Let Me Return Home NURSING HOME REFUSAL TO

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“Let Me Return Home” NURSING HOME REFUSAL TO ALLOW RESIDENTS TO RETURN POST-HOSPITALIZATION Training

“Let Me Return Home” NURSING HOME REFUSAL TO ALLOW RESIDENTS TO RETURN POST-HOSPITALIZATION Training for Hospital Discharge Planners Office of Ombudsman for Long-Term Care Minnesota Board on Aging 2016

Ms. Simpson’s First Day of Work 2 June Simpson– Hospital Discharge Planner Mr. Milton

Ms. Simpson’s First Day of Work 2 June Simpson– Hospital Discharge Planner Mr. Milton – wants to return to his home at Harbor View NH after a one week hospital stay

Mr. Milton’s Story 3 Before Hospital Admission During Hospital Stay �Mr. Milton had raised

Mr. Milton’s Story 3 Before Hospital Admission During Hospital Stay �Mr. Milton had raised �Physicians made his cane and threatened roommate to a “beat down” �History of “behaviors” at Harbor View (HV) including pinching and grabbing staff and residents adjustments to medications �Treated for bladder infection �Mr. Milton is tolerating medication changes and bladder infection resolved �He is ready to return to HV

So Ms. Simpson Calls Harbor View… 4 Mr. Milton Ready To Return Home to

So Ms. Simpson Calls Harbor View… 4 Mr. Milton Ready To Return Home to Harbor View’s Social Worker Says “No” Citing Concerns About Resident and Staff Safety

To Ms. Simpson’s Surprise… ? • Social Worker says Harbor View “discharged Mr. Milton

To Ms. Simpson’s Surprise… ? • Social Worker says Harbor View “discharged Mr. Milton to hospital” ? • Harbor View will not be “readmitting” Mr. Milton ? • Social Worker says June is to call other NHs to find alternative placement 5

What Do You Call This Situation? ? Involuntary Discharge 6

What Do You Call This Situation? ? Involuntary Discharge 6

This Is A Serious Problem 7 NH Residents & Families Admitting Hospital � Violates

This Is A Serious Problem 7 NH Residents & Families Admitting Hospital � Violates residents’ rights � Expends hospital time and � Isolates residents and resources � Compels hospital staff to quickly find alternative placement for patients being involuntarily discharged families from their homes and communities � Creates resident anxiety due to uncertainty about being able to go home � Risk of transfer trauma due to multiple placements

Today’s Training Objectives 8 Understand Mr. Milton’s rights about involuntary discharge Suggest advocacy strategies

Today’s Training Objectives 8 Understand Mr. Milton’s rights about involuntary discharge Suggest advocacy strategies for Mr. Milton & his family Identify resources to help Mr. Milton return to HV

9 So, Ms. Simpson – What’s Next For Mr. Milton?

9 So, Ms. Simpson – What’s Next For Mr. Milton?

How Does Ms. Simpson Advocate For Mr. Milton? 10 Ask Mr. Milton if he

How Does Ms. Simpson Advocate For Mr. Milton? 10 Ask Mr. Milton if he wants to return to Harbor View? * Yes • Inform of right to appeal and • Right to return to Harbor View No • Help Mr. Milton find another home LTC Ombudsman Office is here to help! *If appropriate, contact Mr. Milton’s surrogate decision-maker

Office of Ombudsman for Long-Term Care Minnesota Board On Aging 11 Phone: 651 -431

Office of Ombudsman for Long-Term Care Minnesota Board On Aging 11 Phone: 651 -431 -2555 Toll-Free: 1 -800 -657 -3591 Fax: 651 -431 -7452 Empowers consumers to advocate for themselves and their rights Provides advocacy services and education to LTC consumers With consent, consent works to resolve problems about care and rights

LTC Ombudsman Viewpoint 12 Regulations require that Mr. Milton be issued a “Bed Hold

LTC Ombudsman Viewpoint 12 Regulations require that Mr. Milton be issued a “Bed Hold Notice” HV has a legal obligation to follow federal regulations if it intends to involuntarily discharge Mr. Milton HV should allow Mr. Milton to return to HV once he is ready to discharge from the hospital Absent extraordinary circumstances, residents have a right to return to their nursing homes and the right to due process, even if a notice of discharge has been issued

Types of Transfers & Discharges 13 Voluntary Involuntary �When a resident �When a facility

