U.S. Department of Health and Human Services 
Office of Inspector General 
Facility-Initiated Discharges in 
Nursing Homes Require 
Further Attention 
Christi A. Grimm 
Principal Deputy Inspector General 
November 2021, OEI-01-18-00250  U.S. Department of Health and Human Services 
O  ffice of Inspector General 
 
Report in Brief 
 
N ovember 2021, OEI-01-18-00250 
 
Facility-Initiated Discharges in Nursing Homes 
Why OIG Did This Review 
Nursing homes can legally 
Require Further Attention 
discharge residents for certain 
reasons (known as facility-initiated 
Federal regulations allow nursing homes 
discharges).  Facility-initiated  Key Takeaway 
to discharge residents without their 
discharges that do not comply with 
consent for a specific set of reasons and 
The magnitude of facility-
regulations (i.e., inappropriate 
detail additional requirements for these 
initiated discharges in nursing 
facility-initiated discharges) can be 
discharges, such as the nursing home 
homes is unknown, and the 
unsafe and a traumatic experience 
providing adequate notice to the 
safeguards to protect residents 
for the resident; media reports have 
resident.  CMS oversees nursing homes 
from inappropriate facility-
highlighted the rise in these 
and works with State survey agencies 
initiated discharges need 
discharges.  For example, the police 
(State agencies) to monitor compliance 
improvement.  
found one resident on the streets 
with facility-initiated discharge 
 
after a nursing home discharged 
regulations.  ACL oversees the State Long-Term Care Ombudsman Program 
him to an unlicensed boarding 
(State Ombudsmen), which advocates on behalf of nursing home residents to 
house without notifying his family.  
resolve complaints made by or for these residents.  In 2017, CMS instructed 
In addition, State Ombudsmen 
State agencies to transfer certain cases of noncompliance with facility-
have cited discharge/eviction as 
initiated discharge regulations to CMS ROs for potential enforcement action, 
the top complaint from 2013 
as part of an initiative to review and take appropriate enforcement action in 
through 2019.  Given concerns 
these cases. 
about inappropriate facility-
initiated discharges and the risk to  What OIG Found 
vulnerable nursing home residents,  The magnitude of facility-initiated discharges in nursing homes remains 
efforts to reduce these discharges  unknown.  Many challenges exist to identifying and addressing inappropriate 
warrant our examination.      facility-initiated discharges, including that neither ACL nor CMS collect data 
on the number of facility-initiated discharges, and many State Ombudsmen 
How OIG Did This Review 
do not count or track the notices they receive.  Nursing homes must send 
We surveyed State Ombudsmen in 
facility-initiated discharge notices to State Ombudsmen, but ACL does not 
all 50 States and the District of 
collect data on these.  State Ombudsmen reported facing challenges while 
Columbia.  We also analyzed 
responding to facility-initiated discharges, such as nursing homes sending 
Centers for Medicare & Medicaid 
facility-initiated discharge notices that lack required information.  Moreover, 
Services (CMS) administrative data 
the COVID-19 pandemic exacerbated challenges.  In addition, Ombudsmen, 
to determine the number of 
CMS, and State agencies may differ in their perspectives on regulations and 
nursing homes that received a 
enforcement of facility-initiated discharges.  Following CMSs initiative to 
deficiency related to facility-
review and take appropriate enforcement action in cases of noncompliance 
initiated discharge.  We interviewed 
with facility-initiated discharge requirements, State agencies cited many more 
officials in the Administration for 
nursing homes for not complying with notice requirements for discharges in 
Community Living (ACL), CMS, and 
2018.  CMS has not yet determined the trends and outcomes of its initiative.    
all 10 CMS Regional Offices (ROs) 
about efforts to reduce  What OIG Recommends 
inappropriate facility-initiated  Our findings raise concerns about weaknesses in the safeguards to protect 
discharges.  We also interviewed  nursing home residents from harm that may result from inappropriate 
five State Ombudsmen about the  facility-initiated discharges.  We recommend that CMS provide training to 
effect of COVID-19 on these  nursing homes, assess the effectiveness of its enforcement of inappropriate 
discharges.  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.  ACL and CMS concurred with our recommendation to have an 
ongoing venue to share information about facility-initiated discharges.  
     
TABLE OF CONTENTS 
 
 
BACKGROUND  1 
Methodology  7 
FINDINGS  10 
The magnitude of facility-initiated discharges in nursing homes is unknown  10 
Ombudsmen reported facing challenges while responding to facility-initiated discharges  11 
State agencies cited many more nursing homes for not complying with notice requirements  16 
following CMSs initiative to review inappropriate facility-initiated discharges, announced in 
2017 
CMS has not yet determined the trends and outcomes of its initiative to review and impose  18 
appropriate enforcement actions in cases of inappropriate facility-initiated discharges 
RECOMMENDATIONS  19 
CMS: Provide training for nursing homes on Federal requirements for facility-initiated  19 
discharge notices 
CMS: Assess the effectiveness of its enforcement of inappropriate facility-initiated discharges  20 
CMS: Implement its deferred initiatives to address inappropriate facility-initiated discharges  20 
ACL: Assist State Ombudsman programs in establishing a data-collection system for facility- 21 
initiated discharge notices  
ACL: Establish guidance for analysis and reporting of data collected by State Ombudsman  21 
programs from facility-initiated discharge notices 
ACL and CMS: Coordinate to strengthen safeguards to protect nursing home residents from  22 
inappropriate facility-initiated discharges  
ACL and CMS: Ensure that all State Ombudsmen, State agencies, and CMS ROs have an 
22 
ongoing venue to share information about facility-initiated discharges and potentially other 
systemic problems in nursing homes  
AGENCY COMMENTS AND OIG RESPONSE  23 
DETAILED METHODOLOGY  25 
APPENDIX A  28 
ACKNOWLEDGMENTS AND CONTACT  35 
ABOUT THE OFFICE OF INSPECTOR GENERAL  36 
ENDNOTES  37   
BACKGROUND 
 
Objectives 
1. To determine the extent to which State Long-Term Care Ombudsmen (State
Ombudsmen) received and responded to facility-initiated discharge notices
from nursing homes.
2. To determine the extent to which State Ombudsmen experienced
challenges with addressing inappropriate facility-initiated discharges.
3. To determine the extent to which State survey agencies (State agencies) and
the Centers for Medicare & Medicaid Services (CMS) identified and
addressed inappropriate facility-initiated discharges.
The inappropriate facility-initiated discharge of a resident from a nursing home (i.e., a 
facility-initiated discharge that violates CMS regulations) can be unsafe and traumatic 
for the resident and his or her family.1  To address these concerns, Congress passed 
the Nursing Home Reform Act of 1987 (Nursing Home Reform Act) to protect 
residents against inappropriate facility-initiated discharge.2  However, facility-initiated 
discharges that violate Federal regulations remain a concern, raising questions about 
the extent to which the problem exists and is being addressed.  In fact, the State 
Ombudsman programs, charged with resolving problems for nursing home residents, 
cited complaints about discharge and eviction more frequently than any other 
concern from 2013 through 2019.3, 4   
Nursing homes routinely discharge residents safely and appropriately for reasons 
such as improved health or to receive specialized care, among others.  However, CMS 
and the media have raised concerns about some nursing homes inappropriately 
discharging residents and the negative consequences of these discharges.  CMS has 
noted that the most commonly reported reasons that residents are discharged are 
behavioral issues and that some discharges are driven by payment concerns.5  In one 
example, a resident remained in the hospital for 7 months because the nursing home 
refused to readmit him.6  Another report described some nursing homes discharging 
less profitable residents to make room for residents diagnosed with COVID-19, 
which generally provides the nursing home with higher reimbursements.  According 
to the report, the police found one resident on the streets after a nursing home 
discharged him to an unlicensed boarding house without informing his family.7  
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Background | 1  Federal Regulations for Facility-Initiated Discharges in Nursing 
Homes 
Facility-initiated discharges are discharges that the resident objects to, did not 
request, and/or do not align with the residents stated goals for care and preferences.  
In the case of a facility-initiated discharge, the nursing home moves the resident to 
another nursing home or location in the community and is not expected to take the 
resident back.8   
Federal regulations prohibit nursing homes from initiating the discharge of a resident 
except for a specified set of reasons. 
Nursing homes may only initiate the discharge of a resident for six reasons.  
1.  The residents welfare and the residents needs cannot be met in the facility. 
2.  The residents 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 individuals in the facility would otherwise be endangered. 
5.  The resident has failed, after reasonable and appropriate notice, to pay. 
6.  The facility ceases to operate. 
   
Source: 42 CFR  483.15(c)(1) 
Nursing homes must document all facility-initiated discharges in the residents 
medical record and provide adequate notice to the resident.  Documentation in the 
residents medical record should include a discharge care plan and documented 
discussions with the resident or residents representative regarding discharge 
planning and post-discharge care.9  When a residents needs cannot be met in the 
facility or when a resident no longer needs the services provided by the facility, only 
the residents physician can document these reasons for discharge.  When the safety 
of individuals in the facility is endangered due to the clinical or behavioral status of 
the resident or the health of individuals in the facility would otherwise be endangered, 
any physician can document these reasons for discharge.10   
In the case that the nursing home initiated the discharge because it cannot meet the 
residents needs, the medical record must document the specific needs that cannot be 
met, the nursing homes attempts to meet those needs, and the service available at 
the receiving facility to meet those needs.11  Generally, the nursing home must also 
provide notice to the resident and the residents representative in writing at least 30 
days in advance.12  Notice of facility-initiated discharge must include specific 
information, such as the date and reason for discharge. 
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Background | 2  CMS requires nursing homes to include the following information in facility-initiated 
discharge notices:  
  reason for discharge; 
  specific location to which the resident will be moved; 
  date of discharge; 
  Information about the right to appeal the decision to discharge the 
resident; 
  contact information for the State Ombudsman; 
 
  contact information for the agency responsible for the protection and 
advocacy of individuals with developmental disabilities, when appropriate; 
and 
 
  contact information for the agency responsible for the protection and 
advocacy of individuals with a mental disorder, when appropriate. 
 
