PETS IN ASSISTED LIVING

Pets can be a benefit to residents in assisted living; dogs and cats (and other animals) offer companionship and attention and can enhance the homelike feel of an assisted living community. Regardless of who owns the pet, there are regulatory expectations to follow.

WAC 388-78A-2620 states that if the assisted living facility allows pets to live on the premises, the assisted living must do the following:

• Develop, implement, and disclose to potential and current residents, policies regarding:
• The types of pets that are permitted in the facility and the conditions under which pets may be in the assisted living. This might include limits on the size of the animal, type of animal(s) allowed, and/or the number of pets a resident may have at one time.  
• The conditions under which pets may be in the assisted living facility. This might include expectations of the pet owner; for example, the resident must be able to clean up after the animal, ensure the animal is on a leash when outside of the resident’s apartment, etc.
• Ensure animals living on the premises have regular examinations and all recommended immunizations appropriate for the species. These exams and immunizations must be provided by a veterinarian licensed in Washington State. The veterinarian must certify that the animal is free from diseases that are transmissible to humans.
• Ensure animals are not allowed in central food preparation areas.

Some additional considerations when an assisted living allows pets include:

DEPOSITS. Part of a pet agreement likely includes any pet deposits. These cannot be imposed on residents whose payment source is Medicaid.

HOSPITALIZATIONS. There should be plans in place for ongoing pet care in the event the resident pet owner experiences a hospitalization or prolonged rehabilitation. Likewise, the resident/family should have plans in place should the pet require emergency care.

DISASTERS/EMERGENCIES. Pet care should be included in each facility’s disaster/ emergency plan. Provisions for ongoing food and water, along with other necessary items, must be considered. Evacuation plans should include pet management efforts.

Of note, service animals and emotional support animals are not considered pets but rather are considered health care options and must be allowed under the Fair Housing Act as a reasonable accommodation. Deposits, size limitations, and other aspects of a facility’s pet policy do not apply for service animals. It is recommended that facilities have a service animal policy, separate from a pet policy. For more details on service animals, refer to this document and consider speaking with an attorney should additional questions arise.

If you have questions about assisted living regulations, please contact Vicki McNealley via email or call 1-800-562-6170 extension 107.

ROP PHASE 3-§483.15 ADMISSION, TRANSFER, AND DISCHARGE | SKILLED NURSING

Like many other portions of the requirements of participation (ROP), CMS published changes to the requirements regarding resident admissions, transfers, and discharges, implementation of which were effective on October 24, 2022. Surveyors will be ensuring facility compliance through re-certification surveys or any associated complaint investigations. Before launching into the changes, it is important to review the following definitions:

“Facility-initiated transfer or discharge:” A transfer or discharge which the resident objects to or did not originate through a resident’s verbal or written request, and/or is not in alignment with the resident’s stated goals for care and preferences. 

“Resident-initiated transfer or discharge”: Means the resident or, if appropriate, the resident representative, has provided verbal or written notice of intent to leave the facility (leaving the facility does not include the general expression of a desire to return home or the elopement of residents with cognitive impairment). 

F-622 outlines the CMS requirements and guidance regarding the only situations in which a facility is permitted to initiate a resident’s transfer or discharge. 

Allowable facility initiated-discharges include:

• The transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility. 
• The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility. 
• The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. 
• The health of individuals in the facility would be endangered. 
• The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility; or 
• The facility ceases to operate. 

F-622 also states that all facility-initiated discharges must meet the discharge requirements outlined in the F-tag and facilities must not discriminate based on payment source. CMS added guidance to address situations when a resident is admitted for short‐term, skilled rehabilitation under Medicare, but following completion of the rehabilitation, the resident may communicate that s/he is not ready to leave the facility. In this situation, if the facility proceeds with the discharge, it is facility‐initiated and must meet the discharge requirements outlined in the ROP. CMS encourages surveyors to investigate these situations for discrimination based on payment source. In cases where the resident does not appear to object to the discharge or has not appealed it, CMS states the discharge may still be a facility-initiated discharge. If identified by surveyors, the situation must be investigated to determine if the discharge is resident or facility initiated. 

In addition, CMS outlines the facility responsibilities when Medicare coverage has ended but the resident continues to need long term care services. In these cases, the facility should offer the resident the option to remain in the facility, which may include: the resident paying privately, or if private payment is not an option for the resident, the facility should provide the resident with the necessary assistance to apply for Medicaid. 

• If assisting the resident with applying for Medicaid, the facility should explain to the resident and their representative that if Medicaid is denied, the resident will be responsible for payment for all days in the facility after Medicare payment ended. If found eligible for Medicaid and no Medicaid bed is available or the facility only participates in Medicare, the resident will be discharged to another facility with available Medicaid beds if the resident wishes to have their stay paid by Medicaid. 
• The resident cannot be discharged for nonpayment while a determination on the resident’s Medicaid eligibility is pending or after s/he is found eligible for Medicaid. 
• The guidance from CMS instructs surveyors to be aware of a facility’s Medicare and Medicaid certification status and/or the presence of a distinct part as this can affect whether a resident’s discharge for non‐payment is justified. 

CMS gave further guidance stating that when a resident is transferred to an acute care setting, circumstances require the SNF to permit the resident to return to the facility. 

• First, when a resident is emergently transferred to an acute care setting, these scenarios are considered facility‐initiated transfers, not discharges, because the resident’s return is generally expected. 
• Secondly, when a facility initiates a discharge while the resident is in the hospital following an emergency transfer, the facility must have evidence that the resident’s status at the time they are seeking to return to the facility (not at the time the resident was transferred for acute care) meets one of the qualifying discharge requirements. If the basis for transfer is related to resident-specific needs that cannot be met by the facility, the facility must be able to demonstrate and document how they tried to meet the resident’s needs and what services are available at the receiving facility that can meet the needs.
• The resident also has the right to return to the facility pending an appeal of any facility‐initiated discharge unless the return would endanger the health or safety of the resident or other individuals in the facility. In this situation, the facility must document the danger that the failure to transfer or discharge would pose. 
• Residents who are sent to an acute care setting for routine treatment/planned procedures must be allowed to return to the facility.

Facilities must ensure that transfer and discharge notices contain the required elements and are given timely. It is important to remember that for skilled nursing facilities, when a written discharge notice has been issued and the facility changes the destination from the original location identified on the notice, this change triggers a new written discharge notice and according to CMS, restarts the 30-day clock and additional appeal rights for the new notice.

More information will be coming in future Survey and Regulatory Updates regarding the CMS requirements for skilled nursing facilities. For questions about Resident Rights-Admissions, Transfers and Discharges or the ROP for skilled nursing facilities, contact Elena Madrid via email or call (800) 562-6170 extension 105.