Can a Nursing Home Discharge a Resident Who Is on Hospice?

Not just because they went on hospice. A nursing home that takes Medicare or Medicaid must let a resident stay unless one of six reasons in federal rules applies, and choosing hospice is not one of them. If the home does want your loved one to leave, it generally has to give written notice at least 30 days ahead, state the reason, and explain how to appeal. While an appeal is pending, the resident can usually stay.

The only reasons a certified nursing home may discharge a resident

Federal nursing home rules (42 CFR 483.15) say the facility "must permit each resident to remain in the facility" unless:

• The resident's needs cannot be met in the facility, and the move is necessary for their welfare.
• The resident's health has improved enough that they no longer need nursing home services.
• The resident's clinical or behavioral condition endangers the safety of others in the facility.
• The health of others in the facility would otherwise be endangered.
• The stay has not been paid for, after reasonable and appropriate notice.
• The facility is closing.

CMS tells state inspectors that once a resident is admitted, discharging them violates their right to remain unless the facility can show one of these limited circumstances applies.

Why hospice by itself is not a reason

When a nursing home resident elects hospice, nothing about where they live has to change. The hospice team is added on top of the nursing home's care. Under the hospice rules for facility residents (42 CFR 418.112), the hospice and the nursing home must sign a written agreement, and that agreement must say the nursing home keeps furnishing 24-hour room and board care and the personal care and nursing the resident already received. For how the two teams split the work, see coordinating hospice with a nursing home.

Where hospice families do run into trouble

Medicare rehab coverage for the terminal illness ends when hospice starts

Many residents arrive after a hospital stay with Medicare paying for short-term skilled care. When the goal changes to comfort care, that coverage may end, and families hear "she has to leave." CMS guidance says that if a resident still needs long-term care when Medicare coverage ends, the facility should offer ways to stay, which may include paying privately or getting help applying for Medicaid. Medicare's hospice benefit does not pay the room; see does Medicare pay for the nursing home on hospice.

Payment problems

Nonpayment is a valid reason, but CMS guidance limits it. A resident cannot be discharged for nonpayment while a decision on their Medicaid eligibility is pending. Switching from a private-pay rate to the Medicaid rate is not nonpayment. Once a resident becomes eligible for Medicaid, the facility may charge only what Medicaid allows. If Medicaid will be paying the room on hospice, read does Medicaid pay nursing home room and board on hospice.

"We can't meet her needs"

If the home gives this as the reason, the resident's physician must document it. The record has to name the specific needs the home cannot meet, what the facility tried, and what the receiving facility offers that this one does not. A general statement that a resident is "too much care" does not meet that standard.

The nursing home does not work with the hospice you chose

This is the situation most likely to end in a move. CMS guidance says there is no requirement that a nursing home offer hospice services. If the facility has no agreement with the hospice the resident wants and chooses not to sign one, the resident can pick a hospice the home already works with, move to a setting that uses the hospice they want, or stay without hospice. CMS also notes that when the resident or family asks for that move, it is not a facility-initiated discharge, so the 30-day notice rules do not apply. Be sure you are choosing the move before you agree to it.

A hospital stay

Before sending a resident to the hospital, the nursing home must give written information about the state's bed-hold policy. Every facility must also have a written policy on letting residents come back. A Medicare- or Medicaid-eligible resident whose hospital stay runs past the bed-hold period must get their previous room if it is available, or the first available semi-private bed. If the home decides the resident cannot return, it has to follow the full discharge rules.

Situation	Allowed reason to discharge?
Resident elects hospice	No
Medicaid application pending	No, not for nonpayment
Payment switches from private pay to Medicaid	No, that is not nonpayment
Bill unpaid after reasonable notice	Yes, with notice and appeal rights
Needs cannot be met	Only if the physician documents why
Family asks to move to use a different hospice	Resident-initiated, so no 30-day notice is required

What the discharge notice must say

Before a facility-initiated discharge, the home must notify the resident and their representative in writing, in a language and manner they understand. It must also send a copy to the state Long-Term Care Ombudsman. The notice must include:

• The reason for the discharge and the date it takes effect
• Where the resident is being sent
• The resident's appeal rights, and who to contact to file an appeal and get help with it
• Contact details for the state Long-Term Care Ombudsman

The 30-day minimum has exceptions. Notice can come "as soon as practicable" when others' health or safety is endangered, when urgent medical needs require an immediate transfer, when the resident's health has improved enough to allow it, or when the resident has lived there less than 30 days.

How to push back

If you disagree, appeal right away using the instructions in the notice. Under federal rules the facility may not discharge a resident while their appeal is pending unless staying would endanger the resident or others, and the facility must document that danger. Call your state's Long-Term Care Ombudsman as well. The federal Administration for Community Living runs this program, and it reports that discharge or eviction is the most common complaint ombudsmen handle in nursing homes. Ask the hospice social worker to help you prepare.

Assisted living is different

These federal discharge rules cover nursing homes certified by Medicare or Medicaid. Assisted living and board and care homes are not covered by them. Their move-out terms come from state rules and the residency contract, so read the contract and ask the ombudsman what applies in your state. See can you receive hospice in assisted living.

Frequently asked questions

Can a nursing home force a resident out of the building to start hospice?

No federal rule requires a resident to leave to get hospice. The catch is that a nursing home does not have to work with every hospice. If it has no agreement with the hospice you want, you may need to choose one it does work with, or move.

She was discharged from hospice because she stabilized. Does she lose her bed?

Leaving hospice is not a reason to discharge someone from the nursing home. The improved-health reason applies only when a resident no longer needs nursing home services at all, and that has to be documented by the resident's physician.

Do they have to give 30 days' notice if she is dying?

For a facility-initiated discharge, 30 days is the rule unless an exception applies, such as an urgent medical need that requires an immediate transfer. A move to another room in the same certified facility is not a discharge under CMS's definition, but the home must still give written notice, including the reason, before changing her room, and she can refuse a room move made only for staff convenience.

Who do I call if the home will not back down?

File the appeal named in the notice and call the state Long-Term Care Ombudsman, who receives a copy of every discharge notice.

Questions to ask the nursing home

• Which hospices do you have written agreements with?
• Under which of the six federal reasons are you proposing this discharge?
• Can I see the physician's documentation behind it?
• Will the room be held if she goes to the hospital, and for how long?

Your practical next step

If a nursing home tells you your loved one must leave because of hospice, ask for the reason in writing and do not agree to a move you did not request. Then call the ombudsman and the hospice social worker. If you are still choosing a hospice, compare hospices near you and ask each one whether it already has an agreement with your loved one's nursing home.