 
Source: 42 CFR 483.15(c)(5) 
State Administrative Hearings  
The resident has the right to appeal a facility-initiated discharge through an 
administrative hearing if the resident believes that the nursing home cannot justify 
the discharge.13  The entity that holds administrative hearings varies by State (e.g., 
State Medicaid Office, State survey agency, or Office of Administrative Hearings).  For 
assistance with administrative hearings, residents can appoint an authorized 
representative or contact their State Ombudsman.14  Residents may also represent 
themselves in an administrative hearing.15  If the official overseeing the hearing 
decides in favor of the resident, a designated entity within the State must ensure that 
the nursing home readmits the resident.16 
CMS sets requirements for nursing homes related to appeals of facility-initiated 
discharges.  Nursing homes must provide information in the discharge notice on the 
residents appeal rights on the facility-initiated discharge notice, including the name, 
address (mailing and email), and telephone number of the entity that receives appeal 
requests.17  The discharge notice must also include information on how to obtain an 
appeal form and assistance in completing the form and filing a request for appeal.18  
Furthermore, nursing homes are not allowed to discharge residents while an appeal is 
pending, unless keeping the resident in the nursing home can pose health or safety 
dangers to the resident or others in the nursing home.  In such cases, the nursing 
home must document the danger that failure to discharge would pose.19 
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Background | 3  CMS Oversight and Enforcement 
To participate in Medicare and/or Medicaid, a nursing home must be certified as 
meeting Federal requirements.20  State survey agencies (State agencies) conduct 
certification surveys on behalf of CMS.  These surveys evaluate the safety and quality 
of care nursing homes provide on average every 12 months but no less frequently 
than every 15 months.21  In addition to certification surveys, State agencies conduct 
complaint investigations. 22  Residents, residents families, nursing home staff, and 
Ombudsmen (with the residents permission) can file complaints with State agencies.  
Prior to investigating a complaint, State agencies should contact the State 
Ombudsman to discuss the nature of the complaint and history of similar complaints 
in the nursing home.23  State agencies can identify inappropriate facility-initiated 
discharges through both standard and complaint surveys. 
When a nursing home fails to meet one or more Federal requirements, surveyors cite 
a deficiency.  Surveyors follow CMS guidance when determining whether to cite 
deficiencies during a survey.  CMS updated this guidance in November 2017, 
including the guidance for deficiencies related to facility-initiated discharges.24   
According to CMS, deficiencies with the following Federal requirements may be 
associated with facility-initiated discharges: 
  right to refuse certain transfers,  
  admissions policy,  
  transfer and discharge requirements (reason and documentation for 
transfer or discharge of resident),  
  notice requirements before transfer or discharge,  
  preparation for safe/orderly transfer or discharge,  
  notice of bed hold policy before or upon transfer, and  
  permitting residents to return to facility.  
   
Source: CMS, An Initiative To Address Facility Initiated Discharges That Violate Federal Regulations. S&C 18-08-NH, 
December 22, 2017.25 
When State agencies identify deficiencies, in almost all cases CMS requires the 
nursing home to submit an acceptable plan of correction to the State agency and/or 
CMS.26  The plan of correction must describe how the nursing home will address the 
deficiency, among other things.27  CMS may also impose enforcement remedies that 
may include Civil Money Penalties (CMPs) or denial for new Medicare and Medicaid 
payments.28  State agencies must send deficiencies to their CMS ROs for review and 
enforcement action under certain circumstances, such as when the deficiency has 
caused serious injury or harm.29  CMS ROs may consider all types of deficiencies cited 
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Background | 4  and the nursing homes history of noncompliance, among other factors, when 
imposing enforcement remedies.30   
CMS Initiative To Review Facility-Initiated Discharge Deficiencies  
In a December 2017 memo, CMS announced a new initiative to review cases of 
facility-initiated discharge deficiencies.  Specifically, CMS instructed State agencies to 
send facility-initiated discharge deficiencies to the CMS ROs beyond those usually 
sent.31  According to the memo, State agencies must send deficiencies for certain 
reasons unless otherwise instructed by the CMS RO.  These reasons include cases 
where a nursing home discharges a resident to a questionable or unsafe location, 
cases where a nursing home will not readmit a hospitalized resident, cases that 
represent facility patterns, or cases that include other circumstances identified by 
the CMS RO.  CMS ROs will review these deficiencies and take enforcement actions if 
deemed appropriate.  CMS is also evaluating enforcement options for these types of 
deficiencies as part of the initiative.  In its rationale for the initiative, CMS emphasizes 
concerns with inappropriate facility-initiated discharges and their effect on residents.  
This initiative represents part of CMSs efforts to fully address facility-initiated 
discharges that violate federal regulations.32 
ACL and State Ombudsmen  
In addition to other functions, the Administration for Community Living (ACL) 
oversees programs that aim to protect the rights and prevent abuse of older adults, 
including the State Long-Term Care Ombudsman Program (State Ombudsmen).33  
The Older Americans Act authorized the creation of the State Ombudsman program 
that works to resolve problems related to the safety, welfare, and rights of individuals 
who live in nursing homes.34  Ombudsmen advocate on behalf of nursing home 
residents to resolve complaints made by or for these residents.35  The Ombudsman 
Program operates in all 50 States, the District of Columbia, Puerto Rico, and Guam.36   
A full-time State Ombudsman heads the Ombudsman program in each State, and 
some programs have additional local offices.37  The State Ombudsman designates 
and provides programmatic oversight to both paid staff and volunteers who serve as 
representatives of the Office of Long-Term Care Ombudsman.  They conduct 
advocacy through two channels: (1) individual assistance to residents with concerns 
and (2) advocacy related to laws, regulations, and policies for long-term care 
residents.  Ombudsmen must receive a residents consent to assist with a problem.   
Each State Ombudsman program reports the complaints they receive and investigate 
to ACL through the National Ombudsman Reporting System (NORS).38  NORS 
includes, but is not limited to, information on types of complaints and outcomes, 
Ombudsman program information, and narratives on broader systems issues.39, 40 
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Background | 5  The State Ombudsman program has many functions mandated by law to improve the 
quality of life and care for residents, including, but not limited to: 
  identifying, investigating, and resolving complaints made by or on behalf of 
residents; 
  ensuring that residents have regular and timely access to Ombudsman services 
and receive timely responses from the Ombudsman program; 
  representing the interests of residents before governmental agencies;  
  analyzing, commenting on, and monitoring the development and implementation 
of laws, regulations, and policies pertaining to the health, safety, welfare, and 
rights of residents; and 
  recommending changes to these laws. 
   
Source: 45 CFR  1324.13 
Since November 2016, CMS regulations require nursing homes to send all facility-
initiated discharge notices to a representative of the State Ombudsman program to 
provide added protection to residents.41, 42  In general, nursing homes must send 
these notices at least 30 days in advance of discharge and include all information 
required for the discharge notice to be adequate.  
Exhibit 1: State Ombudsmen receive facility-initiated discharge notices from 
nursing homes as well as complaints from residents, and ACL collects data 
on complaints from Ombudsmen. 
Source: 42 CFR  483.15(c)(3)(i) and 81 Federal Register 68688, 68734 (Oct. 4, 2016). 
The COVID-19 Pandemic 
COVID-19 is a highly contagious disease and can be fatal in some cases.43, 44  Nursing 
home residents are particularly vulnerable to the disease due to their age and 
underlying health conditions.  As of April 4, 2021, more than 131,000 nursing home 
residents died due to COVID-19.45  On January 31, 2020, the Secretary of the 
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Background | 6  Department of Health and Human Services (HHS) declared a public health emergency, 
and on March 13, 2020, the Federal Government declared a national emergency in 
response to the COVID-19 pandemic.46  After these declarations, CMS issued certain 
waivers to provide nursing homes with the flexibilities to respond to the COVID-19 
pandemic.47  Specifically, CMS waived certain facility-initiated discharge requirements 
for the purposes of separating residents due to COVID-19.  For example, CMS waived 
the requirement that, in most cases, nursing homes must provide a facility-initiated 
discharge notice to the resident 30 days before discharge.  Instead, nursing homes 
need to provide the notice as soon as practicable when discharging a resident for 
purposes of separating residents due to COVID-19.48  
CMS also issued guidance to nursing homes regarding visitation protocols during the 
COVID-19 pandemic.  On March 13, 2020, CMS provided guidance to restrict all 
visitors and nonessential health care personnel in nursing homes, including 
Ombudsmen, with the exception of health care workers and surveyors.49  However, 
CMS issued additional guidance in July 2020 reminding nursing homes that they must 
provide Ombudsmen with access to residents through phone or other technology if 
the nursing home restricts in-person visits.50  On September 17, 2020, CMS updated 
its visitation guidance with recommendations on how nursing homes can safely 
facilitate in-person visits while preventing the spread of COVID-19.  The guidance 
noted that nursing homes cannot limit residents in-person access to Ombudsmen 
without reasonable cause, such as Ombudsmen having symptoms of COVID-19.51  On 
March 10, 2021, CMS updated its guidance to recommend that nursing homes allow 
responsible indoor visitation at all times for all residents, with some exceptions.52 
Related OIG Work 
This study is part of the Office of Inspector Generals (OIGs) larger body of work 
examining nursing home resident safety and oversight.  Most recently,  OIG published 
a report examining CMSs and State agencies onsite oversight of nursing homes 
during the COVID-19 pandemic.53  OIG also published a report examining staffing 
levels in nursing homes and a report evaluating States timeliness investigating the 
most serious nursing home complaints.54, 55  In addition, OIG has work underway 
examining CMSs efforts to work with State agencies to improve nursing home 
oversight.56  Finally, to complement this evaluation, OIG is also assessing nursing 
homes compliance with Federal requirements for facility-initiated discharges.  A 
complete listing of OIGs ongoing evaluations and audits is available in our online 
Work Plan at https://www.oig.hhs.gov/.  
Methodology 
Our review includes the following data sources: (1) survey of State Ombudsmen, (2) 
CMS survey and deficiency data, (3) interviews with State Ombudsmen, and (4) 
interviews with CMS and ACL.  We consider facility-initiated discharges from both 
Medicare and Medicaid-only nursing homes in our review.  Most of our data refer to 
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Background | 7  calendar years 2017 and 2018, the latest data available when we initiated this 
evaluation.  However, OIG put this evaluation on hold for several months to direct its 
resources to concerns related to the COVID-19 pandemic.  When we resumed this 
work in late calendar year 2020, we interviewed five State Ombudsmen to provide 
insights on how the pandemic affected facility-initiated discharges.    
Data Sources and Analysis 
Survey of State Ombudsmen.  We sent an electronic survey to the State 
Ombudsman in all 50 States and the District of Columbia.  State Ombudsmen could 
respond to the survey from June 3, 2019, through September 5, 2019.  We received 
responses from 47 State Ombudsmen, for a response rate of 92 percent.  We analyzed 
their responses to describe Ombudsmens experiences and challenges with receiving, 
investigating, and resolving facility-initiated discharge notices.  We also analyzed their 
responses related to their experiences working with State agencies and CMS ROs on 
facility-initiated discharges.  All survey questions referred to calendar years 2017 
and/or 2018.   
CMS Survey and Deficiency Data.  CMS provided data on all standard and 
complaint surveys and resulting deficiencies of Medicare/Medicaid-certified nursing 
homes from CMSs Certification and Survey Provider Enhanced Reporting (CASPER) 
and Automated Survey Process Environment (ASPEN) for years 2014 through 2018.  
We analyzed trends in deficiencies related to facility-initiated discharges from 2014 
through 2018 to determine the number and percentage of deficiencies that may 
relate to facility-initiated discharges over time and by State.   
Interviews With State Ombudsmen.  We conducted structured interviews with a 
purposive sample of five State Ombudsmen in October and November 2020.  We 
asked the State Ombudsmen about the impact of the COVID-19 pandemic on facility-
initiated discharges in nursing homes.  We analyzed these interviews to identify 
themes. 
Interviews With CMS and ACL.  We conducted structured interviews with all 10 CMS 
ROs in July 2019.  We asked CMS ROs about their implementation of CMSs 
December 2017 memo to address inappropriate facility-initiated discharges.  In 
addition, we conducted multiple interviews with CMS and ACL Headquarters staff 
from 2018 through 2020.  We asked about each agencys efforts to address 
inappropriate facility-initiated discharges and about challenges they face in doing so, 
among other questions.  In addition, we asked CMS and ACL staff about the impact of 
the COVID-19 pandemic on facility-initiated discharges.   
See the Detailed Methodology section on page 25 for additional information about 
our data collection and analysis.  
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Background | 8  Limitations 
We did not independently verify the survey responses that State Ombudsmen 
provided.  Data from the State Ombudsmen survey represent the views and 
experiences of the 47 responding State Ombudsmen rather than all 51 State 
Ombudsmen.  We also did not independently verify the accuracy of CMSs CASPER 
and ASPEN data.  Finally, we did not interview State agencies for this evaluation and 
cannot make statements about their experiences with facility-initiated discharges in 
nursing homes. 
Standards 
We conducted this study in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.  
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Background | 9   
FINDINGS 
 
