2016 Connecticut General Statutes
Title 19a - Public Health and Well-Being
Chapter 368v - Health Care Institutions
Section 19a-537 - (Formerly Sec. 19-617a). Definitions. Nursing home responsibilities re reservation of beds. Reimbursement. Readmission.
(a) As used in this section and section 19a-537a:
(1) “Vacancy” means a bed that is available for an admission;
(2) “Nursing home” means any chronic and convalescent facility or any rest home with nursing supervision, as defined in section 19a-521;
(3) “Hospital” means a general short-term hospital licensed by the Department of Public Health or a hospital for mental illness, as defined in section 17a-495, or a chronic disease hospital, as defined in section 19-13-D1(a) of the Public Health Code.
(b) A nursing home shall:
(1) Reserve the bed of a self-pay resident of such facility who is absent from the facility due to hospitalization whenever payment is available to reserve the bed;
(2) Inform the self-pay resident and such resident's relatives or other responsible persons, upon admission of a person to the facility and upon transfer of a resident to a hospital, that the bed of a resident will be reserved as long as payment is available to the facility to reserve the bed and that if payment is not made, the resident will be admitted to the next available bed in accordance with subsection (e) of this section;
(3) Reserve the bed of a resident who is a recipient of medical assistance when the resident is absent from the facility for home leave days authorized under the Medicaid program;
(4) Inform the resident who is a recipient of medical assistance and such resident's relatives or other responsible persons, upon admission of a person to the nursing home and upon transfer of a resident to a hospital of the conditions under which the nursing home is required to reserve the bed of a resident and that if the home is not required to reserve the bed, the resident will be admitted to the next available bed in accordance with subsection (e) of this section; and
(5) Not make the bed reserved for a hospitalized resident available for use by any other person unless the nursing home records in such resident's medical record the medical reasons justifying the change in such resident's bed, and the necessity of making the change before the resident's return to the facility, provided no resident's bed shall be changed if (A) such a change is medically contraindicated as defined in subsection (a) of section 19a-550; or (B) if the resident does not consent to the change, except when the change is made (i) to protect the resident or others from physical harm; (ii) to control the spread of an infectious disease; or (iii) to respond to a physical plant or environmental emergency that threatens the resident's health or safety. In the case of such an involuntary change of a resident's bed, disruption of residents shall be minimized, notice shall be provided to the resident or representative not later than twenty-four hours after the change and, if practicable, the resident, if he or she wishes, shall be returned to his or her room when the threat to health or safety which prompted the transfer has been eliminated. When a resident's bed is changed without his or her consent to protect the resident or others from physical harm, a consultative process shall be established on the first business day following the resident's return to the facility. The consultative process shall include the participation of the attending physician, a registered nurse with responsibility for the resident, other appropriate staff in disciplines as determined by the resident's needs and the participation of the resident, such resident's family or other representative. The consultative process shall determine what caused the change in bed, whether the cause can be removed and, if not, whether the facility has attempted alternatives to the change. The resident shall be informed of the risks and benefits of the change in bed and of any alternatives.
(c) A nursing home shall reserve, for at least fifteen days, the bed of a resident who is a recipient of medical assistance and who is absent from such home due to hospitalization unless the nursing home documents that it has objective information from the hospital confirming that the resident will not return to the nursing home within fifteen days of the hospital admission including the day of hospitalization.
(d) The Department of Social Services shall reimburse a nursing home at the per diem Medicaid rate of the facility for each day that the facility reserves the bed of a resident who is a recipient of medical assistance in accordance with the following conditions:
(1) A facility shall be reimbursed for reserving the bed of a resident who is hospitalized for a maximum of seven days including the admission date of hospitalization, if on such date the nursing home documents that (A) it has a vacancy rate of not more than three beds or three per cent of licensed capacity, whichever is greater, and (B) it contacted the hospital and the hospital failed to provide objective information confirming that the person would be unable to return to the nursing home within fifteen days of the date of hospitalization.
(2) The nursing home shall be reimbursed for a maximum of eight additional days provided:
(A) On the seventh day of the person's hospital stay, the nursing home has a vacancy rate that is not more than three beds or three per cent of licensed capacity, whichever is greater; and
(B) Not later than seven days after the date of hospitalization of a resident who is a recipient of medical assistance, the nursing home has contacted the hospital for an update on the person's status and the nursing home documents such contact in the person's file and that the information obtained through the contact does not indicate that the person will be unable to return to the nursing home not later than fifteen days after the date of hospitalization.
