If a patient plans on returning home prior to set last covered skilled day, is that considered an "unplanned discharge" or would I complete a COMNC and date it for that resident's planned discharge date? What if the resident only gives me a day's notice, do I still date the NOMNC the day he/she wants to discharge as it would not be a proper notice of 48 hours but it was the decision of the resident, not the facility.
If a resident states they are going home before the planned discharge then they are driving the discharge and it becomes an unplanned discharge.
If the attending M.D. does not issue a discharge order, then this also qualifies as an AMA discharge.
In this case, the facility is not denying the services. The NOMNC template says, “Your Medicare provider and/or health plan have determined that Medicare probably will not pay for ... services after the effective date.”
Facilities should never administer a document stating the facility has decided to deny Medicare services unless the interdisciplinary team decides the patient’s treatment regimen is essentially stabilized. Administering a NOMNC “just to be on the safe side,” is not safe at all. You’re saying you cut a person while they still had a skilled need.
Instead, hold a team conference and articulate that you believe the patient still requires skilled care. Spell out any complications or anticipated problems on the discharge documents. For example, “You want to discharge on Saturday, January 1, but the Home Health agency you selected cannot start services until Monday, January 4.”
Clearly state in the conference note that a NOMNC was not issued because the patient was driving their own discharge, and the facility believes they still have a skilled need for “x, y, and z.”
These are your big risks for rehospitalizations. Someone should call to check on these folks for the first few days and perhaps weekly until the 30-day window for readmit closes. It’s got to be handled in a way that clearly communicates that you want them to stay, but you also respect their right to make decisions. Stress to them that if they get home and it’s too much, they can return and resume their stay.
A NOMNC is not required when it is the resident’s decision to leave. You need clear documentation in the medical record that the facility planned to skill the patient longer and it is the resident’s decision to leave earlier.
The RAI Manual does not define an unplanned discharge but gives examples. HHI recommends making determinations on a case-by-case basis. When there is a set discharge date, but the date needs to change based on resident/family needs and there is time to prepare and re-plan the discharge, it might be a planned discharge.
Certainly, if the facility does not have adequate time to plan the services nor meet the needs and goals for a planned discharge, then it is considered an unplanned discharge.
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