The magnitude of facility-initiated discharges in nursing homes 
is unknown  
Neither ACL nor CMS know the number of facility-initiated discharges in nursing 
homes or the number of these discharges that are inappropriate because they do not 
collect these data.  Although CMS requires nursing homes to send a copy of all 
facility-initiated discharge notices to their State Ombudsmen, ACL does not collect 
data on these notices from the Ombudsmen.57  ACL collects national-level data, such 
as complaints that Ombudsmen receive, which may concern inappropriate facility-
initiated discharges among other complaints.58  Furthermore, CMSs data on 
inappropriate facility-initiated discharges are limited to State agency citations for 
deficiencies related to these discharges.  Neither CMS nor ACL has plans to collect 
additional data on facility-initiated discharges.   
Although State Ombudsmen receive facility-initiated discharge notices, 
24 of 47  many do not count or extract information from the notices received.  In fact, 
24 of 47 Ombudsmen could not provide the number of notices they received 
Ombudsmen 
in 2018.  Furthermore, our review indicates that even those who provided 
could not provide the  the number of notices may not have provided a complete or accurate 
number of facility- number.  For example, two Ombudsmen told us they provided numbers of 
initiated discharge  complaints related to facility-initiated discharges rather than notices 
notices they received  received, and another Ombudsman provided numbers that included other 
in 2018  types of notices.  In addition, at least one Ombudsman manually counted 
the notices in response to our survey.  Some Ombudsmen reported 
receiving fewer than 10 notices in 2018, while others reported receiving more than 
  1,000 notices.  Although State size may affect the number of notices received, it likely 
does not explain the large variation between State Ombudsman programs.  Also, 
most Ombudsmen (31 of 47) could not provide data on the reason for discharge 
included in the notices. 
Ombudsmen attribute their inability to count or extract 
information from the notices they receive, at least in  Our State LTCO Program 
part, to limited resources.  A few Ombudsmen told us  simply does not capture 
that they do not have an established database to  the data points being 
collect data on facility-initiated discharge notices.   requested. 
Instead, they use a database designed to collect data   
on complaints and Ombudsman activity to report this  State Ombudsman 
information to ACL.  One Ombudsman volunteered 
that her database does not have a field for capturing the total number of facility-
initiated discharge letters [notices] since this is not a NORS [National Ombudsman 
Reporting System] requirement.  This means that Ombudsmen who decide to track 
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Findings | 10  notices need to develop and implement their own system to do so, which may require 
significant resources.  Indeed, one Ombudsman said that the program hired an 
additional staff member to help track notices but described this process as time-
consuming.  Nine other Ombudsmen told us that they do not have enough staff to 
extract data from the notices.  
Many Ombudsmen expressed concerns about inappropriate facility-initiated 
discharges, and some described the negative effects on residents.  For example, most 
Ombudsmen (41 of 47) agreed that nursing homes discharging a resident while the 
resident is in the hospital is a problem in their States.  One Ombudsman described a 
situation prior to the COVID-19 pandemic where a nursing home initially refused to 
readmit a resident after sending him to the emergency room; as a result, the resident 
ended up homeless for a week.  The Ombudsman assisted the resident with an appeal 
and the resident eventually returned to the nursing home.  In addition, most 
Ombudsmen (41 of 47) agreed that in their State, nursing homes discharging a 
resident to an inappropriate location is a problem.  One Ombudsman told us that a 
nursing home discharged a resident with complex and ongoing medical needs to a 
motel, only notifying the residents family when the resident was in transit.  By the 
time the family arrived, the resident was in acute physical distress and needed 
hospital care.  Similarly, another Ombudsman said that a nursing home in his State 
discharged a wheelchair-bound resident to a hotel, and within hours the resident 
was unresponsive and required emergency medical treatment.   
One Ombudsman provided examples of facility-initiated discharges that were tied 
to the COVID-19 pandemic.  
 
The stress of the pandemic, isolation, and limits on visitors affected some residents 
behaviors.  For example, the behavior of one resident with dementia became more 
problematic without regular visits from his spouse.  Ultimately, the nursing home 
called the police to transport the resident to the hospital.  The hospital would not 
admit him, and the nursing home refused to allow him back.  The Ombudsman helped 
the resident find another facility that would admit him. 
 
Another nursing home restricted residents from leaving, even for a walk, during the 
pandemic.  When one resident violated the policy and left, the nursing home 
discharged the resident to the hospital, which refused to admit him.  The hospital gave 
the resident bus fare to leave and a nursing home 3 hours away from the original 
nursing home eventually admitted the resident.  
 
Ombudsmen reported facing challenges while responding to 
facility-initiated discharges 
As part of their duties, Ombudsmen must respond to complaints made by or on 
behalf of nursing home residents.  Ombudsmen may also offer assistance to residents 
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Findings | 11  in the absence of a complaint but must have the residents permission to provide 
assistance.  For example, Ombudsmen can contact the resident associated with a 
facility-initiated discharge notice and, if given permission by the resident, investigate 
the discharge.   
Ombudsmen vary in how they identify which facility-initiated 
discharge notices to respond to  
Ombudsmen have discretion in determining which notices they respond to.  In most 
cases, the local representatives of the Ombudsman program, overseen by the State 
Ombudsman, contact the resident associated with a facility-initiated discharge notice, 
but Ombudsmen vary in determining which residents to contact.  Just over one-third 
of Ombudsmen (17 of 47) contact every resident or most residents associated with a 
facility-initiated discharge notice, while others contact the resident only when the 
notice appears to be noncompliant with regulations or only when a complaint is 
made.  In addition, two Ombudsmen outlined additional criteria that they use to 
identify notices for follow up, such as nonpayment as the reason for discharge and a 
nursing homes history with discharges.  Most Ombudsmen (30 of 47) told us they can 
respond to each notice they identify for followup.   
After receiving permission from the resident, Ombudsmen conduct a variety of 
activities when investigating and resolving those facility-initiated discharge notices 
they identified for followup.  Over half said that they interview the resident or 
residents representative, interview the nursing home administrative staff, or review 
the residents discharge summary in most if not all investigations.  In addition, most 
Ombudsmen contact the nursing home directly all or most of the time to resolve a 
facility-initiated discharge notice.  For those Ombudsmen who contact the nursing 
home, about half said that most of the time, this results in a satisfactory outcome for 
the resident.    
Noncompliant facility-initiated discharge notices hinder 
Ombudsmens ability to investigate and resolve these discharges  
Receiving timely, complete, and accurate facility-initiated discharge notices provides 
the Ombudsmen the best opportunity to investigate and resolve the situation.  
However, 31 of 47 Ombudsmen reported that nursing homes in their States do not 
have a clear understanding of CMSs requirements for facility-initiated discharge 
notices.  (See Exhibit 2.)   
Timeliness. Some Ombudsmen told us that nursing homes do not send notices in a 
timely manner or send notices after the discharge occurred.  Thirteen Ombudsmen 
volunteered that receiving notices close to or after discharge is a challenge, with one 
Ombudsman noting that this makes it difficult to get out to assist the resident prior 
to discharge.  Another Ombudsman told us that in some cases, the resident has 
already left the facility by the time the Ombudsman receives the discharge notice. 
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Findings | 12  Indeed, 40 of 47 Ombudsmen found achieving a 
resolution before a nursing home discharges a 
Facility staff usually are 
resident to be a challenge.  
not familiar with the 
regulations regarding 
Missing Information. In addition, nursing homes 
when to send discharge 
send Ombudsmen facility-initiated discharge 
notices and what 
notices with required information missing.  CMS 
information they should 
requires nursing homes to include the reason for 
contain. 
discharge and the specific discharge location in the 
State Ombudsman 
notices.  However, for the year 2018, a total of 38 
Ombudsmen said that nursing homes did not 
always provide the reason for discharge on the 
notice, and 45 Ombudsmen said that nursing homes did not always provide a specific 
discharge location on the notice (see Exhibit 2).  Almost all (43 of 47) Ombudsmen 
found that receiving notices with required information missing was a challenge to 
investigating notices.   
 
Exhibit 2: Most Ombudsmen reported that nursing homes in their State do not clearly 
understand requirements for facility-initiated discharge notices. 
 
 
Source: OIG analysis of survey of State Ombudsmen. 
 
 
Unnecessary Notices. Lastly, Ombudsmen reported receiving notices beyond those 
CMS requires, such as for room transfers within a nursing home.  In fact, 36 of 47 
Ombudsmen found receiving these additional notices to be a challenge.  A State 
Ombudsman told us that one nursing home in her State continues to send facility-
initiated discharge notices to the residents family and the State Ombudsman when a 
resident dies, with the reason that the nursing home can no longer meet the 
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Findings | 13  residents needs.  Receiving notices beyond what 
CMS requires creates additional burden for  Nursing homes struggle with 
Ombudsmen programs to review and determine  understanding what is 
which notices should be tracked and investigated.   facility-initiated and, as a 
In response to our survey, 43 of 47 Ombudsmen  result, nursing homes either 
indicated that having too few local representatives  send notices not required by 
in the State Ombudsman program was a challenge  regulations or do not send 
to investigating facility-initiated discharges.   notices at all. 
 
Almost all Ombudsmen said that they conducted 
State Ombudsman 
outreach to help nursing homes in their States 
comply with notice requirements.  For example, 
one State Ombudsman told us that his program developed a booklet outlining 
requirements for facility-initiated discharge notices to send to all nursing homes in 
the State.  Another State Ombudsman volunteered that her program provided 
nursing homes that issued incorrect notices with a template to help these nursing 
homes comply with notice requirements.  
The COVID-19 pandemic exacerbated challenges that Ombudsmen face with 
receiving notices for, investigating, and resolving facility-initiated discharges. 
  