(3) A facility shall be reimbursed for reserving the bed of a resident who is absent for up to twenty-one days of home leave as authorized under the Medicaid program if on the day of such an absence the facility documents that it has a vacancy rate of not more than four beds or four per cent of licensed capacity, whichever is greater. No facility shall require or request a resident who is a recipient of medical assistance to provide payment for such authorized home leave days, whether or not such payment is available from the department.
(e) If a resident's hospitalization exceeds the period of time that a nursing home is required to reserve the resident's bed or the nursing home is not required to reserve the resident's bed under this section, the nursing home:
(1) Shall, upon receipt of notification from the hospital that a resident is medically ready for discharge, provide the resident with the first bed available in a semiprivate room or a private room, if a private room is medically necessary;
(2) Shall grant the resident priority of admission over applicants for first admission to the nursing home;
(3) May charge a fee to reserve the bed, not exceeding the facility's self-pay rate for the unit in which that resident resided, or not exceeding the per diem Medicaid rate for recipients of medical assistance, whichever charge is applicable, for the number of days which the resident is absent from the facility.
(f) When the Commissioner of Social Services, or the commissioner's designee, makes a finding that a resident has been refused readmission to a nursing home in violation of this section, the resident shall retain the right to be readmitted to the transferring nursing home pursuant to subsection (e) of this section regardless of whether or not the resident has accepted placement in another nursing home while awaiting the availability of a bed in the facility from which the resident was transferred.
(g) Whenever a nursing home has concerns about the readmission of a resident, as required by subsection (e) of this section, based on whether the nursing home has the ability to meet the resident's care needs or the resident presents a danger to himself or herself or to other persons, not later than twenty-four hours after receipt of notification from a hospital that a resident is medically ready for discharge, a nursing home shall request a consultation with the hospital and the resident or the resident's representative. The purpose of the consultation shall be to develop an appropriate care plan to safely meet the resident's nursing home care needs, including a determination of the date for readmission that best meets such needs. The resident's wishes and the hospital's recommendations shall be considered as part of the consultation process. The nursing home shall reserve the resident's bed until completion of the consultation process. The consultation process shall begin as soon as practicable and shall be completed not later than three business days after the date of the nursing home's request for a consultation. The hospital shall participate in the consultation, grant the nursing home access to the resident in the hospital and permit the nursing home to review the resident's hospital records.
(h) A nursing home shall not refuse to readmit a resident unless: (1) The resident's needs cannot be met in the facility; (2) the resident no longer needs the services of the nursing home due to improved health; or (3) the health and safety of individuals in the nursing home would be endangered by readmission of the resident. If a nursing home decides to refuse to readmit a resident either without requesting a consultation or following a consultation conducted in accordance with subsection (g) of this section, the nursing home shall, not later than twenty-four hours after making such decision, notify the hospital, the resident and the resident's guardian or conservator, if any, the resident's legally liable relative or other responsible party, if known, in writing of the following: (A) The determination to refuse to readmit the resident; (B) the reasons for the refusal to readmit the resident; (C) the resident's right to appeal the decision to refuse to readmit the resident; (D) the procedures for initiating such an appeal, as determined by the Commissioner of Social Services; (E) the resident has twenty days from the date of receipt of the notice from the facility to initiate an appeal; (F) the possibility of an extension of the time frame for initiating an appeal for good cause; (G) the contact information, including the name, mailing address and telephone number, for the Long-Term Care Ombudsman; and (H) the resident's right to represent himself or herself at the appeal hearing or to be represented by legal counsel, a relative, a friend or other spokesperson. If a resident is, or the nursing home alleges a resident is, mentally ill or developmentally disabled, the nursing home shall include in the notice to the resident the contact information, including the name, mailing address and telephone number of the Office of Protection and Advocacy for Persons with Disabilities. The Commissioner of Social Services, or the commissioner's designee, shall hold a hearing in accordance with chapter 54 to determine whether the nursing home has violated the provisions of this section. The commissioner, or the commissioner's designee, shall convene such hearing not later than fifteen days after the date of receipt of the request. The commissioner, or the commissioner's designee, shall issue a decision not later than thirty days after the date on which the hearing record is closed. The commissioner, or the commissioner's designee, may require the nursing home to readmit the resident to a semiprivate room or a private room, if a private room is medically necessary. The Superior Court shall consider an appeal from a decision of the commissioner pursuant to this section as a privileged case in order to dispose of the case with the least possible delay.
