Harmony Healthcare International (HHI) Blog

Leave of Absence



Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

Extended family at the christmas dinner table at home in the living roomThis is the time when friends and family are asking patients and residents to take a trip out of the facility to enjoy some holiday cheer. There are a few comments I must share with you around this scenario. 

  1. Practical Matter Criterion

    If the patient is on Medicare Part A, do not interpret the regulation so strictly that the patient is denied an outing or leave because you are worried about Medicare payment.  “As a practical matter, considering economy and efficiency the services can only be provided in a SNF.” Remember that if the patient leaves and returns within the 30-day window, access to Medicare benefits exists.  (30-day rule.)

“While most beneficiaries requiring an SNF level of care find that they are unable to leave the facility for even the briefest of time, the fact that a patient is granted an outside pass, or short leave of absence, for attending a special religious service, holiday meal or family occasion, for going on a ride or for a trial visit home, is not by itself evidence that the individual no longer needs to be in a SNF to receive required skilled care.  Very often special arrangements, not feasible on a daily basis, have had to be made to allow for absence from the facility.

Where frequent or prolonged periods away from the SNF become possible, however, then questions as to whether the patient’s care can, as a practical matter, only be furnished on an inpatient basis in an SNF may be raised.  Base decisions in these cases on information reflecting the care needed and received by the patient while in the SNF and on the arrangements needed for the provision, if any, of this care during any absences.  (See §242.3 for counting inpatient days during a leave of absence.}”

Source: This is from the Medicare SNF Manual (Pub 12}

A leave of absence day, also known as a “skip” day, occurs when a patient leaves the facility before midnight, returns within 24 hours, and is not admitted to the hospital as an inpatient.

In these situations, since the resident has not been discharged, it is not necessary to complete a discharge assessment or restart the PPS Schedule.  The day before the midnight out of the facility is not a Medicare covered day and the PPS Schedule should be adjusted to skip the non-covered day when determining when the next scheduled PPS assessment is due.  

  1. MD Order

    Most admissions have an order for LOA.  However, be careful because the standing LOA may not support skilled coverage. If a Medicare Part A patient is going to take a leave:
    • Obtain MD Order stating the “Therapeutic Leave.”
    • Therapy and Nursing notes should detail the skilled level and caregiver training that occurs before and after the therapeutic leave. 
  2. Midnight Rule / 24 Hour Rule

    Harmony Healthcare International (HHI) has received a massive amount of calls on the patients leaving the facility on a therapeutic pass the patient inadvertently stays out passed midnight. The discussion is tricky because one must define where the patient is at midnight and if they are gone greater than 24 hours.  To simplify:
    • If greater 24 hours to home
      • No discharge assessment
      • Still under the same plan of care and evaluate if need new evaluation
    • If greater 24 hours to hospital
      • Discharge Assessment
      • New Plan of Care
      • New therapy Evaluation
      • New PPS Schedule
      • If the patient is on leave of absence greater than 24 hours or is actually admitted to the hospital, the patient begins a New Cycle of PPS Assessments and the day of return is day 1. In this case, the skip day rule does not apply.
    • Less than 24 hours, regardless of destination, gone at midnight, a skip day. 
  3. MDS Assessments

    The most commonly asked MDS specific questions related to Therapeutic Pass, LOA and Midnight Rule relate to the Tracking Data and Assessment Reference Date (ARD). 
    • Date of Entry: Do not complete the face sheet following temporary discharges to hospitals or after therapeutic leaves/home If the face sheet was transmitted prior to the hospital stay, and none of the information has changed, a new face sheet is not required. If you identify changes to the face sheet data, you should update it and transmit the revised fact sheet with your next assessment.
    • Tracking Documents: Discharge and Re-Entry 
      In some situations, Discharge and Re-entry Tracking forms are not completed:
      • When the resident leaves the facility on a temporary visit home, or on another type of therapeutic or social
      • When residents are in a hospital outpatient department or an observational stay of less than 24 hours or if the resident is admitted for acute care, then a Discharge Tracking form must be completed within seven The discharge date entered at 24 would be the date that the resident left the facility, not the date he was admitted to the hospital. (Editor's note: Also see the discharge/re-entry flow chart on page 9-26)
    • Assessment Reference Date-Leave and return middle of an ARD period:
      • The ARD is not altered if the beneficiary is out of the facility for a temporary leave of absence during part of the observation In this case, the facility may include services furnished during the beneficiary's temporary absence (when permitted under MDS coding guidelines -see Chapter 3) but may not extend the observation period.
    • Assessment Reference Date
      • The observation period may not be extended simply because a resident was out of the facility during a portion of the observation period: g., a home visit or therapeutic leave.

        For example, the ARD is set at Day 14, and there is a 2-day temporary leave during the observation period, the two leave days are still considered part of the observation period.  When collecting assessment information, you may use data from the time of the LOA as long as the particular MDS item allows you.  For example, section P7, if the family takes the resident to the physician, the visit may be counted.
      • This procedure applies to all assessments, regardless of whether or not they are being completed for clinical or payment purposes.

        For Example:
        • A resident leaves a SNF at 6:00 p.m. on Wednesday, which is day 27 of the resident’s stay, and
        • Returns to the SNF on Thursday at 9:00 a.m. without a hospital admission.
        • Then, Wednesday becomes a non-billable leave of absence day and
        • Thursday becomes day 27 of the resident’s Medicare schedule.
    • Change of Therapy COT and End of Therapy EOT:

      Pursuant to the policy outlined in Chapter 2 of the MDS 3.0 RAI User’s Manual, the Medicare assessment schedule is adjusted to exclude the LOA when determining the appropriate ARD for a given assessment.  It is important to note that the schedule for the unscheduled assessments, such as the COT and EOT assessment is not affected by the LOA. 

Source: (MDS RAI Manual) 

Interested in learning more? Join us at harmony18, our 7th annual interdisciplinary LTPAC symposium.  This year’s symposium features former NFL and Super Bowl player, Joe Andruzzi; Inspirational Charity Founder, Ellie Anbinder; AHCA Sr. VP, Dr. David Gifford; an entire panel on PDPM; and more!  10 continuing education hours for all disciplines.  November 1-2, 2018 at Mohegan Sun Resort and Casino.

Click Here to Register. Room block expires early October. 

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have.  You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 

harmony20 October 29-30 2020 Encore Boston Harbor

Topics: Leave of Absence

Kris Mastrangelo, OTR/L, LNHA, MBA


Kris Mastrangelo, OTR/L, LNHA, MBA

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