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TN Nursing Home Ombudsman Reporting

For Transfers and Discharges

To:                   Tennessee Nursing Homes
From:              Office of the Tennessee State Long-Term Care Ombudsman
Re:                   42 CFR 483.15 Notice Requirements
Date:               June 1, 2017


Effective: July 1, 2017

It has come to the attention of the office of State Long-Term Care Ombudsman that there are questions regarding notification of the State Long-Term Care Ombudsman upon the transfer or discharge of a resident as set forth in 42 CRF 483.15 (effective November 28, 2016.).

Facility-Initiated Transfers and Discharges

The regulation at 42 CFR 483.15(c)(3)(i) requires, in part, that before a facility transfers or discharges a resident, the facility must “notify the resident and the resident’s representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand….” 42 CFR 483.15(c)(3)(i) states:

(3)Notice before transfer. Before a facility transfers or discharges a resident, the facility must -

 (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.

The new requirement of participation rules and CMS guidance (S&C 17-27 NH May 12, 2017) state that all involuntary discharge and transfer notices must be sent to the Office of the State Ombudsman at the time of issuance to the resident to meet compliance.

The Notices must be emailed to the State Long Term Care Ombudsman to ensure that this regulation is met.

If you choose to send the notice mail/certified mail, please add an additional 5 days to the notice to account for the delay which will be caused by this method.

Do NOT fax the notice. HIPAA compliance and receipt by the intended party cannot be ensured.

In keeping with what is already in the state regulations, the following notices must be emailed to the Tennessee State Long Term Care Ombudsman.

·         All facility-initiated involuntary discharges and
·         All facility-initiated transfers home and transfers to another LTC facility

Please send all notices to lauren.owens@tn.gov with the subject line: Facility (County) type of discharge.

Ex: Sunny Meadows Nursing Home (Davidson) Involuntary Discharge

In order to meet state and federal requirements, all involuntary discharge and transfer notices must contain the information of the State Long-Term Care Ombudsman, as well as the contact information for the District Long Term Care Ombudsman that serves the county where the nursing home is located. [Note there are also other required names and addresses required by 42 CFR 483.15(c)(5)]  

42 CFR 483.15(c)
(5) Contents of the notice. The written notice specified in paragraph (b)(3) of this section must include the following:

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

The contact information for the State Long-Term Care Ombudsman is as follows:

Lauren Owens
State Long Term Care Ombudsman
502 Deaderick St.
9th Floor-Andrew Jackson Building
Nashville, TN 37243
(615) 837-5112
lauren.owens@tn.gov

CLICK HERE to see the document that contains the information for the appropriate District Long Term Care Ombudsman that serves your area.  

To watch a ‘How To” webinar on compliance with the Involuntary Discharge Process CLICK HERE

To ensure that you are compliant with all required information you can use this template which was created to meet all State and Federal Nursing Home Regulations, in addition to TennCare Regulations for Medicaid certified facilities. CLICK HERE

CLICK HERE for more information on Involuntary Discharges and Transfers from the Division of TennCare.

Emergency Transfers to Acute Care Facilities

CMS Guidance for Emergency Transfers

When a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable, according to 42 CFR 483.15(c)(4)(ii)(D). Copies of notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis.

To make this new requirement easier, we have created a document that you can fill out and email to us on a monthly basis. (See attached) Please send this document to ombudsman.notification@tn.gov on or before the 20th of each month for the preceding month, with the subject line: Facility (County) Emergency notice.

Please see the FAQ’s section for further information on submission.

Ex: Sunny Meadows Nursing Home (Davidson) Emergency Notice

To get the form required to be sent to the State Long Term Care Ombudsman CLICK HERE

Resident-Initiated Transfers and Discharges

A resident-initiated transfer or discharge means the resident or, if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility. The medical record must contain documentation or evidence of the resident’s or resident representative’s verbal or written notice of intent to leave the facility. A resident’s expression of a general desire or goal to return home or to the community or elopement of a resident who is cognitively impaired should not be taken as notice of intent to leave the facility. For resident-initiated transfers or discharges, sending a copy of the notice to the ombudsman is not required.

The Office of the State Long Term Care Ombudsman welcomes resident-initiated transfer/discharge notices, but as stated, this is not a requirement. Should you decide to send a resident initiated notice to the Office of the State Long Term Care Ombudsman, please send it to ombudsman.notification@tn.gov, with the subject line: Facility (County) Resident-Initiated Discharge.

Ex: Sunny Meadows Nursing Home (Davidson) Resident Initiated Discharge

Sending copies of these notices to the Office of the State Long-Term Care (LTC) Ombudsman provides added protection to residents and ensures the Office of the State LTC Ombudsman is aware of facility practices and activities related to transfers and discharges. Thank you for your cooperation.