(a) Examples. Transfer and discharge includes movement of a resident to a bed outside the certified facility, whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement within the same certified facility.
(b) Transfer and discharge requirements. The facility must permit each resident to remain in the facility and must not transfer or discharge the resident from the facility unless:
  (1) the transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility;
  (2) the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
  (3) the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
  (4) the health of other individuals in the facility would otherwise be endangered;
  (5) the resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for the resident's stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid;
  (6) the resident or resident representative requests a voluntary transfer or discharge; or
  (7) the facility ceases to operate as a nursing facility and no longer provides resident care.
(c) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in subsection (b)(1) - (7) of this section, the facility must ensure that the transfer or discharge is documented in the resident's clinical record and appropriate information is communicated to the receiving health care institution or provider.
  (1) Documentation must include:
    (A) the basis for the transfer per subsection (b)(1) - (7) of this section; and
    (B) in the case of subsection (b)(1) of this section, the specific resident's needs that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the needs.
  (2) The documentation required by paragraph (1) of this subsection, must be made by:
    (A) the resident's physician when transfer or discharge is necessary under subsection (b)(1) or (b)(2) of this section; or
    (B) a physician when transfer or discharge is necessary under subsection (b)(3) or (b)(4) of this section.
  (3) Information provided to the receiving health care institution or provider must include the following:
    (A) contact information of the practitioner responsible for the care of the resident;
    (B) resident representative information, including contact information;
    (C) advance directive information;
    (D) all special instructions or precautions for ongoing care, as appropriate;
    (E) comprehensive care plan goals; and
    (F) all other necessary information, including a copy of the resident's discharge summary, consistent with §19.803 of this chapter (relating to Discharge Summary (Discharge Plan of Care)), as applicable, to ensure a safe and effective transition of care.
(d) Notice before transfer or discharge. Before a facility transfers or discharges a resident, the facility must:
  (1) notify the resident and the resident representative about the transfer or discharge and the reasons for the move in writing and in a language and manner the resident understands;
  (2) if the discharge or transfer is initiated by the facility, send a copy of the notice to a representative of the Ombudsman Program at the time a discharge notice is presented to the resident and resident representative, in accordance with the timeframes described in subsection (e) of this section, except that the notice may be provided as soon as practicable, such as in a list of residents sent on a monthly basis, when a resident is temporarily transferred on an emergency basis to an acute care facility;
  (3) record the reasons for the transfer or discharge in the resident's clinical record;
  (4) include in the notice the items described in subsection (f) of this section; and
  (5) comply with §19.2310 of this chapter (relating to Nursing Facility Ceases to Participate) when the facility voluntarily withdraws from Medicaid or Medicare or is terminated from Medicaid or Medicare participation by HHSC or the secretary.
(e) Timing of the notice.
  (1) Except when specified in paragraph (3) of this subsection or in §19.2310 of this chapter, the notice of transfer or discharge required under subsection (d) of this section must be made by the facility at least 30 days before the resident is transferred or discharged.
  (2) The requirements described in paragraph (1) of this subsection and subsection (h) of this section do not have to be met if the resident or resident representative requests the transfer or discharge.
  (3) Notice must be made as soon as practicable before transfer or discharge when:
    (A) the safety of individuals in the facility would be endangered, as specified in subsection (b)(3) of this section;
    (B) the health of individuals in the facility would be endangered, as specified in subsection (b)(4) of this section;
    (C) the resident's health improves sufficiently to allow a more immediate transfer or discharge, as specified in subsection (b)(2) of this section;
    (D) the transfer and discharge is necessary for the resident's welfare because the resident's needs cannot be met in the facility, as specified in subsection (b)(1) of this section, and the resident's urgent medical needs require an immediate transfer or discharge; or
    (E) a resident has not resided in the facility for 30 days.
  (4) When an immediate involuntary transfer or discharge as specified in subsection (b)(3) or (4) of this section, is contemplated, unless the discharge is to a hospital, the facility must:
    (A) immediately call the staff of the Office of the State Long-term Care Ombudsman to report its intention to discharge; and
    (B) submit to HHSC the required physician documentation regarding the discharge.
(f) Contents of the notice. For nursing facilities, the written notice specified in subsection (d) of this section must include the following:
  (1) the reason for transfer or discharge;
  (2) the effective date of transfer or discharge;
  (3) the location to which the resident is transferred or discharged;
  (4) a statement of the resident's appeal rights, including:
    (A) the resident has the right to appeal the action as outlined in HHSC's Fair and Fraud Hearings Handbook by requesting a hearing within 90 days after the date of the notice;
    (B) if the resident requests the hearing before the discharge date, the resident has the right to remain in the facility until the hearing officer makes a final determination unless failure to transfer or discharge would endanger the health or safety of the resident or individuals in the facility. The facility must document the danger failure to discharge would present; and
    (C) information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
  (5) the name, address, email address, and telephone number of the managing local ombudsman and the toll-free number of the Ombudsman Program;
  (6) in the case of a resident with mental illness, the address, email address, and phone number of the state mental health authority; and
  (7) in the case of a resident with an intellectual or developmental disability, the authority for individuals with intellectual and developmental disabilities, and the phone number, address, and email address of the agency responsible for the protection and advocacy of individuals with intellectual and developmental disabilities.
(g) Changes to the notice. If the information in the notice changes before effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.
Cont'd...