there are problems,” added Danielle Fletcher, deputy regional inspector general in the OIG’s Boston, Mass. office.
The report mentioned one specific example where a resident was found on the street after a nursing home discharged him to an unlicensed boarding house — without notifying his family.
“Our main takeaway here is that [Centers for Medicare & Medicaid Services (CMS)] and [Administration for Community Living (ACL)] need better data and more coordination,” said Shanna Weitz, social science research analyst in Boston, and lead analyst on the report.
Forthcoming work set to publish tentatively in November 2022 will take a sample of nursing homes and document whether facilities followed regulations for facility-initiated discharges, OIG said.
State ombudsmen, who advocate on behalf of nursing home residents to resolve complaints, noted discharge and evictions as the top complaint for nursing homes from 2013 to 2019: “efforts to reduce these discharges warrant our examination,” researchers conducting the report said.
Ombudsmen in all 50 states and the District of Columbia were surveyed for the report; Centers for Medicare & Medicaid Services (CMS) data was analyzed to determine the number of nursing homes that received a discharge-related deficiency from the entity.
Neither CMS nor the Administration for Community Living (ACL) collect data on facility-initiated discharges, instead leaving the task to state ombudsmen.
A 2017 initiative did require state agencies to transfer cases of discharge noncompliance to CMS reporting officers for potential action, but CMS hasn’t identified trends and outcomes from the initiative yet, the report said, citing the entity’s shift in priorities during the pandemic.
“The magnitude of facility-initiated discharges in nursing homes remains unknown,” OIG said in its report. “…many State Ombudsmen do not count or track the notices they receive.”
When ombudsmen respond to concerning facility-initiated discharge notices, oftentimes nursing homes haven’t provided “required information,” OIG added.
OIG suggests in its report that CMS conduct in-facility education, assess enforcement effectiveness and implement “deferred” CMS initiatives to tackle facility-implemented discharges negatively impacting residents.
ACL needs to help ombudsman programs with data collection as well to more easily keep track of discharge notices, OIG said.
“It’s the regulatory versus the advocacy role — while state ombudsman work directly with residents and help them, even to the point of helping them with legal services, there isn’t a regulatory role for them,” said Fletcher. “They can’t fine a nursing home, they can’t impose penalties and so they really need to have a good working relationship with the state agencies so that there’s accountability.”
CMS concurred with OIG’s three suggested recommendations, while ACL agreed to two of four recommendations — continuing to provide technical assistance to state ombudsmen and working with state and national ombudsmen to track information on facility-initiated discharge notices. Both entities agreed that ongoing meetings were needed to discuss such discharges and exchange information.
State ombudsmen, ACL, state agencies and CMS have “different roles stemming from different authorities,” OIG said, and these divergences likely inhibit agency efforts to cut down on negative facility-initiated discharges.
“We wanted to highlight the different roles that these entities play,” noted Weitz. “There needs to be more coordination across these entities in order to promote better oversight and better protection for residents.”
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