Some of the Ombudsmen we interviewed told us that they had challenges receiving 
facility-initiated discharge notices during the COVID-19 pandemic.  CMS waived the 
requirement for nursing homes to provide a facility-initiated discharge notice 30 
days prior to discharge, but only for those discharges initiated to prevent the 
spread of COVID-19.  For these discharges, nursing homes must provide the notice 
as soon practicable.  For discharges not related to preventing the spread of COVID-
19, nursing homes generally must continue to provide notices 30 days prior to 
discharge.  However, some Ombudsmen expressed concerns that, early in the 
pandemic, nursing homes were not issuing the required notices on time or at all.  
Moreover, one Ombudsman told us that her program had to ask her State agency 
to instruct nursing homes to send notices.  
 
In addition, CMS provided guidance to restrict Ombudsmens in-person visits to 
nursing homes early in the pandemic, presenting a challenge to investigating and 
resolving facility-initiated discharges.  Although Ombudsmen used the telephone 
and other virtual technology to communicate with residents and nursing homes, 
one Ombudsman said that it was a struggle to reach nursing homes through these 
means.  In addition, two Ombudsmen noted that, without in-person visits, they 
could not observe conditions in the nursing home, which hindered investigations.  
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Findings | 14  The administrative hearing process does not always resolve the 
facility-initiated discharge as intended  
According to State Ombudsmen, the administrative hearing process falls short of 
protecting residents against inappropriate facility-initiated discharges.  CMS requires 
that a designated entity within the State ensure that nursing homes readmit a 
resident when the resident wins an administrative hearing.59, 60  However, nearly two-
thirds of Ombudsmen (30 of 47) said that enforcing an administrative hearing 
decision that is favorable to the resident is a challenge in their States.  Two 
Ombudsmen told us that residents may still be discharged from the nursing home 
even after winning an appeal.  Furthermore, over 
one-quarter of Ombudsmen (13 of 47) said that no  If a resident facing 
entities in their States are responsible for enforcing  discharge does not have a 
administrative hearing decisions.  Problems with  professional advocate (like 
enforcement may affect nursing homes compliance  an Ombudsman) or legal 
with facility-initiated discharge regulations.   representation, the 
According to CMS, a favorable administrative  nursing home is going to 
hearing for the resident may prompt nursing homes  get the OK to discharge 
to increase compliance with regulations for facility- the resident. 
initiated discharges, resulting in fewer deficiencies.    
However, CMS noted that it does not have much  State Ombudsman 
information about States processes for 
administrative hearings.   
Ombudsmen reported additional challenges with the administrative hearing process.  
Nearly all Ombudsmen found the residents lack of knowledge regarding 
administrative hearings to be a challenge, with over half finding it to be a major 
challenge.  In addition, five Ombudsmen told us that State hearing officers were 
unfamiliar with facility-initiated discharge regulations.  A few specifically noted that 
some hearing officers focus on State regulations for discharge and are unfamiliar with 
or do not consider Federal regulations.  Finally, four Ombudsmen said that increasing 
resident access to legal resources would help Ombudsmen better address facility-
initiated discharges.      
Ombudsmen, CMS, and State agencies may differ in their 
perspectives on facility-initiated discharges  
Perspectives on the effectiveness of enforcement 
varied.  Although Ombudsmen do not cite 
When a hearing officer 
deficiencies and take enforcement actions, they do 
sides with the resident, it 
work directly with residents to resolve facility-
doesnt confirm that [the] 
initiated discharges and have knowledge of the 
resident isnt discharged. 
circumstances of individual discharges.  Half of 
 
Ombudsmen raised questions about how well  State Ombudsman 
enforcement addressed inappropriate facility-
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Findings | 15  initiated discharges.  For example, a few Ombudsmen volunteered that nursing homes 
have said that they would rather accept a deficiency or enforcement penalty than 
keep the resident.  And several Ombudsmen opined that stronger enforcement 
actions could help to reduce these discharges.  However, CMS ROs did not generally 
share those concerns.  Half of CMS ROs volunteered that enforcement tools are 
adequate to address inappropriate facility-initiated discharges, and 7 of 10 CMS ROs 
told us that they do not consider these discharges a problem in their regions.  
Notably, CMS ROs consider factors in addition to the specific deficiency when taking 
enforcement action, such as a nursing homes history of noncompliance, which may 
contribute to the difference in perspectives between CMS ROs and Ombudsmen.   
A common understanding of the regulations for 
The State Survey Agency 
facility-initiated discharges also appeared to be 
has a different 
lacking.  For example, about half of Ombudsmen (23 
understanding of what 
of 47) stated that interpreting regulations for facility-
constitutes a facility-
initiated discharges differently than their State 
initiated discharge. 
agencies was a challenge.  One CMS RO offered an 
 
example.  Specifically, an Ombudsman informed the 
State Ombudsman 
CMS RO of facility-initiated discharges that the State 
agency did not consider facility-initiated.  This 
discrepancy led the CMS RO to step in and clarify the definition of facility-initiated 
discharge with the State agency.  The CMS RO also had Federal surveyors accompany 
the State agency on the complaint investigation related to these discharges. 
CMS and ACL may be missing opportunities to foster a common understanding of 
regulations and reduce inappropriate facility-initiated discharges.  Six of 10 CMS ROs 
do not regularly communicate with the Ombudsmen in their regions about facility-
initiated discharges.  Furthermore, ACL does not have specific plans to facilitate 
communication between CMS and the Ombudsmen.  ACL said that it previously 
hosted a few regional meetings with both Ombudsmen and CMS ROs to discuss 
systemic problems in nursing homes, including inappropriate facility-initiated 
discharges.  A common understanding among Ombudsmen, CMS, and State agencies 
benefits nursing home residents because these entities rely on each other for 
referring complaints, sharing information, and ultimately resolving facility-initiated 
discharges.   
 
State agencies cited many more nursing homes for not 
complying with notice requirements following CMSs initiative 
to review inappropriate facility-initiated discharges, announced 
in 2017 
State agencies cited more than six times as many nursing homes for deficiencies with 
facility-initiated discharge notices in 2018 compared to 2017.61  Coupled with CMSs 
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Findings | 16  updated survey guidance, CMSs initiative to review cases of facility-initiated 
discharge deficiencies, which it announced in a memo issued in December 2017, may 
have contributed to this increase in deficiencies.  In 2018, State agencies cited 1,924 
nursing homes (13 percent of those surveyed) for a deficiency with facility-initiated 
discharge notices, an increase from 297 nursing homes (2 percent of those surveyed) 
in 2017 (see Exhibit 3 below).  From 2014 through 2016, State agencies cited about 
200 nursing homes for this deficiency each year (about 1 percent of nursing homes 
surveyed).  Nearly all States (48 of 51) cited more nursing homes for this deficiency 
from 2017 to 2018.   
Exhibit 3: State agencies cited many more nursing homes for not complying 
with notice requirements before transfer or discharge in 2018 than in 2017.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Source: OIG analysis of CMS CASPER and ASPEN data, 20172018 
 
 
However, we cannot directly tie these specific deficiencies to enforcement actions 
taken by CMS.  Rather than considering a single deficiency, CMS typically considers all 
cited deficiencies for a nursing home during a survey as well as other factors, such as 
the nursing homes history of compliance, when taking enforcement actions.   
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Findings | 17  CMS has not yet determined the trends and outcomes of its 
initiative to review and impose appropriate enforcement actions 
in cases of inappropriate facility-initiated discharges 
The results of CMSs initiative to review deficiencies for facility-initiated discharges 
and take appropriate enforcement actions are unknown.  CMS told us it could not 
readily identify the number of cases State agencies sent in response to CMSs memo 
without reviewing each case individually.  Some CMS ROs provided us an estimate for 
the number of cases State agencies transferred to the RO since CMS released the 
memo, which varied from 0 cases for one RO to over 100 cases for another RO.62  
CMS has also noted, as acknowledged previously, that it considers more than a single 
deficiency in determining its enforcement actions.  Therefore, it is unclear how CMS 
intends to evaluate enforcement actions imposed because of its memo.   
However, 5 of the 10 CMS ROs volunteered that they have taken enforcement actions 
for at least 27 inappropriate facility-initiated discharges (as of July 2019) because of 
the additional review prompted by CMSs December 2017 memo.  For example, one 
RO imposed a CMP on a nursing home for refusing to readmit a resident from the 
hospital and for failing to properly document the reason for discharge in the medical 
record.  Two other CMS ROs imposed a CMP on nursing homes for failing to provide 
facility-initiated discharge notices to residents. 
CMS postponed its planned actions to address inappropriate facility-initiated 
discharges because of COVID-19. 
 
According to CMS Headquarters, it plans to take actions to address 
inappropriate facility-initiated discharges, such as providing training to State 
surveyors on discharge requirements and implementing a Federal workgroup 
to discuss concerns related to facility-initiated discharges.   
 
   
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Findings | 18   
CONCLUSION AND RECOMMENDATIONS 
 
