Minnesota Nursing Home Abuse and Neglect Lawyer Kenneth LaBore 1-888-452-6589

Discharge Plan Must Be Created for Residents

Nursing Homes Must Have Discharge Plan for Residents

Nursing Homes Must Have Discharge Plan for Residents

Facilities Must Have Discharge Plan for Residents

According to 42 CFR 483.21(2)(c) Discharge planning—(1) Discharge planning process. The facility must develop and implement an effective discharge planning process that focuses on the resident’s discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility’s discharge planning process must be consistent with the discharge rights set forth at §483.15(b) as applicable and—

(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident.
(ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.
(iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan.
(iv) Consider caregiver/support person availability and the resident’s or caregiver’s/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.
(v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan.
(vi) Address the resident’s goals of care and treatment preferences.
(vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community.
(A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose.
(B) Facilities must update a resident’s comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities.
(C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why.
(viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident’s goals of care and treatment preferences.
(ix) Document, complete on a timely basis based on the resident’s needs, and include in the clinical record, the evaluation of the resident’s discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident’s representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident’s discharge or transfer.

Nursing Homes Must Have Discharge Summary

(2) Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following:

(i) A recapitulation of the resident’s stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident’s status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident’s representative.
(iii) Reconciliation of all pre-discharge medications with the resident’s post-discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services

For more information about resident assessment and discharge planning requirements or other questions about elder abuse and neglect contact Nursing Home Neglect Attorney Kenneth LaBore for a free consultation at 612-743-9048 or by email at KLaBore @ MNnursinghomeneglect.com.

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Personalized Care Plan is Required for Each Resident

Nursing Home Resident Care Plan

Nursing Home Resident Care Plan

Resident Care Plan Requirements for Nursing Homes

According to federal regulation 42 CFR § 483.21   Comprehensive person-centered care planning. (a) Baseline care plans. (1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must—

(i) Be developed within 48 hours of a resident’s admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to:
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.
(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan—
(i) Is developed within 48 hours of the resident’s admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).
(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident’s medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
(b) Comprehensive care plans. (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following:
(i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25, or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25, or §483.40 but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record.
(iv) In consultation with the resident and the resident’s representative(s)—
(A) The resident’s goals for admission and desired outcomes.
(B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section

Timing for Resident Care Plan

(2) A comprehensive care plan must be—

(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to—
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident’s representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident’s needs or as requested by the resident.
(iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must—
(i) Meet professional standards of quality.
(ii) Be provided by qualified persons in accordance with each resident’s written plan of care.
(iii) Be culturally-competent and trauma-informed.

For more information about resident assessment and planning of care requirements or other questions about elder abuse and neglect contact Nursing Home Neglect Attorney Kenneth LaBore for a free consultation at 612-743-9048 or by email at KLaBore@MNnursinghomeneglect.com.

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Resident Assessment Required by Federal Law

Nursing Homes Must Conduct Regular Comprehensive Assessment of Needs and Risks

Nursing Homes Must Conduct Regular Comprehensive Assessment of Needs and Risks

Nursing Home Must Make Comprehensive Assessment of Residents Needs

Pursuant to 42 CFR § 483.20, the facility must conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessments of each resident’s functional capacity.

(a) Admission orders. At the time each resident is admitted, the facility must have physician orders for the resident’s immediate care.

(b) Comprehensive assessments—(1) Resident assessment instrument. A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS.

Resident Assessment Must Include Key Issues of Resident Risks and Needs

The assessment must include at least the following:

(i) Identification and demographic information.
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychosocial well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnoses and health conditions.
(xi) Dental and nutritional status.
(xii) Skin condition.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

The failure of facilities to evaluate the risks and needs of residents leads to many types of elder abuse and neglect including falls, pressure sores, medication errors, sexual assault and others.

Unlike many other types of injury claims, there are standards and regulations, both state and federal for most care provided in a nursing home, which apply to all facilities which accept Medicare and Medicaid residents. Pursuant to Minnesota Rule 4658.0015 a nursing home must “operate and provide services in compliance with all applicable federal, state, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in a nursing home.”

