Nursing Home Discharge Requirements

September 29, 2011

DAL: DRS-NH 11-11 - Nursing Home Discharge Requirements

Dear Nursing Home Administrator,

The purpose of this letter is to remind providers of the requirements for individualized discharge care planning for all nursing home residents. Additionally, this letter highlights portions of the new Preadmission Screen and Resident Review (PASRR) Level II Evaluation Report that must be incorporated into the resident's discharge plan of care.

Pursuant to 10 NYCRR§ 415.3(h) (1), when a resident, or his/her guardian, expresses a desire to leave the nursing home, in every instance, the nursing home must evaluate the resident for discharge to the community. Following that evaluation, when placement in a setting other than the Residential Health Care Facility (RHCF) is determined to be appropriate, it is the provider's responsibility to plan for the safe and orderly discharge of the resident to an appropriate community housing option with the services necessary for community reintegration.

It is critical that providers adequately prepare and orient residents for such discharges. The Department strongly recommends that for all residents the nursing homes develop a system to ensure satisfactory progress is achieved when implementing the resident's discharge plan of care, including clear policies and protocols for managing and directing the practice of discharge planning.

For all residents, the discharge planning process must include direct communication with the resident and, as appropriate, families, guardians and legally authorized representatives. Residents must be provided access to information that allows them to make informed decisions regarding discharge. This can be accomplished through a referral to the Money Follows the Person (MFP) Demonstration Project. MFP is a federal demonstration project through which residents are provided the information necessary to make informed decisions about their long-term care options. Providers are urged to learn about housing and care opportunities available in their communities. Discharge planning resources, and information about MFP, are available at and via the Department's Health Commerce System.

Effective September 1, 2011, all completed PASRR Level II Adult Mental Health Evaluation Reports contain one of the three recommendations listed below for placement of an individual. Those recommendations are listed in the following manner:

  • 1. _____The individual's total needs are such that his or her needs can be met in the appropriate community setting.
  • 2. _____The individual's total needs are such that they can be met through placement in a home and community-based waiver program, and such a program is available to the individual. A waiver program provides support and services to assist individuals with disabilities and seniors toward successful inclusion in the community, when otherwise inpatient care would be required.
  • 3. _____The individual's total needs are such that placement in a home and community-based waiver program was considered, but determined not to be appropriate or feasible at this time. Inpatient care is appropriate and desired, and the nursing facility is an appropriate setting for meeting the individual's needs.

If a Resident Review for Significant Change in Status evaluation results in recommendation #1 or #2, the provider must immediately develop, implement, facilitate and coordinate an active discharge plan in accordance with the individual's needs and desires. This includes the safe and orderly discharge of the resident to the most integrated, appropriate "Community Housing" with appropriate "Community Services." For PASRR purposes, "Community Housing" means the most integrated setting appropriate to the needs of a person with serious mental illness, where the setting is designed to promote independence in daily living, economic self-sufficiency and the ability to interact with non-disabled persons to the fullest extent possible.[1] "Community Services" means services and supports provided in New York State that assist individuals with serious mental illness to live in the community.[2]

Providers must adequately prepare and orient residents for such discharges. If the evaluation concludes that the resident is appropriate for nursing home placement as indicated in recommendation #3, the individual may remain in the RHCF. The Level II Evaluation Report will contain the rationale for this nursing facility recommendation and must be reviewed and incorporated into the resident's overall plan of care.

The Department remains committed to ensuring the highest quality of life in the most integrated setting for all New York State residents and will continue to review the nursing home's compliance with State and federal discharge planning and PASRR requirements. Facilities found to be non-compliant with the requirements will be cited with a violation of the applicable regulation and subject to State and federal enforcement actions. Questions regarding this letter may be directed to the Division of Residential Services, Bureau of Quality Assurance at (518) 408-1282.


Jacqueline Pappalardi, Director
Division of Residential Services
Office of Health Systems Management

[1] Community Housing includes, but is not limited to: (1) Supportive Housing, including Community Residence Single Room Occupancy (CR/SRO), Apartment Treatment, and Family Care; (2) Supported Housing, including Scattered Site Apartments and Single Site Apartments; (3) independent housing with the person's family or friends; (4) independent housing not owned or operated by a social service entity; (5) Senior Housing; and (6) such other housing alternatives as are clinically appropriate for the needs of the particular person. No adult home in New York City and no impacted adult home outside of New York City shall be considered to be Community Housing. For purposes of this letter, an impacted adult home is an adult home in which at least 25% of the resident population or 25 residents, whichever is less, are persons with mental disabilities who have been released or discharged from facilities operated or certified by an Office of Mental Health. Notwithstanding this definition, an individual may make an informed choice to live in housing that is not Community Housing.

[2] Such services and supports include, but are not limited to, Assertive Community Treatment (ACT), Intensive Case Management (ICM), Case Management, Personalized Recovery Oriented Services (PROS), Continuing Day Treatment (CDT), Medicaid benefits for which the individual is eligible, including home and community based services (HCBS) waivers, clinic services, certified home health care, personal care assistance, nursing and rehabilitative services.