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Facility-Initiated Discharges in Nursing Homes Require Further Attention


Nursing homes can legally discharge residents for certain reasons (known as facility-initiated discharges). Facility-initiated discharges that do not comply with regulations (i.e., inappropriate facility-initiated discharges) can be unsafe and a traumatic experience for the resident; media reports have highlighted the rise in these discharges. For example, the police found one resident on the streets after a nursing home discharged the resident to an unlicensed boarding house without notifying the resident's family. In addition, State Ombudsmen have cited "discharge/eviction" as the top complaint from 2013 through 2019. Given concerns about inappropriate facility-initiated discharges and the risk to vulnerable nursing home residents, efforts to reduce these discharges warrant our examination.


We surveyed State Ombudsmen in all 50 States and the District of Columbia. We also analyzed CMS administrative data to determine the number of nursing homes that received a deficiency related to facility-initiated discharge. We interviewed officials in ACL, CMS, and all 10 CMS Regional Offices about efforts to reduce inappropriate facility-initiated discharges. We also interviewed five State Ombudsmen about the effect of COVID-19 on these discharges.


The magnitude of facility-initiated discharges in nursing homes remains unknown. Many challenges exist to identifying and addressing inappropriate facility-initiated discharges, including that neither ACL nor CMS collect data on the number of facility-initiated discharges, and many State Ombudsmen do not count or track the notices they receive. Nursing homes must send facility-initiated discharge notices to State Ombudsmen, but ACL does not collect data on these. State Ombudsmen reported facing challenges while responding to facility-initiated discharges, such as nursing homes sending facility-initiated discharge notices that lack required information. Moreover, the COVID-19 pandemic exacerbated challenges. In addition, Ombudsmen, CMS, and State agencies may differ in their perspectives on regulations and enforcement of facility-initiated discharges. Following CMS's initiative to review and take appropriate enforcement action in cases of noncompliance with facility-initiated discharge requirements, State agencies cited many more nursing homes for not complying with notice requirements for discharges in 2018. CMS has not yet determined the trends and outcomes of its initiative.


Our findings raise concerns about weaknesses in the safeguards to protect nursing home residents from harm that may result from inappropriate facility-initiated discharges. We recommend that CMS provide training to nursing homes, assess the effectiveness of its enforcement of inappropriate facility-initiated discharges, and implement its deferred initiatives to address inappropriate facility-initiated discharges. CMS concurred with these recommendations. We recommend that ACL assist State Ombudsman programs with a data-collection system for facility-initiated discharge notices and establish guidance for analysis and reporting of data from these notices. ACL concurred with these recommendations. Finally, we recommend that ACL and CMS coordinate to strengthen safeguards to protect nursing home residents and ensure that all State Ombudsmen, State agencies, and CMS ROs have an ongoing venue to share information about facility-initiated discharges. ACL and CMS did not explicitly state whether they concurred with our recommendation to coordinate to strengthen safeguards to protect nursing home residents but stated that they will continue to work together as well as with other stakeholders to address concerns related to inappropriate discharges. CMS and ACL concurred with our recommendation to have an ongoing venue to share information about facility-initiated discharges.