In Part 1 of our recently-posted article concerning the new law, A.R.S. § 36-4204.04 that went into effect January 1, 2024, we addressed facility and EMT obligations upon sending a resident out for emergency care. The second half of that statue addresses hospital obligations upon discharge of that individual back to the care home or assisted living center. The public has generally been unaware of the challenges encountered by these facilities when hospitals call stating that the patient is ready for discharge and then they arrive back at the facility with no written scripts for changed prescriptions; no coordinated post-discharge care (i.e. PT, or home health for services beyond the scope of the assisted living facility), or sometimes the resident is discharged to a rehab center and then switched to a different facility altogether while their home is holding their bed waiting for their return. These challenges were particularly acute when the discharges occurred on a Friday evening or weekend and the hospital would not give out any further information or issue any orders or scripts following discharge.
Hospitals are now statutorily required to coordinate with the transferring or receiving health care institution and provide a written discharge plan for each inpatient. Key elements of the discharge plan include:
- Preparation by Appropriate Staff: The discharge plan should be prepared by qualified hospital staff. Case managers are integral to discharge planning, but any post-discharge orders must be signed-off by a qualified medical professional.
- Point-of-Contact Information: The plan must include contact details for the discharging hospital, and a designated point of contact should be available for 48 hours post-discharge to respond to inquiries from the assisted living facility. We haven’t heard any real-world feedback if this is occurring yet, but it will be interesting to learn if the Arizona Department of Health Services will be citing hospitals if they do not comply with these requirements.
- Patient Evaluation and Assessment: Documented information about the patient’s medical and health conditions, including pressure injuries, cognitive or physical impairments, weight-bearing status, dietary requirements, need for medical services or nursing, and any specialized equipment or home health services required. A number of our clients have complained that their residents have returned from a hospital admission only to have had a pressure sore documented upon arrival back to the facility, or erupt shortly after discharge. Skin care checks are highly recommended within the forty-eight (48) hour window when a hospital representative must be available if the discharge paperwork does not document a pressure sore that does exist upon discharge.
- Prescription and Medication Information: If applicable, include a copy of prescriptions sent to the patient’s pharmacy, medication summary, or instructions, including the patient’s name, administration instructions, and prescriber’s signature. This is extremely important where so many patients were previously discharged with a summary sheet of medication changes, but not the scripts that complied with A.A.C. R9-10-816(B)(3) allowing the assisted living facility to be in compliance with healthcare facility regulations and for the resident to obtain the new or changed medication order from the pharmacy after discharge.
- Notification of New Device Orders: Document any new device orders for the patient and inform the receiving facility. Durable medical equipment coordination is difficult, particularly with so many different Medicare plans and occasional delays obtaining the needed equipment. On occasion, it may be deemed an unsafe discharge if the facility is unable to have the equipment available upon the individual’s arrival back from the hospital (i.e. O2 concentrator). Facility managers now have a definitive statute to point to if they feel the discharge may be unsafe if the hospital does not do its part to ensure the needed equipment will be available outside of the hospital setting.
- Communication with Authorized Representative: Hospitals must inform the patient’s authorized representative about the discharge and provide details of the receiving facility. If the hospital intends to discharge the patient to anywhere other than the facility where they resided prior to the admission (i.e. a rehab center), the hospital must notify the previous facility prior to the discharge.
- Postdischarge Health Care Needs Evaluation: The hospital must contact the assisted living center or home from which the patient entered the hospital to discuss the patient’s likely postdischarge health care needs, reevaluate the patient’s condition, and identify changes that may impact care needs.
- Patient Screening Before Discharge: An opportunity for a patient screening by the assisted living facility representative must be provided before discharge to determine if the assisted living facility can meet the patient’s postdischarge care needs. While the assisted living facility is not required to perform this screening, they are required to accept that individual upon hospital discharge unless they’ve utilized this process and indicated that the person would now be beyond their authorized scope of care.
- Coordination for New Admissions: For patients not previously admitted to an assisted living facility, the hospital should coordinate to obtain necessary documentation from a healthcare professional regarding the required level of care. This will allow facilities to be compliant with regulatory requirements regarding pre-admission paperwork and allow them to be prepared for the level of care that will be required to be provided to the resident upon admission.
- Emergency Department or Observation Patients: Similar requirements apply to patients from emergency departments or observation units, including providing a point of contact, responding to inquiries for 48 hours post-discharge, and providing necessary information and prescriptions. It is not uncommon for a hospital to maintain a patient in a non-admitted status, yet supply new orders following an ER visit. This new law attempts to close any loopholes in care coordination based solely upon the patient’s hospitalization visit status.
- Development of a Discharge Document: Each hospital should create a discharge document that encompasses the above information for inpatient discharges, to be provided to the assisted living center or home to which the patient is being discharged.
This law does not apply to discharges to skilled nursing facilities, nor behavioral health residential facilities. It also does not apply if an individual goes back to a private residential setting, rather than a licensed assisted living facility. Assisted living facilities have experienced many challenges with hospital discharges that this law intends to address, and were instrumental in lobbying for its passage.
What is missing from the statute, however, are consequences for failure to comply. The Arizona Department of Health Services is generally charged with enforcing laws such as this, but the administrative rulemaking process is slow and they have not been given specific instruction by the legislature in the wording of this statute. Davis Miles will be following developments in this law and welcome feedback from assisted living facilities affected by it.
The information herein is intended to be educational and an introduction to the subject matter presented. Despite any statutory or regulatory references cited in the article above, it is NOT specific legal advice to be relied upon for specific individual circumstances. Contact your own legal professional or reach out to Davis, Miles PLLC if you would like specific advice on this topic.
Look for additional blog posts on topics of interest to Assisted Living and Behavioral Health operators. We welcome topic suggestions! Write to jwassermann@davismiles.com if you are curious to learn more about a certain topic impacting assisted living or other group housing concerns.