 
Our findings raise concerns about weaknesses in the safeguards to protect nursing 
home residents from harm that may result from inappropriate facility-initiated 
discharges.  State Ombudsmen, ACL, State agencies, and CMS share a common goal 
to protect residents from harm, but have different roles stemming from different 
authorities.  Those differences may, in fact, inhibit efforts to prevent inappropriate 
facility-initiated discharges.  CMS and State agencies are regulatory entities 
responsible for ensuring nursing home compliance and can take enforcement action 
against nursing homes to address inappropriate discharges.  In contrast, ACL and 
State Ombudsmen serve in a resident advocacy role and directly assist 
residents.  State Ombudsmen receive notices of facility-initiated discharges
positioning them to advocate where necessary.  We found that State Ombudsmen, 
CMS, and State agencies may differ in their perspectives on regulations and 
enforcement of facility-initiated discharges  Improved informationincluding fully 
compliant notices from nursing homes on their facility-initiated dischargesas well as 
coordination and information sharing could better protect nursing home residents 
from harm.  
Critical questions remain, including how many residents are subject to facility-initiated 
discharges in nursing homes, how many of those discharges are inappropriate, which 
nursing homes have concerning rates or patterns of facility-initiated discharges, and 
how well oversight and enforcement address and reduce inappropriate 
discharges.  Answers to these questions would provide important information to aid 
those responsible for safeguarding residents.  Answers would allow for targeted 
interventions and enhanced oversight with the goal to reduce harm to residents from 
inappropriate discharges.  
We have forthcoming work that will determine the extent to which a sample of 
nursing homes followed regulations for facility-initiated discharges in 2019.63  In the 
meantime, this report highlights opportunities to strengthen the safeguards in place 
to ensure residents rights and prevent inappropriate discharges.  To that end, we 
offer recommendations to CMS, which oversees nursing homes, to ACL, which 
oversees the Ombudsman program, and joint recommendations to both agencies.   
We recommend that CMS: 
Provide training for nursing homes on Federal requirements for 
facility-initiated discharge notices  
Ombudsmen rely on timely and accurate facility-initiated discharge notices to fulfill 
their responsibilities of protecting residents and staying informed of facility activities.  
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Conclusion and Recommendations | 19  But not all nursing homes consistently follow the requirements, which can hinder 
Ombudsmens ability to investigate potentially inappropriate discharges.  Improving 
nursing homes understanding of and compliance with notice requirements would 
help Ombudsmen better protect residents from inappropriate facility-initiated 
discharges. 
CMS should provide training for nursing homes on the Federal requirements for 
facility-initiated discharge notices.  This training should include when to send the 
notices to State Ombudsmen, the types of notices that nursing homes need to send 
to State Ombudsmen, and information required in the notices.  Specifically, CMS 
should highlight the importance of including the specific discharge location in the 
notice.   
Assess the effectiveness of its enforcement of inappropriate 
facility-initiated discharges   
In its December 2017 memo, CMS outlined an initiative to examine and mitigate 
facility-initiated discharges that violate federal regulations.  However, it is unclear 
how CMS is evaluating enforcement actions imposed in response to the memo 
because CMS cannot readily identify the number of cases received from State 
agencies.  CMS should evaluate the enforcement actions imposed in noncompliant 
facility-initiated discharge cases.  CMS could do this by determining how many cases 
State agencies have transferred to ROs and analyzing the enforcement remedies that 
CMS imposed in these cases considering all the relevant factors.  CMS could also 
assess differences in deficiencies transferred and enforcement actions across State 
agencies and CMS ROs to identify any inconsistencies that should be addressed.  CMS 
could use the results of this assessment to inform guidance and training for State 
agencies and CMS ROs related to its initiative. 
Implement its deferred initiatives to address inappropriate 
facility-initiated discharges 
Prior to the COVID-19 pandemic, CMS was working on developing and implementing 
initiatives to address inappropriate facility-initiated discharges in nursing homes, 
including: developing guidance for States to respond to complaints, training State 
surveyors on discharge requirements and CMSs survey guidance, implementing a 
Federal workgroup to discuss concerns related to facility-initiated discharges, and 
identifying root causes of inappropriate facility-initiated discharges.  CMS postponed 
these actions due to the COVID-19 pandemic.  Once appropriate, CMS should 
implement these actions to help reduce inappropriate facility-initiated discharges. 
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Conclusion and Recommendations | 20  We recommend that ACL: 
Assist State Ombudsman programs in establishing a data-
collection system for facility-initiated discharge notices  
Many State Ombudsman programs could not provide data from the facility-initiated 
discharge notices they receive from nursing homes.  Having information on the extent 
and nature of facility-initiated discharges would help Ombudsmen learn of nursing 
home practices, establish best practices for triaging notices, and develop a targeted 
response to address inappropriate discharges  all of which would enhance 
Ombudsmens advocacy of residents experiencing inappropriate discharges and 
better protect residents from harm.  We recognize that ACL and State Ombudsman 
programs have limited resources to establish a data collection system.  However, 
taking steps to collect data from facility-initiated discharge notices is a critical first 
step.  
To start, ACL should provide State Ombudsman programs with technical assistance to 
establish a system to count and extract information from facility-initiated discharge 
notices.  Each State Ombudsman program should aim to determine the number of 
notices received, the reasons nursing homes provide for discharge, and the discharge 
locations.  ACL could establish best practices from State Ombudsman programs that 
have already developed effective systems and share those practices.   
ACL could consider other avenues for collecting these data.  For example, it could 
work with State Ombudsman programs to develop a template for notices in each 
State to make it easier for Ombudsmen to abstract information from noticesthis 
could also help nursing homes comply with notice requirements.   
Establish guidance for analysis and reporting of data collected 
by State Ombudsman programs from facility-initiated discharge 
notices  
Having data on facility-initiated discharge notices creates opportunities for deeper 
understanding through analysis and for enhanced advocacy to protect residents from 
harm.  Establishing expectations for analysis ensures progress toward that 
understanding and enhanced advocacy.  At a minimum, each State Ombudsman 
program should be able to determine the number of facility-initiated discharge 
notices received from each nursing home in their State within a given time period.  
ACL could instruct State Ombudsman programs to analyze the reasons for discharge 
and discharge locations on the notices on a regular basis through written guidance.  
Identifying patterns in the number, reasons, and locations of these discharges would 
help Ombudsmen target advocacy efforts to residents of nursing homes whose 
discharge practices raise concerns (e.g., nursing homes initiating a large number of 
discharges or discharging residents to inappropriate locations).  In addition, ACL 
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Conclusion and Recommendations | 21  could require State Ombudsmen to report this information to ACL on an annual basis, 
as it does with complaint data.  This would allow ACL to aggregate data from facility-
initiated discharge notices at the national level. 
We recommend that ACL and CMS:  
Coordinate to strengthen safeguards to protect nursing home 
residents from inappropriate facility-initiated discharges 
ACL and CMS should work together to improve safeguards to protect residents from 
inappropriate facility-initiated discharges.  Specifically, ACL and CMS should 
collaborate on collecting data from facility-initiated discharge notices, such as 
through an electronic portal, to allow for easier data abstraction.  In addition, ACL and 
CMS could determine whether State agencies could benefit from receiving facility-
initiated discharge notices in addition to the State Ombudsman program, which is the 
only entity that currently receives them.  State agencies could use the notices to 
identify nursing homes that discharge residents to inappropriate locations and 
educate those nursing homes about appropriate discharge practices.  CMS and ACL 
could coordinate to determine if the information from discharge notices would help 
improve State agencies oversight of inappropriate discharges.   
Ensure that all State Ombudsmen, State agencies, and CMS ROs 
have an ongoing venue to share information about facility-
initiated discharges and potentially other systemic problems in 
nursing homes 
 
Both State Ombudsmen and State agencies share the goal of protecting residents 
from inappropriate discharges and often work together to do so.  Developing a 
common understanding of regulations for facility-initiated discharges would 
strengthen this collaboration and help reduce inappropriate facility-initiated 
discharges.   
ACL and CMS could establish ongoing regional venues to ensure that all State 
Ombudsmen, State agencies, and CMS ROs can communicate and share information 
with one another about facility-initiated discharges.  This venue could take different 
forms, such as an annual meeting within each CMS Region dedicated to discussing 
problems with facility-initiated discharges and/or a website where State Ombudsmen 
can ask their CMS RO questions about facility-initiated discharges and share concerns.  
In addition, this venue could provide State Ombudsmen the opportunity to share data 
extracted from facility-initiated discharge notices with their State agencies and CMS 
ROs.  Finally, CMS ROs could use this venue to share information about oversight and 
enforcement practices, including the assessment of their December 2017 memo.  
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Conclusion and Recommendations | 22   
A  GENCY COMMENTS AND OIG RESPONSE 
 
 
 
