Nursing homes most often initiated a discharge because a resident’s behavior endangered the resident or others in the facility, a rationale fully within their rights, a government watchdog reported Wednesday.
But some are still not fully documenting facility-initiated discharges, undermining residents’ rights to appeal or plan for a move, the Health and Human Services Office of Inspector General said in a companion report.
Providers have long taken heat for the use of facility-initiated discharges — essentially evictions — which consumer advocates tend to portray as heartless decisions made for financial reasons. But the OIG reports on Wednesday found, a resident’s failure to pay was a documented factor in just 26% of 126 sample cases; most residents (62%) were instead asked to leave because of physically or verbally “aggressive” behaviors or because the facility could not keep the resident safe from wandering, elopement suicide or self-harm.
Slightly more than 93% of residents discharged due to behavior had a mental health disorder, compared to 70% of residents who were discharged for other allowable reasons. Report authors acknowledged nursing homes’ “challenges” in admitting and caring for residents with mental health disorders, especially as demand grows.
“Although nursing homes cannot anticipate all that a resident will need throughout a stay, nursing homes should be generally familiar with the demands of residents with mental health disorders, especially those who are admitted for long-term care,” the report said. “Our review raises questions about whether nursing homes accurately assessed the behavioral health needs of residents upon admission, as well as whether nursing homes had the appropriate staff, resources, and capacity to care for residents.”
OIG questions support for behaviorally challenged residents
Co-author and OIG analyst Shanna Weitz told McKnights Long-Term Care News on Wednesday that the research extends a body of work most recently visited by OIG in 2021. It finds that many of the same issues persist.
“We know any discharge can be a difficult experience for a nursing home resident, but when it’s facility-initiated, the nursing home is making the resident leave against their wishes, which means it could be especially traumatic or even unsafe,” Weitz said. “CMS does have extra guardrails up in these cases to help make sure that these residents are protected. [But the reports] raise concerns about how well nursing homes even understand what a facility-initiated discharge even is, and how it should be handled.”
Identifying the correct type of discharge is not only important for compliance, but it also triggers additional support that could help residents better navigate the change. That extra help may be especially important among affected residents with behavioral health challenges.
“It was surprising to see how prevalent those situations were in the data we had,” Weitz added. “The main goal of our data brief, our second report, was to highlight that and raise concerns as to whether those residents are receiving appropriate care.”
A third OIG report made public on Wednesday, however, shows how challenging increasing behavioral health resources is for many nursing home patients, especially those on Medicaid and Medicare. An analysis of providers in 20 US counties found fewer than five active mental health providers for every 1,000 enrollees.
Medicare Advantage averaged 4.7 providers per 1,000 enrollees, while Medicare fee-for-service has 2.9 providers and Medicaid had 3.1 providers. Some counties had not even a single provider per 1,000 enrollees.
“When you have so few providers available to see this many enrollees, patients start running into significant problems finding care,” Deputy Regional Inspector General Meridith Seife told NPR. “You have 1 in 4 Medicare enrollees who are living with a mental illness. Yet less than half of those people are receiving treatment.”
The OIG’s discharge data brief lauded the new Center for Excellence for Behavioral Health in Nursing Facilities as holding “promise” for nursing home improvements, but it didn’t offer details on how center services could strengthen admission or discharge processes for patients with mental health needs.
Attempts to retain residents
OIG noted that almost all nursing homes included in the review tried some different interventions prior to discharging residents due to endangering behaviors.
Most used one or two interventions, but nursing homes documented no interventions for six facility-initiated discharges in the review. The most common interventions nursing homes implemented were medication changes and counseling.
For example, one nursing home documented medicating a resident for agitation and pain to decrease aggressive behavior. Several nursing homes noted that the residents, following aggressive behavior, received counseling such as education and guidance on appropriate behavior, healthy conflict resolution, or positive coping skills. Nursing homes also counseled residents who violated smoking policy.
Less common responses were redirection or new activities or monitoring, such as one-on-one staff supervision or by checking residents every 15 minutes. Even less frequently used tools were room changes, temporary hospital transfers, and the use of wearable bracelets for residents known to elope.
Documentation concerns
CMS generally requires nursing homes to provide written notice to residents of facility-initiated discharges 30 days prior and include information and resources the resident can use to help with a move or an appeal.
In all but about 15% of cases reviewed, nursing homes discharged residents for allowable reasons — failure to pay among them. In this sample, debts ranged from $716 to $173,000, with a median of $8,960. And most nursing homes, OIG said, provided residents “with a reasonable and appropriate notice,” which is what CMS requires when a nursing home initiates a discharge for failure to pay.
Nursing homes documented notifying residents of changes in payment status and/or attempted to collect payments in three-quarters of these discharges, sometime setting up payment plans or helping them apply for Medicaid coverage.
But facilities often fell short on notice and documentation requirements, regardless of their reason for discharge.
For instance, the OIG found that nursing homes failed to give a complete written notice to more than three-quarters of discharged residents. Most commonly, nursing homes did not provide full information about the appeals process or the state entity to contact for an appeal.
Also notable: Nearly half of the nursing homes that provided notices to residents did not provide notices to an ombudsman, which the report said undermines the CMS goal of providing protections to residents.
OIG recommended that CMS develop a facility-initiated discharge template that could be easily shared with all nursing homes, giving staff an easy way to share all needed information with residents and advocates.
Weitz said the 126-case sample included cases from 13 states that had to be largely collected with the help of ombudsman and specific nursing homes because there is no easy access to facility-initiated discharge data. She said OIG also recommended CMS use existing systems to record facility-initiated discharges and bring more transparency to the issue.