Types of Transfers & Discharges 13 Voluntary Involuntary �When a resident �When a facility initiates a request for transfer or discharge the transfer or discharge Regardless of the resident’s choice or preference Even if the resident does not object to it

The “Voluntary Discharge” Dialogue “We can’t meet your husband’s needs. ” “You need to

The “Voluntary Discharge” Dialogue “We can’t meet your husband’s needs. ” “You need to find another place. ” “This isn’t the best place for your father. ” These Situations are NOT Voluntary Discharges Because NH Initiates These Dialogues 14

Why Not “Voluntary Discharge? ” “We can’t meet your husband’s needs. ” “You need

Why Not “Voluntary Discharge? ” “We can’t meet your husband’s needs. ” “You need to find another place. ” Discuss Each Scenario 15 “This isn’t the best place for your father. ”

Involuntary Discharge Regulations 16 Resident must receive a written involuntary discharge notice Notice must

Involuntary Discharge Regulations 16 Resident must receive a written involuntary discharge notice Notice must contain specific and detailed legal requirements, including reason for discharge and location of discharge Must provide 30 day* timeframe to exercise right to appeal (see exceptions on slide 19) Right to remain in or return to NH pending appeal to an administrative law judge, absent extraordinary circumstances

Grounds for NH Discharges 17 Common Less Common • Needs (welfare) cannot be met

Grounds for NH Discharges 17 Common Less Common • Needs (welfare) cannot be met at NH • Safety of individuals in the facility is endangered • Health of individuals in the facility is endangered • NH ceases to operate • Nonpayment, after appropriate notice • Improved health - no longer requires NH level care

*Exceptions To 30 Day Notice Period 18 * Needs cannot be met at NH

*Exceptions To 30 Day Notice Period 18 * Needs cannot be met at NH * No longer requires NH level of care * Health or safety of individuals in the facility is endangered * Has resided in NH for fewer than 30 days

Required Documentation 19 “Can’t Meet Needs” �Clinical documentation from resident’s physician stating resident’s health

Required Documentation 19 “Can’t Meet Needs” �Clinical documentation from resident’s physician stating resident’s health care needs cannot be met at NH “Danger To Self or Others” �Clinical documentation from a physician stating health of other individuals at NH is endangered by the resident - and the basis for the endangerment Resident has right to review documentation, with rare exceptions

Bed Hold Notice 20 � “Bed Hold Notice” defines � Must be in writing

Bed Hold Notice 20 � “Bed Hold Notice” defines � Must be in writing under what circumstances MA will pay to hold the bed � Bed hold notice also contains HV’s bed-hold policies � Harbor View must give Mr. Milton option to pay to “hold” his bed regardless of NH current occupancy � Should be provided to Mr. Milton and/or his representative before transfer to hospital � Obtaining resident signature on the bed hold notice is not required, but best practice � If unable to provide bed hold notice at time of transfer to the hospital, bed hold notice should be provided within 24 hours

Does Mr. Milton Have a Signed BED HOLD? 21 Request to Hold • Proceed

Does Mr. Milton Have a Signed BED HOLD? 21 Request to Hold • Proceed with discharge Bed at Harbor View planning for return to HV Elected Not to Hold His Bed at Harbor View No Bed Hold On File At Hospital • Discuss with Mr. Milton why he decided not to hold his bed • Assist Mr. Milton in requesting copy of notice from NH; call LTC Ombudsman immediately if NH refuses to issue one

22 �Medical Assistance (MA) pays to Bed Hold Notice, continued hold bed for 18

22 �Medical Assistance (MA) pays to Bed Hold Notice, continued hold bed for 18 days in Minnesota �Includes NH’s policy if Mr. Milton’s hospital stay exceeds 18 days �If >18 days, Mr. Milton’s right to return to the first available semiprivate NH bed as long as he requires skilled nursing care

Why Does a Bed Hold Notice Matter? 23 �Explains Mr. Milton’s rights �Lack of

Why Does a Bed Hold Notice Matter? 23 �Explains Mr. Milton’s rights �Lack of Bed Hold Notice identifies potential transfer/discharge issues �Understanding the policy and regulations prepares you to advocate for Mr. Milton’s rights �If the NH refuses to provide a Bed Hold Notice to your patient, consult with LTC Ombudsman office immediately!