Most cases are a result of some combination of short staffing, poor training, lack of medical supplies and equipment and a failure to follow care plans and to regularly assess residents especially when there has been a change of condition, including medical conditions and accidents/incidents. The failure to respond to changes in condition in a timely manner leads to many serious injuries such as amputations and often times death. Injuries and death due to the lack of proper supervision and assessment are truly preventable and the type of situations that could be improved with a movement towards holding facilities accountable.

KLaBore@MNnursinghomeneglect.com

Please contact elder abuse and neglect Attorney Kenneth LaBore with any questions you may have at 612-743-9048.

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Bed Hold Policies in Nursing Homes

Bed Hold Regulations in Nursing Homes

Bed Hold Regulations in Nursing Homes

Federal Bed Hold Policies for Nursing Homes

Pursuant to federal regulation contained in 42 CFR 483.15(d),  Notice of bed-hold policy and return—(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies—

(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;

(ii) The reserve bed payment policy in the state plan, under §447.40 of this chapter, if any;

(iii) The nursing facility’s policies regarding bed-hold periods, which must be consistent with paragraph (c)(3) of this section, permitting a resident to return; and

(iv) The information specified in paragraph (c)(3) of this section.

More Information About Federal Nursing Home Bed Hold Regulations

(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (c)(1) of this section.
(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following.

(i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident

(A) Requires the services provided by the facility; and
(B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services.

(ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges.

(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in §483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there.

KLaBore@MNnursinghomeneglect.com
Please contact elder abuse and neglect Attorney Kenneth LaBore with any questions you may have at 612-743-9048.

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Nursing Home Discharge and Transfer Notice Requirments

Nursing Home Discharge Notice Requirements

Nursing Home Discharge Notice Requirements

Federal Nursing Home Discharge Notice Requirments

Pursuant to 42 CFR § 483.15(b)(4) Admission, transfer, and discharge rights.

(4) Timing of the notice. (i) Except as specified in paragraphs (b)(4)(ii) and (b)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.

(ii) Notice must be made as soon as practicable before transfer or discharge when—

(A) The safety of individuals in the facility would be endangered under paragraph (b)(1)(ii)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (b)(1)(ii)(D) of this section;
(C) The resident’s health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (b)(1)(ii)(B) of this section;
(D) An immediate transfer or discharge is required by the resident’s urgent medical needs, under paragraph (b)(1)(ii)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

(5) Contents of the notice. The written notice specified in paragraph (b)(3) of this section must include the following:
(i) The reason for transfer or discharge;

(ii) The effective date of transfer or discharge;

(iii) The location to which the resident is transferred or discharged;

(iv) A statement of the resident’s appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;

(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;

(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and

(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.
(7) Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand.
(8) Notice in advance of facility closure. In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at §483.70(l).
(9) Room changes in a composite distinct part. Room changes in a facility that is a composite distinct part (as defined in §483.5) are subject to the requirements of §483.10(e)(7) and must be limited to moves within the particular building in which the resident resides, unless the resident voluntarily agrees to move to another of the composite distinct part’s locations.

KLaBore@MNnursinghomeneglect.com
Please contact elder abuse and neglect Attorney Kenneth LaBore with any questions you may have at 612-743-9048.

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Minnesota Nursing Home Lawyer

MINNESOTA ELDER ABUSE AND NEGLECT LAWYER - MN Nursing Home Law


Kenneth L. LaBore, Esq, Phone: 612-743-9048 or Toll Free: 1-888-452-6589


This web site is designed for general information only. The information presented at this site should not be construed to be formal legal advice nor the formation of a lawyer/client relationship. Minnesota Nursing Home Lawyer & Attorney of Kenneth LaBore - Attorney at Law, offering services related to elder abuse and neglect, nursing home, assisting living, and other senior or elder care facilities, serving Minneapolis, St Paul, Twin Cities, Bemidji, Rochester, Alexandria, Marshall, Grand Rapids, Anoka, Apple Valley, Arden Hills, Burnsville, Lakeville, St Cloud, Monticello, Duluth, Owatonna, Austin, Bloomington, Mankato and throughout Minnesota.


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