In its comments, CMS concurred with our first three recommendations and stated that 
it will make training available on Federal requirements related to facility-initiated 
discharge notices to all Long-Term Care stakeholders.  CMS also stated that it will 
assess the effectiveness of its enforcement actions imposed in noncompliant facility-
initiated discharge cases but noted that such an evaluation would take time and will 
also depend on the public health emergency and resources.  Lastly, CMS stated that, 
as soon as possible, it will implement a variety of initiatives to address inappropriate 
facility-initiated discharges that were paused during the COVID-19 pandemic.  We 
look forward to details on CMSs plan to implement these recommendations in its 
Final Management decision.   
In its comments, ACL concurred with our fourth recommendation and stated that it 
will continue to provide State Ombudsmen programs with technical assistance to help 
them establish systems to count and extract information from facility-initiated 
discharge notices.  We ask that ACL, in its Final Management Decision, provide details 
on the additional steps it will take to assist State Ombudsmen programs in 
establishing a system to specifically collect information from facility-initiated 
discharge notices.  
ACL also concurred with our fifth recommendation and stated that it will continue to 
work with State Ombudsmen and the National Ombudsman Resource Center to 
provide guidance, training, and technical assistance in assessing and tracking 
information on facility-initiated discharge notices for analysis.  ACL also noted the 
benefits of the National Ombudsman Reporting System (NORS) that tracks 
complaints and provided examples on how complaint data improves advocacy to 
address facility-initiated discharges.  We acknowledge ACLs efforts in collecting 
complaint data and appreciate the examples of how these data improve advocacy.  
However, NORS does not collect data on all facility-initiated notices.  We continue to 
recommend that ACL assist State Ombudsmen to collect and analyze data on facility-
initiated discharge notices, beyond complaint data, as the information can create a 
deeper understanding of the effects of facility-initiated discharges on residents and 
enhance advocacy.  We look forward to ACLs sharing, in its Final Management 
Decision, its plan to assist State Ombudsmen programs in establishing a system to 
specifically analyze facility-initiated discharge notices. 
ACL and CMS did not explicitly state whether they concurred with our joint 
recommendation to improve coordination between the two agencies; however, they 
expressed commitment to working closely together and with other stakeholders to 
strengthen safeguards that protect nursing home residents from inappropriate 
facility-initiated discharges.  We appreciate this commitment and ask that their 
collaboration include collection of data from facility-initiated discharge notices and 
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Agency Comments and OIG Response | 23  consider providing discharge notices to State agencies in addition to State 
Ombudsmen.  In its comments, ACL noted that the State Ombudsmen are primarily 
focused on addressing facility-initiated discharges that the resident objects to, 
regardless of whether the discharge complied with CMS requirements.  However, 
improved coordination between ACL and CMS can help State Agencies identify 
inappropriate facility-initiated discharges that a resident may not have objected to yet 
warrants enforcement actions.  We ask that ACL and CMS provide details in their Final 
Management Decision on how they plan to implement this recommendation.  
ACL and CMS concurred with OIGs joint recommendation that all State Ombudsmen, 
State agencies, and CMS ROs have an ongoing venue to share information about 
facility-initiated discharges.  However, ACL and CMS did not provide details on how 
they plan to implement the recommendation.  We recognize that some regions have 
a venue for CMS, State Ombudsmen, and State agencies to discuss facility-initiated 
discharges, and we emphasize the importance for CMS officials, State Ombudsmen, 
and State agencies in all regions to have such an opportunity to share information.  
We ask that ACL and CMS provide additional details on their plans to implement the 
recommendation in their Final Management Decision. 
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Agency Comments and OIG Response | 24  DETAILED METHODOLOGY 
Data Sources 
This study used the following data sources: (1) an electronic survey administered to 
State Ombudsmen, (2) deficiency and enforcement data from CMSs Certification and 
Survey Provider Enhanced Reporting (CASPER) and Automated Survey Process 
Environment (ASPEN) systems, (3) interviews with a purposive sample of five State 
Ombudsmen, (4) interviews with the 10 CMS ROs, (5) interviews with CMS 
headquarters staff, and (6) interviews with ACL headquarters staff. 
Data Analysis 
State Ombudsman Survey 
We sent an electronic survey to State Ombudsmen in all 50 States and the District of 
Columbia.  State Ombudsmen could respond to the survey from June 3, 2019, 
through September 5, 2019.  We received responses from 47 State Ombudsmen, for a 
response rate of 92 percent.  State Ombudsmen in Arizona, District of Columbia, Iowa, 
and Tennessee did not respond to the survey.  The survey included questions related 
to Ombudsmens experiences and challenges with receiving facility-initiated discharge 
notices, and with investigating and resolving these discharges.  The survey also 
included questions about Ombudsmens collaboration with State agencies and CMS 
ROs to address facility-initiated discharges and data on the number of facility-
initiated discharge notices that Ombudsmen received.  All survey questions refer to 
calendar years 2017 and/or 2018.  
Some questions in our survey offered response options on a 3- or 4-point ranked 
scale.  For some questions, respondents could choose major challenge, minor 
challenge, or not a challenge.  For another question, respondents could choose 
strongly agree, somewhat agree, somewhat disagree, or strongly disagree.  We 
report our findings by aggregating all categories that positively identify something as 
challenging or that identify the respondent as being in agreement.  Other questions in 
the survey offered open-ended responses.  We categorized responses to open-ended 
questions by theme.   
We analyzed data from our survey to describe Ombudsmens experiences and 
challenges with receiving, investigating, and resolving facility-initiated discharge 
notices.  We also analyzed data on Ombudsmens experiences working with State 
agencies and CMS ROs on facility-initiated discharges.   
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Detailed Methodology | 25  CMS Deficiency and Enforcement Data 
CMS provided us data on all standard and complaint surveys, deficiencies, and 
enforcement actions of Medicare/Medicaid-certified nursing homes from CMSs 
CASPER/ASPEN system for years 2014 through 2018.  Our final data set includes 
standard and complaint surveys, associated deficiencies, and associated enforcement 
actions for all 50 States and the District of Columbia.   
We analyzed trends in deficiencies associated with facility-initiated discharges from 
2014 through 2018.  We analyzed these data to determine the number and 
percentage of deficiencies that were related to facility-initiated discharge over time 
and across States.  We determined the number of deficiencies associated with a 
facility-initiated discharge by calculating the total number of each deficiency type 
listed in CMSs December 2017 memo.  To determine the percentage of nursing 
homes cited for a deficiency associated with a facility-initiated discharge, we used the 
number of nursing homes surveyed for each year.  We also examined trends in each 
type of deficiency over time.  
Interviews With State Ombudsmen 
We conducted structured interviews with a purposive sample of five State 
Ombudsmen in October and November 2020.  We selected the sample of State 
Ombudsmen to provide variation in geography and in State size.  We also selected 
our sample based on information received from our 2019 survey to State 
Ombudsmen.  During the interviews, we asked the State Ombudsmen about facility-
initiated discharges during the COVID-19 pandemic.  Specifically, we asked about the 
effect of COVID-19 on facility-initiated discharges; how Ombudsmen addressed 
inappropriate facility-initiated discharges during the COVID-19 pandemic; and 
challenges that Ombudsmen faced with addressing these discharges during the 
COVID-19 pandemic.  We analyzed these interviews to identify themes.   
Interviews With CMS ROs 
We conducted structured interviews with all 10 CMS ROs in July 2019.  We asked CMS 
ROs about their implementation of CMSs December 2017 memo.  Specifically, we 
asked CMS ROs about the number of cases that State agencies transferred as a result 
of the memo and the CMS ROs review process for these cases.  We also asked CMS 
ROs about their communication with State agencies and Ombudsmen in their regions.  
Finally, we asked CMS ROs about their experiences and challenges with addressing 
inappropriate facility-initiated discharges.  We categorized the interview data to 
identify themes across ROs. 
Interviews With CMS Headquarters and ACL 
We also conducted interviews with CMS Headquarters staff and ACL staff.  We 
conducted multiple interviews with CMS and ACL separately from 2018 through 2020.  
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Detailed Methodology | 26  We asked about each agencys efforts to address inappropriate facility-initiated 
discharges and about challenges they face in doing so, among other questions.  We 
used these interviews to report on CMSs and ACLs efforts and to provide clarification 
and context. 
In addition, we interviewed CMS and ACL staff about the impact of the COVID-19 
pandemic on facility-initiated discharges.  We conducted these interviews in October 
and November 2020.  We asked CMS and ACL about how they addressed 
inappropriate facility-initiated discharges and about challenges in addressing these 
discharges during the COVID-19 pandemic, among other questions. 
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Detailed Methodology | 27  APPENDIX A:  AGENCY COMMENTS
DATE:  October 5, 2021 
TO:  Christi A. Grimm 
Principal Deputy Inspector General 
Office of Inspector General 
FROM:  Chiquita Brooks-LaSure 
Administrator 
Centers for Medicare & Medicaid Services 
SUBJECT:  Office of Inspector General (OIG) Draft Report: Facility-Initiated Discharges in 
Nursing Homes Require Further Attention (OEI-01-18-00250) 
The Centers for Medicare & Medicaid (CMS) appreciates the opportunity to review and 
comment on the Office of Inspector Generals (OIG) draft report.  
CMS is committed to enforcing long-term care (LTC) requirements, including those to prevent 
inappropriate discharges, and has worked to ensure health care facilities have the tools and 
flexibilities they need to respond to COVID-19, while maintaining patient and resident safety. 
Federal regulations governing LTC facilities provide many protections for all nursing home 
residents, including the right to remain in the facility, and not be transferred or discharged, 
except in a limited set of circumstances, including when the transfer or discharge is necessary for 
the residents welfare and the residents needs cannot be met in the facility (42 C.F.R.  
483.15(c)(1)). Nursing homes must document all facility-initiated discharges in the residents 
medical record and provide adequate notice to the resident. Documentation in the residents 
medical record should include a discharge care plan and documented discussions with the 
resident or residents representative regarding discharge planning and post-discharge care. 
Nursing homes routinely discharge residents safely and appropriately, however, to ensure 
nursing homes are in compliance with federal requirements, CMS provides ongoing oversight of 
nursing homes through certification and complaint surveys conducted by State Survey Agencies 
(SSAs). To assist SSAs in the survey process, in November 2017, CMS revised interpretive 
guidance to address discharges that would violate federal requirements, and directed surveyors to 
investigate fully to determine whether a discharge is in accordance with the residents and/or 
resident representatives wishes and complies with federal requirements.1 Subsequently, CMS 
released a survey and certification memorandum, S&C-18-08-NH, in December 2017, 
announcing an initiative to address inappropriate discharges through a number of new actions.2 
The initiative directed SSAs to transfer to CMS any case involving facility-initiated discharge 
1 Transmittal 173, CMS Manual System, Pub. 100-07 State Operations, Appendix PP - Guidance to Surveyors for 
Long Term Care Facilities, see guidance for F Tags F622, F623, https://www.cms.gov/Regulations-and-
Guidance/Guidance/Transmittals/2017Downloads/R173SOMA.pdf. 
2 An Initiative to Address Facility Initiated Discharges that Violate Federal Regulations, Ref: S&C 18-08-NH (Dec. 
22, 2017), https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-18-08.pdf. 
Facility-Initiated Discharges in Nursing Homes Require Further Attention
OEI-01-18-00250    Appendix A | 28 APPENDIX A:  AGENCY COMMENTS
violations where there is a discharge to a questionable or unsafe setting, where residents remain 
hospitalized (because the nursing home will not permit the resident to return), where there is a 
facility pattern of inappropriate discharges, or other circumstances that CMS may identify. 
Following the review of such cases, CMS may take enforcement action for identified 
noncompliance, including imposing civil monetary penalties (CMP), when appropriate. In 
addition, CMS encouraged states to use the CMP Reinvestment Program to pursue CMP-funded 
projects to help prevent improper facility-initiated discharges. Such projects reinvest funds 
collected from CMPs into initiatives that benefit nursing home residents, which may include 
those to prevent improper discharges, including for example, projects designed to educate 
residents and their families on their rights in relation to facility-initiated discharge. CMS is also 
examining SSAs intake and triage practices for discharge complaints to ensure they are 
investigated timely, developing examples of inappropriate and appropriate discharges for 
surveyors, identifying best practices for nursing homes, considering additional training for SSAs, 
and evaluating enforcement options for these types of violations.  
The Office of the State LTC Ombudsman also plays an important role in addressing concerns 
with inappropriate discharges. CMS regulations require facilities to provide immediate access to 
any resident by any representative of an Office of the State LTC Ombudsman (42 C.F.R.  
483.10(f)(4)(i)). CMS also requires that facilities send a copy of each transfer or discharge notice 
to the Office of the State LTC ombudsman (42 C.F.R  483.15(c)(3)). Such notice explains the 
transfer or discharge and the reason for the move in writing, and must be supplied to the resident 
and the residents representative(s) before a facility transfers or discharges a resident, and in a 
language and manner they understand. Facilities that do not comply with these and all other 
requirements are subject to deficiency citation and enforcement action.  
CMS thanks the OIG for its efforts on this important issue and looks forward to working with the 
OIG on this and other issues in the future. The OIGs recommendations and CMSs responses 
are below. 
Recommendations to CMS: 
OIG Recommendation 
Provide training for nursing homes on federal requirements for facility-initiated discharge 
notices 
CMS Response  
CMS concurs with OIGs recommendation. CMS is committed to preventing inappropriate 
facility-initiated discharges in nursing homes, and will make training available on federal 
requirements related to facility-initiated discharge notices to all Long-Term Care stakeholders. 
OIG Recommendation 
Assess the effectiveness of its enforcement of inappropriate facility-initiated discharges 
CMS Response  
CMS concurs with OIGs recommendation. CMS is committed to enforcing our discharge 
requirements to prevent inappropriate discharges and will assess the effectiveness of our 
Facility-Initiated Discharges in Nursing Homes Require Further Attention
OEI-01-18-00250              Appendix A | 29 APPENDIX A:  AGENCY COMMENTS
enforcement actions imposed in noncompliant facility-initiated discharge cases within the 
broader context of our oversight priorities and resources. CMS notes, however, that 
implementation of this recommendation will depend on the public health emergency and limited 
resources. Additionally, as with any evaluation, it may take several subsequent survey cycles to 
accurately assess the effectiveness of our enforcement.  
OIG Recommendation 
Implement its deferred initiatives to address inappropriate facility-initiated discharges 
CMS Response  
CMS concurs with OIGs recommendation. CMSs long-term initiatives to address 
inappropriate facility-initiated discharges were paused during the COVID-19 pandemic to focus 
its resources on urgent patient and resident safety needs that arise during the public health 
emergency. CMS continues to evaluate facility-initiated discharge issues in nursing homes and 
plans to implement a variety of interventions, including those that were previously planned, as 
soon as is possible.  
Recommendations to CMS and ACL: 
OIG Recommendation  
Coordinate to strengthen safeguards to protect nursing home residents from inappropriate 
facility-initiated discharges  
CMS Response 
CMS and ACL are committed to coordinating to strengthen safeguards to protect nursing home 
residents from inappropriate facility-initiated discharges. CMS and ACL will continue to work 
closely with our colleagues and other nursing home advocates regularly to address concerns 
regarding inappropriate discharges. 
OIG Recommendation 
Ensure that all State Ombudsmen, State agencies, and CMS ROs have an ongoing venue to 
share information about facility-initiated discharges and potentially other systemic problems in 
nursing homes  
CMS Response  
CMS and ACL concur with OIGs recommendation. CMS and ACL will continue to work 
closely with our partners to ensure there is an ongoing venue to share information about facility-
initiated discharges and potentially other systemic problems in nursing homes. 
Facility-Initiated Discharges in Nursing Homes Require Further Attention
OEI-01-18-00250    Appendix A | 30 APPENDIX A:  AGENCY COMMENTS
DATE:  October 8, 2021 
TO:  Christi A. Grimm 
Principal Deputy Inspector General 
Office of Inspector General 
FROM:  Alison Barkoff   
Acting Administrator & Assistant Secretary for Aging 
Administration for Community Living 
SUBJECT:  Office of Inspector General (OIG) Draft Report: Facility-Initiated Discharges in 
Nursing Homes Require Further Attention OEI-01-18-00250 
The Administration for Community Living (ACL) appreciates the opportunity to respond to the 
Office of the Inspector Generals (OIG) report on facility-initiated discharges in nursing homes. 
ACL shares the OIGs concerns about the harms that can be caused by inappropriate discharges, 
and addressing them are a significant focus for the Long-Term Care Ombudsman (LTCO) 
program.  As the OIGs report notes, facility-initiated discharges are the most common 
complaints addressed by LTCO programs.  
Facility-initiated discharges in nursing homes also are a significant focus of the National 
Ombudsman Resource Center (NORC), which is funded by ACL through a cooperative 
agreement to provide technical assistance to state LTCO programs.  Through the NORC, LTCOs 
and their representatives have access to a number of tools and resources, as well as training, to 
help them address inappropriate discharges  both for individual residents and at the facility and 
system levels.  
For example, in January 2021, the NORC published a primer on the issue, Enhancing Your 
Advocacy Toolbox: Protecting Residents from Nursing Facility-Initiated Discharges. This 
resource covers federal requirements and guidance for state survey agencies, as well as action 
steps to help LTCO programs address common issues related to facility-initiated discharges. The 
NORC also has presented several training courses, which also can be downloaded for LTCO 
programs to use with their staff; shared information about promising practices and presentations 
that are available for download; created materials to help educate residents; and more. 
The NORC has aggregated these resources in a dedicated section of its website. Also included 
are resources provided by CMS, such as this memo from CMS to state survey agency directors, 
which describes CMSs initiative to examine and mitigate facility-initiated discharges that 
violate federal regulations, and this Survey and Certification memo from 2017, that clarifies 
requirements for sharing discharge notices with the state LTCO.  
Facility-Initiated Discharges in Nursing Homes Require Further Attention
Appendix A | 31
OEI-01-18-00250    APPENDIX A:  AGENCY COMMENTS
ACL also supports CMS in developing guidance for state survey agencies about issues 
encountered by LTCO programs and the nursing home residents they support.  
ACL appreciates the attention that the OIG has given to this important issue and looks forward to 
working with OIG on this and other matters in the future. OIGs recommendations and ACLs 
response are below.  
Recommendations for ACL: 
OIG Recommendation 1  
Assist State Ombudsman programs in establishing a data collection system for facility-initiated 
discharge notices.  
ACL Response:   
ACL concurs with this recommendation. ACL supports data collection to assist the LTCO 
program in each state in upholding the rights of nursing facility residents. Through the National 
Ombudsman Resource Center, ACL will continue to provide state LTCO programs with 
technical assistance to help them establish systems to count and extract information from 
facility-initiated discharge notices.  Because each state has different needs, staffing capacity, and 
software to capture data, the approach for capturing data will vary between states.  
OIG Recommendation 2  
Establish guidance for analysis and reporting of data collected by State Ombudsman programs 
from facility-initiated discharge notices. 
ACL Response:   
ACL concurs with this recommendation. ACL agrees that analysis of data can reveal patterns of 
inappropriate discharges that can inform the programs advocacy work; in fact, it often does.  
State ombudsman programs currently record and report information about the complaints they 
receive from residents, including complaints about facility-initiated discharges, through ACLs 
National Ombudsman Reporting System (NORS). With that information, they regularly identify 
systemic issues they can address. 
For example, noting large numbers of resident complaints about discharge notices based on non-
payment, the LTCO in Alabama discovered that resident and family misunderstanding of 
Medicaid requirements were causing delayed approval and payments to nursing homes, putting 
residents at risk of involuntary discharge. The Ombudsman was then able to resolve the issue by 
working with the state Medicaid agency, facility associations and individual facilities. 
Information on that issue was reported through NORS, enabling the NORC to share the lessons 
learned with LTCO programs across the country.  
Similarly, it was analysis of complaint data that led LTCO programs to identify facility-initiated 
discharges as a systemic problem and to raise concerns with ACL and CMS. Those concerns 
ultimately led to the requirement for nursing facilities to send discharge notices to the LTCO to 
create an opportunity for timely intervention when residents object to the discharge or have 
Facility-Initiated Discharges in Nursing Homes Require Further Attention
Appendix A | 32
OEI-01-18-00250    APPENDIX A:  AGENCY COMMENTS
questions about their options. This has proven successful; in 2020, Ombudsman programs were 
able to fully or partially resolve 73 percent of complaints about facility-initiated discharges and 
17 percent of complaints were withdrawn. Only 10 percent were not resolved to the full or partial 
satisfaction of the discharged resident.    
In recent years, the NORC has provided a number of training and resources to support LTCO 
programs in addressing involuntary discharges, and the importance of discharge notices is 
included. For example, the primer described above includes a checklist for investigating 
complaints that highlights the discharge notice as a key source of information. ACL will 
continue to work with states and the NORC to provide guidance, training, and technical 
assistance to support LTCO programs in assessing and tracking information included in 
discharge notices to enable that crucial analysis.  
ACL also will engage with state LTCO programs to determine whether there is additional 
information that could be gleaned from facility discharge notices that would assist them in 
responding to complaints and/or advocating at the system level. If so, ACL will explore options 
for modifying the NORS system to collect such data when resources become available. In 
addition, ACL will explore possibilities for incorporating additional information about discharge 
notices into existing data collection systems.  
In addition, ACL will engage with state LTCO programs to identify barriers to data collection 
and analysis and possible options for overcoming them. For example, some nursing homes 
routinely send all discharge notices to the state LTCO, not only the notices that are required by 
CMS regulations. The office of the Pennsylvania LTCO reported that in one month, it received 
more than 5,000 discharge notices, only 26 of which were involuntary discharges. Reviewing 
each of those notices to find the few that may require the assistance of the LTCO program 
consumes significant staff time; recording and reporting on all of them would be an 
administrative burden that would significantly degrade the Ombudsmans ability to meet its 
statutory responsibilities. 
Similarly, the LTCOs role in facility-initiated discharges is primarily focused on discharges to 
which the resident objects  whether or not the discharge notification complied with 
requirements or the discharge itself is appropriate.  A resident may request assistance with a 
facility-initiated discharge, even if the discharge fully complied with requirements. On the other 
hand, if a resident does not object to a facility-initiated discharge, the LTCO may not be involved 
even if the discharge notification was not handled properly. Recording, reporting, and analyzing 
data from facility notices that do not require assistance from the Ombudsman also will require 
diversion of staff time from direct support to residents and advocacy activities.  
Finally, ACL will provide to CMS all data on involuntary discharges reported annually through 
NORS to inform CMSs development of training and guidance for state survey agencies about 
issues encountered by LTCO programs and the nursing home residents they support.  
Recommendations for ACL and CMS: 
Facility-Initiated Discharges in Nursing Homes Require Further Attention
Appendix A | 33
OEI-01-18-00250    APPENDIX A:  AGENCY COMMENTS
OIG Recommendation 1  
Coordinate to strengthen safeguards to protect nursing home residents from inappropriate 
facility-initiated discharges. 
ACL Response  
ACL will continue to work with CMS, state long-term care LTCO programs, state protection and 
advocacy agencies, older adults and people with disabilities, and other stakeholders to address 
concerns and explore strategies regarding inappropriate discharges.  
OIG Recommendation 2 
Ensure that all State Ombudsmen, State agencies, and CMS ROs have an ongoing venue to share 
information about facility-initiated discharges and potentially other systemic problems in nursing 
homes. 
ACL Response 
ACL concurs with this recommendation. ACL will continue to work with CMS to ensure regular 
dialogue between CMS regional offices, long-term care Ombudsmen, state survey agencies and 
other partners.   
Facility-Initiated Discharges in Nursing Homes Require Further Attention Appendix A | 34
OEI-01-18-00250    ACKNOWLEDGMENTS AND CONTACT 
 