Additional Protections as “Prohibited Practice” Under Medical Assistance Rules 24 MN Statute 256 B.

Additional Protections as “Prohibited Practice” Under Medical Assistance Rules 24 MN Statute 256 B. 48 CONDITIONS FOR PARTICIPATION Subdivision 1. Prohibited Practices. “A nursing facility is not eligible to receive medical assistance payments unless it refrains from all of the following: (g) refusing, for more than 24 hours, to accept a resident returning to the same bed or a bed certified for the same level of care, in accordance with a physician’s order authorizing transfer, after receiving inpatient hospital services. ”

25 �On Day of Hospital Admission Confirm General Advocacy Strategies Be Proactive! resident’s desire

25 �On Day of Hospital Admission Confirm General Advocacy Strategies Be Proactive! resident’s desire to return to facility and facility’s preparation for return before the resident is medically ready for discharge from the hospital Ask resident or surrogate decision - maker if a bed hold notice was received �If Yes – get a copy �If N 0 – assist resident in requesting a copy and discuss resident rights with facility staff

26 �Questions to ask if NH refuses to BE PRO ACTIVE Suggested Advocacy Strategies

26 �Questions to ask if NH refuses to BE PRO ACTIVE Suggested Advocacy Strategies accept resident back: Ask resident or representative if the facility has issued an Involuntary Discharge Notice � If Yes – inform resident of the right to return to the NH during the 30 day notice period* � If Yes – inform the resident of the right to appeal the discharge notice; contact the OOLTC � If No – advise resident to request a written notice of discharge; contact OOLTC � *subject to exceptions stated in slide 19

Advocacy Steps for Mr. Milton 27 1 2 3 • Ask Mr. Milton if

Advocacy Steps for Mr. Milton 27 1 2 3 • Ask Mr. Milton if he wants to return to Harbor View NH. • Review Bed Hold Notice from Harbor View sent with Mr. Milton to hospital ASAP. Identify any problems now to avoid crisis later. • Contact OOLTC, assist Mr. Milton in speaking to the NH Administrator about his desire to return Harbor View.

Suggested Advocacy Steps 28 4 5 • If Administrator refuses, ask if Mr. Milton

Suggested Advocacy Steps 28 4 5 • If Administrator refuses, ask if Mr. Milton has been issued a “Notice of Involuntary Discharge” and the effective date. • If No Notice: Refer Mr. Milton to advocacy agencies to begin appeal in absence of proper discharge notice. • If Yes: Remind Administrator that HV is still legally responsible for Mr. Milton’s return until discharge date and of Mr. Milton’s right to appeal the involuntary discharge.

Suggested Advocacy Steps 29 • MN Department of Health’s Office of Health Facility Complaints

Suggested Advocacy Steps 29 • MN Department of Health’s Office of Health Facility Complaints (OHFC): 1 -800 -369 -7994 • Website: http: //www. health. state. mn. us/divs/fpc/oh fcinfo/contohfc. htm • OHFC investigates complaints about: • quality of care • violations of rights for NH residents including refusal to take back residents transferred to hospitals • If OHFC substantiates a complaint, it has discretion to issue a deficiency, state licensing orders, and fines.

Suggested Advocacy Steps 30 • Refer Mr. Milton to the Office Of Ombudsman for

Suggested Advocacy Steps 30 • Refer Mr. Milton to the Office Of Ombudsman for Long-Term Care for appeal assistance: • 1 -800 -657 -3591 or • 651 -431 -2555

Suggested Advocacy Steps 31 8 • Mr. Milton and/or his family may benefit from

Suggested Advocacy Steps 31 8 • Mr. Milton and/or his family may benefit from legal advice. • Some elder law attorneys specialize in nursing home law. • To find an attorney, contact the Minnesota State Bar Association Lawyer Referral System at 1 -800 -292 -4152 or visit its website: www. Mnfindalawyer. com. • Minnesota Legal Services Coalition may be another resource: 1 -651 -228 -9105.

