Interpretive Guidance Regarding RoPs: Focus on Admission, Transfer and Discharge Requirements

The CMS Requirements of Participation (RoP) that were implemented effective November 28, 2016 (also known as Phase 1), included revised requirements for the admission, transfer and discharge of nursing facility residents. The more recently published State Operations Manual - Appendix PP provides the Interpretive Guidance that surveyors will utilize to assess a facility’s compliance with the requirements. Key components of the new requirements include the following:


  • The Admission policy may not request or require residents or potential residents to waive potential facility liability for losses of personal property. The Interpretive Guidance specifies that the facility may not require that personal property be safeguarded in a manner that makes the property essentially inaccessible to the resident.
  • Prior to admission, the facility must disclose and provide information related to any special characteristics or service limitations of the facility. This can include any specialized services or care that the facility provides, such as rehabilitation or dementia. It would also include any religious affiliation(s) that guide practices and routines. Limitations that must be disclosed prior to admission are focused on making the potential resident aware of service needs that may result in a transfer or discharge, such as a facility’s inability to provide ventilator care or other specialized services.


  • The Interpretive Guidance defines the difference between a facility-initiated transfer/discharge and a resident-initiated transfer/discharge, which requires that the resident provide verbal or written notice of intent to leave the facility in order for it to be considered a resident-initiated discharge. A facility-initiated transfer/discharge is defined as one that the resident objects to, was not initiated by the resident and /or is not necessarily aligned with the resident’s goals and preferences.
  • The Guidance states that discharges following a completion of skilled rehabilitation may not always be resident-initiated, even if the resident does not object to the discharge. In those situations, facilities must meet all pertinent discharge requirements.
  • Surveyors are responsible for determining whether a transfer/discharge is resident- or facility-initiated, as evidenced in the medical record, including documentation of the resident’s intent to leave the facility, the inclusion of a discharge plan, and documented discussions with the resident or the representative regarding post discharge care.
  • Emergent transfers to the hospital are considered facility-initiated transfers because the resident’s return is generally expected. Residents transferred to the emergency room must be permitted to return to the facility. If the facility initiates discharge while a resident is in the hospital following an emergent transfer, the facility must have supporting documentation that the decision for the discharge was not based on the resident’s condition at the time of transfer.
  • Facility-initiated discharges that do not honor the resident’s right to return following hospitalization or therapeutic leave must provide clear documentation as to the basis for the decision for discharge. The facility must conduct and document an appropriate assessment to determine whether revisions to the care plan would allow the facility to meet the resident’s needs.
  • For facility-initiated transfer/discharges related to the facility’s inability to meet the resident’s needs, or if the resident has improved sufficiently and is no longer in need of care and/or services of the facility, the resident’s physician or a non- physician practitioner must document the specific needs that could not be met, the efforts made to meet the needs, and the services provided at the receiving facility to meet the needs.
  • Specific medical record information must be provided to the receiving provider/facility depending on whether or not the resident is expected to return, including the resident’s comprehensive care plan goals. If the care plan information cannot be provided prior to urgent transfers, it must be conveyed as soon as possible after the actual time of transfer. The facility may choose their own method of communicating the transfer/discharge information, provided the required elements are included.
  • For facility-initiated transfer/discharges, a notice must be provided to the resident and the resident’s representative, which states the reasons for the move. A copy of the notice must also be sent to a representative of the State LTC Ombudsman Office prior to or as close as possible to the time of transfer/discharge. For emergent transfers to the hospital, the notice to the resident and representative must be provided as soon as practical. The notification to the Ombudsman can be included in a list that is provided monthly. This notice requirement is distinct from the bed hold notice requirement.
  • The facility is required to prepare and orient the resident as to where they are being transferred, and to take steps to minimize their anxiety. The new facility orientation must be documented in the medical record.
  • Bed hold notices must be provided to the resident or his/her representative at the time of transfer, or within 24 hours in cases of emergency. It is expected that facilities will document multiple attempts to reach the resident’s representative in cases where the facility was unable to notify them within those timeframes.


It is important that facilities identify any areas of vulnerability with respect to the admission, transfer, and discharge requirements prior to a survey under the new Interpretive Guidance and survey process. Specific steps may include:

  1. Reviewing the admission packet to ensure that all required documentation is provided;
  2. Reviewing processes and required documentation for all hospital transfers, including the information provided to the receiving facility to ensure that all required elements are included;
  3. Reviewing the medical records of residents recently transferred and/or discharged, to identify any potential areas of noncompliance with the new requirements;
  4. Providing staff education on the new requirements so staff can adequately address surveyor questions during the survey process. 

For more information or assistance, please contact Joanne Jones, RN Director of Clinical Consulting at