Acknowledgments 
Kimberly Ruppert served as the team leader for this study, and Shanna Weitz served 
as the lead analyst.  Others in the Office of Evaluation and Inspections who conducted 
the study include Shweta Palakkode and Malaena Taylor.  Office of Evaluation and 
Inspections staff who provided support include Joe Chiarenzelli, Kevin Farber, and 
Christine Moritz.  
This report was prepared under the direction of Joyce Greenleaf, Regional Inspector 
General for Evaluation and Inspections in the Boston regional office, and Danielle 
Fletcher and Ken Price, Deputy Regional Inspectors General. 
Contact 
To obtain additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found 
on the OIG website at oig.hhs.gov. 
Office of Inspector General 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC 20201 
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  Acknowledgments and Contact | 35   
ABOUT THE OFFICE OF INSPECTOR GENERAL 
 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-
452, as amended, is to protect the integrity of the Department of Health and Human 
Services (HHS) programs, as well as the health and welfare of beneficiaries served by 
those programs.  This statutory mission is carried out through a nationwide network 
of audits, investigations, and inspections conducted by the following operating 
components: 
The Office of Audit Services (OAS) provides auditing services for HHS, 
either by conducting audits with its own audit resources or by overseeing audit work 
done by others.  Audits examine the performance of HHS programs and/or its 
grantees and contractors in carrying out their respective responsibilities and are 
intended to provide independent assessments of HHS programs and operations.  
These audits help reduce waste, abuse, and mismanagement and promote economy 
and efficiency throughout HHS. 
The Office of Evaluation and Inspections (OEI) conducts national 
evaluations to provide HHS, Congress, and the public with timely, useful, and reliable 
information on significant issues.  These evaluations focus on preventing fraud, waste, 
or abuse and promoting economy, efficiency, and effectiveness of departmental 
programs.  To promote impact, OEI reports also present practical recommendations 
for improving program operations. 
The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, operations, and 
beneficiaries.  With investigators working in all 50 States and the District of Columbia, 
OI utilizes its resources by actively coordinating with the Department of Justice and 
other Federal, State, and local law enforcement authorities.  The investigative efforts 
of OI often lead to criminal convictions, administrative sanctions, and/or civil 
monetary penalties. 
The Office of Counsel to the Inspector General (OCIG) provides 
general legal services to OIG, rendering advice and opinions on HHS programs and 
operations and providing all legal support for OIGs internal operations.  OCIG 
represents OIG in all civil and administrative fraud and abuse cases involving HHS 
programs, including False Claims Act, program exclusion, and civil monetary penalty 
cases.  In connection with these cases, OCIG also negotiates and monitors corporate 
integrity agreements.  OCIG renders advisory opinions, issues compliance program 
guidance, publishes fraud alerts, and provides other guidance to the health care 
industry concerning the anti-kickback statute and other OIG enforcement authorities.
Facility-Initiated Discharges in Nursing Homes Require Further Attention 
OEI-01-18-00250  About OIG | 36   
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1 CMS regulations refer to both facility-initiated discharges and transfers from nursing homes.  Transfer specifically refers to the 
movement of a resident from one certified facility to another when the resident expects to return to the original facility.  In 
contrast, discharge specifically refers to the movement of a resident from a certified facility to another certified facility or other 
location in the community when there is no expectation of return to the original facility (42 CFR 483.15; CMS, SOM, Appendix 
PP Tag 622).  This report will examine only facility-initiated discharges.  
2 Congress.gov, H.R. 3545Omnibus Budget Reconciliation Act of 1987.  Accessed at https://www.congress.gov/bill/100th-
congress/house-bill/3545 on September 25, 2020.   
3 National Ombudsman Reporting System, Appendix B.  Accessed at https://www.acl.gov/programs/long-term-care-
Ombudsman/ltc-Ombudsman-national-and-state-data on October 20, 2020. 
4 National Ombudsman Reporting System 2016 Multi-Year Complaint Trends Report.  Accessed at 
http://ltcOmbudsman.org/omb_support/nors/nors-data on May 8, 2018. 
5 CMS, An Initiative to Address Facility Initiated Discharges That Violate Federal Regulations. S&C 18-08-NH, December 22, 
2017. 
 