32 Back To Mr. Milton Suggested Advocacy Strategies �Facilitate Mr. Milton’s communication with staff

32 Back To Mr. Milton Suggested Advocacy Strategies �Facilitate Mr. Milton’s communication with staff at HV �Try to understand Harbor View’s point of view; clarify facility concerns about Mr. Milton’s return �Work with HV social worker to provide seamless care coordination in Mr. Milton’s best interest Continue progress achieved at Hospital Develop proper discharge plan

33 �Share possible resources for facility Back To Milton Suggested Advocacy Strategies to address

33 �Share possible resources for facility Back To Milton Suggested Advocacy Strategies to address resident’s needs: MN/ND Alzheimer’s Association: 1 -800 -272 -3900; www. alz. org National Alliance for Mental Illness (NAMI): 1 -651 -645 -2948; www. namihelps. org Office of Ombudsman for Mental Health and Developmental Disabilities: (651) 757 -1800 or 1800 -657 -3506; http: //mn. gov/omhdd/ if resident has MI diagnosis.

Goals with Advocacy Strategies 34 �Mr. Milton is informed of his right to appeal

Goals with Advocacy Strategies 34 �Mr. Milton is informed of his right to appeal an involuntary an or discharge. �Mr. Milton has the right to return to Harbor View. �Mr. Milton - and every resident - has the right to proper notification and due process.

Assisted Living & Housing with Services 35 �Not subject to the same laws/rules as

Assisted Living & Housing with Services 35 �Not subject to the same laws/rules as NHs �In MN, these establishments are subject to: Landlord and Tenant Law - MN Stat. 504 B et. Seq. Terms and conditions of the tenant’s lease and service agreement MN Stat. 144 D (housing with services) and 144 G (assisted living establishments) Fair Housing Act protects consumers from disability-related discrimination Americans with Disabilities Act (ADA)

“Housing With Services” 36 �Residential setting (primarily for ages 55 and older) that arranges

“Housing With Services” 36 �Residential setting (primarily for ages 55 and older) that arranges for health-related services on-site. The housing provider may also be the arranged home care provider/home health care agency license holder Or the housing provider contracts with a licensed home health care agency (HCA) �Must register with the Minnesota Department of Health (MDH) �MN Statutes 144 D apply �Eviction Process under Landlord Tenant Laws apply

“Assisted Living” in Plain Language 37 �Package of health-related services provided in a housing

“Assisted Living” in Plain Language 37 �Package of health-related services provided in a housing with services (HWS) setting Must be provided under appropriate licensure and quality of care standards Generally have a Comprehensive Home Care Licensed by MN Dept. of Health (MDH) MN Statutes 144 G apply �Service Agreement termination under MDH scope – 30 -day notice necessary *Ask About Additional OOLTC Training on Curriculum Available

Understanding AL/HWS Regulations 38 Landlord Home Care Provider Landlord – Tenant Lease Contract Service

Understanding AL/HWS Regulations 38 Landlord Home Care Provider Landlord – Tenant Lease Contract Service Agreement Between Provider and Tenant

For HWS/AL: Ask These Questions 39 Confirm provider’s status: comprehensive license and assisted living

For HWS/AL: Ask These Questions 39 Confirm provider’s status: comprehensive license and assisted living (AL) provider. Has AL provider appropriately re-assessed resident? Has AL provider given tenant a service agreement termination in writing with at least 30 day notice? Has HWS establishment given an eviction notice/lease termination in writing? Has AL provider reviewed options with tenant for alternate agencies to provide health-related services? Is consumer receiving EW/CADI/CAC/BI waivered services? If so, there may be additional protections to discuss with waiver case manager.

40 Additional Training Available Let Me Return Home: Home Assisted Living Edition Eviction and

40 Additional Training Available Let Me Return Home: Home Assisted Living Edition Eviction and Service Termination in Housing with Services/Assisted Living Establishments Training Objectives: o Strategies to resolve/address an Assisted Living provider’s statement that a tenant cannot return to the establishment post-hospitalization o Understand consumer rights o Understand current laws and regulations regarding HWS/AL settings

Office of Ombudsman for Long-Term Care Minnesota Board On Aging 41 Phone Intake Line:

Office of Ombudsman for Long-Term Care Minnesota Board On Aging 41 Phone Intake Line: 1 -800 -657 -3591 or 651431 -2555 Mailing: PO Box 64971, St. Paul, MN, 551640971 Site: Site 540 Cedar St. , St. Paul Website: mnaging. orgadvocateo oltc. htm

QUESTIONS? 42 THANK YOU FOR YOUR TIME AND ATTENTION! Please take the time to

QUESTIONS? 42 THANK YOU FOR YOUR TIME AND ATTENTION! Please take the time to provide feedback on the evaluation form.