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New Jersey Long-Term Care Ombudsman

Untitled Document

LTCO Guidance on Emergency Transfer Notification Requirements

The LTCO has received numerous requests for clarification about what information facilities should send to LTCO when a resident is subject to a transfer to an acute care facility on an emergency basis. Below is an explanation of the background of this issue and direction on what information the LTCO will accept.

Background: On May, 12, 2017 CMS drafted a memorandum to State Survey Agency Directors. The CMS memorandum explained notification requirements for facilities when transferring residents to an acute care facility on an emergent basis. The memorandum directed facilities operating pursuant to CMS regulations to do the following:

  • When a resident is temporarily transferred to an acute care facility, CMS affirms that this temporary transfer is a facility-initiated transfer.
  • CMS requires that the NOTICE of the temporary transfer MUST be provided to the resident and the resident representative as soon as practicable.
  • CMS requires that copies of the NOTICE for temporary emergency transfer MUST also be sent to the Ombudsman.
  • CMS states that notification to the Ombudsman MUST be sent by the facility, but allows that this notification can be made “when practicable, such as a list of residents on a monthly basis.”

In the event of an emergency transfer to an acute care facility, the notice provided to the resident or their representative and copied to the LTCO MUST contain:

  1. The reason for transfer;
  2. The effective date;
  3. The location to which the resident is transferred:
  4. Contact information for the NJ LTCO and other entities referred to in the Content of Notice as stated in the CMS regulations.

As per the above CMS guidance, the LTCO will accept list of residents who are subject to a temporary emergency transfer on a monthly basis. However, the list must also include a copy of the notice that was given to the resident or their legal representative. Here is a template for a grid/list that facilities can use to provide LTCO with the monthly list.

In addition, the list of temporary emergency transfers should indicate the four elements listed above: reason for discharge; effective date; location to which resident is being transferred; and contact information for LTCO. Here is a template for letter that includes all of the above elements

The NOTICES to the Ombudsman may be sent via:

  • Fax -- 609-943-3479
  • Email
  • Regular mail

NJ Long-Term Care Ombudsman
PO Box 852
Trenton, NJ 08625-0852

IMPORTANT – Per CMS, in situations where the facility has decided to discharge the resident while the resident is still hospitalized, the facility must immediately send a SEPARATE standard discharge notice to the resident or the resident’s representative and must copy the Ombudsman simultaneously. Sending a monthly list of involuntary discharges does not meet the standard for Ombudsman notification in facility-initiated discharges under 42 CFR 483.15 (c) (3)(i) and is UNACCEPTABLE.

Last Updated: Thursday, 12/05/19