6 Sedensky, Matt. Nursing Homes Turn to Eviction To Drop Difficult Patients, Associated Press.  Accessed at 
https://apnews.com/95c33403b5024b4380836d3ed3dfecb0/nursing-homes-turn-eviction-drop-difficult-patients May 8, 2016. 
7 The New York Times, They Just Dumped Him Like Trash: Nursing Homes Evict Vulnerable Residents, June 21, 2020.  Accessed 
at https://www.nytimes.com/2020/06/21/business/nursing-homes-evictions-discharges-coronavirus.html on November 5, 
2020. 
8 CMS, State Operations Manual (SOM), Appendix PP (Rev. 11-22-17), Tag 622. 
9 CMS, SOM, Appendix PP, Tag 622. 
10 42 CFR  483.15(c)(2)(i)-(ii). 
11 42 CFR  483.15(c)(2)(i)(B). 
12 Nursing homes must send the discharge notice as soon as practicable before transfer or discharge in certain circumstances, 
which are: the endangerment of the health or safety of individuals in the facility, a sufficient improvement in the residents 
health to allow for a more immediate transfer or discharge, an immediate transfer or discharge is required by the residents 
urgent medical needs, or the resident has not resided in the facility for 30 days (see 42 CFR 483.15(c)(4)).   
13 42 CFR  431.220(a)(2). 
14 42 CFR  431.206(b)(3). 
15 42 CFR  431.206(b)(3). 
16 42 CFR  431.246. 
17 42 CFR  483.15(c)(5)(iv). 
 
 
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OEI-01-18-00250  Endnotes | 37 
   
 
18 42 CFR  483.15(c)(5)(iv). 
19 42 CFR  483.15(c)(1)(ii). 
20 Sections 1819 and 1919 of the Social Security Act. 
21 42 CFR 488.308 
22 Sections 1819(g)(4)(A) and 1919(g)(4)(A) of the Social Security Act. 
23 CMS, SOM Chapter 5Complaint Procedures (Rev. 191, 07-19-19), 5300.1.  
24 CMS, SOM Appendix PPGuidance to Surveyors for Long-Term Care Facilities (Rev. 11-22-17).   
25 In 2017, CMS revised its list of deficiencies for nursing homes and combined the deficiency for transfer and discharge 
requirements under one deficiency.  Previously, two deficiencies related to transfer and discharge requirements: basis for 
transfer or discharge of residents and documentation for transfer or discharge of residents.  
26 42 CFR 488.402(d)(1) 
27 CMS, SOM, Chapter 7 7304.4; this section was updated and moved to section 7317, effective Nov. 16, 2018 (Rev. 185).  
28 CMS, SOM, Chapter 7. 
29 CMS, SOM, Chapter 7Enforcement Action when Immediate Jeopardy Exists (Rev. 185, 11-16-18), 7308. 
30 CMS, SOM, Chapter 7 7400.4 (Rev. 185, 11-16-19).   
31 In February 2020, CMS changed its internal structure to allow for better coordination between CMS ROs (now known as 
CMS-Locations) and the CMS Central Office (now known as the Quality, Safety, and Oversight Group).  According to CMS, this 
reorganization brings CMS staff who develop enforcement policies and staff who implement these policies under the same 
organizational leadership to help ensure consistency. 
32 CMS, An Initiative To Address Facility Initiated Discharges that Violate Federal Regulations. S&C 18-08-NH, December 22, 
2017. 
33 ACL, Program Areas: Protecting Rights and Preventing Abuse. Accessed at https://acl.gov/programs/protecting-rights-and-
preventing-abuse on May 10, 2021. 
34 ACL, Older Americans Act, Accessed at https://acl.gov/about-acl/authorizing-statutes/older-americans-act 
35 42 U.S. Code  3058gState Long-Term Care Ombudsman program. 
36 Ibid. 
37 45 CFR parts 1321 and 1324.  
38 The National Long-Term Care Ombudsman Resource Center, National Ombudsman Reporting System (NORS), Accessed at 
https://ltcOmbudsman.org/omb_support/nors on September 25, 2020.   
39 The National Long-Term Care Ombudsman Resource Center, Introduction to the Revised National Ombudsman Reporting 
System (NORS), Accessed at https://ltcOmbudsman.org/uploads/files/support/NORS_February_5_2019_webinar_-
_FINAL_w_notes.pdf on September 25, 2020.   
 
 
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OEI-01-18-00250  Endnotes | 38 
   
 
40 ACL revised the NORS data collection strategy on October 1, 2019 (see endnote 20).  The revised guidance requires 
Ombudsmen to provide specific data for cases and complaints rather than aggregate data reporting as in the past.  (See ACL, 
Introduction: Moving From Aggregated to Case Record Data; accessed at https://acl.gov/sites/default/files/about-acl/2018-
02/Introduction%20to%20Revised%20NORS%20.pdf on September 25, 2020.) 
41 42 CFR  483.15(c)(3)(i). 
42 81 Federal Register 68688, 68734 (Oct. 4, 2016). 
43 CDC, Coronavirus Disease 2019 (COVID-19) Symptoms of Coronavirus.  Accessed at https://www.cdc.gov/coronavirus/2019-
ncov/symptoms-testing/symptoms.html on October 7, 2020. 
44 National Public Radio, How COVID-19 Kills: The New Coronavirus Disease Can Take a Deadly Turn.  Accessed at 
https://www.npr.org/sections/goatsandsoda/2020/02/14/805289669/how-covid-19-kills-the-new-coronavirus-disease-can-
take-a-deadly-turn, on October 7, 2020. 
45 CMS, COVID-19 Nursing Home Data, submitted data as of week ending April 4, 2021.  Accessed at 
https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg/ on April 19, 2021. 
46 The White House, Proclamation on Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) 
Outbreak, March 13, 2020.  Accessed at Proclamation on Declaring a National Emergency Concerning the Novel Coronavirus 
Disease (COVID-19) OutbreakThe White House (archives.gov) on October 8, 2020.  
47 CMS, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers.  Accessed at COVID-19 Emergency 
Declaration Blanket Waivers for Health Care Providers (cms.gov) on May 10, 2021.  
48 Ibid.  This waiver has since been terminated, effective May 10, 2021. 
49 CMS, Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (Revised), 
QSO-20-14-NH, March 13, 2020. 
50 CMS, Nursing Home Five-Star Quality Rating System updates, Nursing Home Staff Counts, Frequently Asked Questions, and 
Access to Ombudsmen (REVISED), QSO-20-28-NH, April 24, 2020 (revised July 9, 2020, and updated September 28, 2020, and 
March 10, 2021).  
51 CMS, Nursing Home VisitationCOVID-19, QSO-20-39-NH, September 17, 2020.   
52 CMS, Nursing Home VisitationCOVID-19 (REVISED), QSO-20-39-NIH, revised March 10, 2021 (subsequently revised April 27, 
2021). 
53 OIG, Nursing Home Oversight During the COVID-19 Pandemic.  Accessed at https://oig.hhs.gov/reports-and-
publications/workplan/summary/wp-summary-0000473.asp on November 5, 2020.   
54 OIG, Some Nursing Homes Reported Staffing Levels in 2018 Raise Concerns; Consumer Transparency Could Be Increased. 
Accessed at https://oig.hhs.gov/oei/reports/OEI-04-18-00450.pdf on September 25, 2020.   
55 OIG, States Continued to Fall Short in Meeting Required Timeframes for Investigating Nursing Home Complaints: 2016-2018, 
OEI-01-19-00421, September 2020.  Accessed at https://oig.hhs.gov/oei/reports/OEI-01-19-
00421.asp?utm_source=web&utm_medium=web&utm_campaign=nh-trends-OEI-01-19-00421 on January 11, 2021.  
56 OIG Work Plan, Nursing Homes: CMS Oversight of State Survey Agencies, OEI-06-19-00460. 
 
 
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57 In its October 2016 Final Rule, CMS stated that the requirement for nursing homes to send a copy of the facility-initiated 
discharge notice to the State Ombudsmen will provide added protection to the resident and assist the State Ombudsman to 
keep informed of facility activities (see 81 Federal Register 68688, 68734; October 4, 2016).  
58 NORS includes a complaint category for discharge or eviction but does not include a specific category for complaints 
directly related to facility-initiated discharges.  
59 42 CFR  431.246. 
60 The timeframe in which residents must file for an administrative hearing varies by State, but CMS requires that this not 
exceed 90 days (see 42 CFR  431.221(d)). 
61 Deficiencies with notice requirements before transfer or discharge includes both facility-initiated discharges and transfers. 
  
62 In February 2020, CMS restructured its Regional Offices (now CMS-Locations) to increase consistency in enforcement actions. 
63 OIG Work Plan, Nursing Homes Compliance With Facility-Initiated Discharge Requirements, OEI-01-19-00251.  Accessed at 
https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000541.asp.  
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