(i) If, following a consultation convened pursuant to subsection (g) of this section, a nursing home does not readmit a resident, the resident may file a complaint with the Commissioner of Social Services pursuant to section 19a-537a. If the resident has requested a hearing pursuant to subsection (h) of this section, the commissioner shall stay an investigation of such complaint until the issuance of a determination following the hearing. Each day a nursing home fails to readmit a resident in violation of this section may be considered a separate violation for the purpose of determining a penalty pursuant to section 19a-537a, except no penalty shall accrue during the period of time beginning with the date a consultation is requested until the date a hearing decision is issued, if a hearing is requested, provided the commissioner, or the commissioner's designee, finds the nursing home has acted in good faith in refusing to readmit the resident. If the resident does not request a hearing and the resident files a complaint with the commissioner pursuant to section 19a-537a, no penalty shall accrue during the time an investigation is conducted, provided the commissioner finds the facility acted in good faith in refusing to readmit the resident.
(P.A. 80-170, S. 1, 2; P.A. 83-348, S. 1, 3; P.A. 85-453, S. 1, 3; P.A. 87-178, S. 1; P.A. 88-197, S. 1; P.A. 93-262, S. 1, 87; 93-381, S. 9, 39; P.A. 95-160, S. 3, 69; 95-257, S. 12, 21, 58; P.A. 96-81, S. 2; 96-139, S. 12, 13; June Sp. Sess. P.A. 01-2, S. 64, 69; June Sp. Sess. P.A. 01-9, S. 129, 131; P.A. 11-236, S. 2.)
History: Sec. 19-617a transferred to Sec. 19a-537 in 1983; P.A. 83-348 amended Subsec. (b) by adding the requirement that on and after October 1, 1983, a nursing home reserve the bed of a resident who is a recipient of medical assistance and who is absent from such home due to hospitalization for the time it may be reimbursed and by requiring the commissioner to adopt regulations to establish a monetary penalty; P.A. 85-453 amended Subsec. (a) to include “any licensed home for the aged” in the definition of “nursing home” and amended Subsec. (b) to authorize reimbursement at per diem boarding home rate; P.A. 87-178 amended Subsec. (a) to delete “licensed home for the aged” from the definition and amended Subsec. (b) to delete a reference to the “per diem boarding home rate”; P.A. 88-197 added definitions of “vacancy”, “level of care” and “hospital”, distinguished between nursing homes' obligations to self-pay patients and to patients receiving medical assistance, and substantially revised prior provisions re reservation of beds including provisions re patient information, reimbursement rates and 15-day mandatory bed reservation policy for residents on assistance; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; P.A. 93-381 replaced department of health services with department of public health and addiction services, effective July 1, 1993; P.A. 95-160 amended Subsec. (b)(2) by adding a provision that if payment is not made, the resident will be admitted to the next available bed, added Subsec. (b)(3) requiring a nursing home to reserve the bed of a resident who is a recipient of medical assistance when the resident is absent for home leave days authorized under the Medicaid program, amended Subsec. (b)(4) by adding a provision that if the home is not required to reserve the bed, the resident will be admitted to the next available bed, added Subsec. (d)(3) providing for a facility to be reimbursed for reserving the bed of a resident who is absent for up to 21 days of home leave as authorized under the Medicaid program and amended Subsec. (e)(3) by changing the amount that a nursing home shall not exceed when charging a fee to reserve a bed from “the maximum allowable charge for the accommodation being reserved as established by the Department of Social Services for persons who are not recipients of medical assistance” to “the facility's self-pay rate for the unit in which that resident resided”, effective July 1, 1995; P.A. 95-257 replaced Commissioner and Department of Public Health and Addiction Services with Commissioner and Department of Public Health, effective July 1, 1995; P.A. 96-81 amended Subsec. (b)(5) to prohibit making the reserved bed available unless such change is medically contraindicated or if the resident does not consent to the change, with exceptions and required a consultation process to be established if the resident's bed is changed without his consent; P.A. 96-139 changed effective date of P.A. 95-160 but without affecting this section; June Sp. Sess. P.A. 01-2 amended Subsec. (a) to eliminate definition of “level of care”, renumbering existing Subdiv. (4) as Subdiv. (3), and to make technical changes in definition of “hospital”, amended Subsec. (b) to make technical changes for the purposes of gender neutrality, amended Subsec. (c) to delete phrase “at the same level of care”, and amended Subsec. (d) to delete references to “at the same level of care as the hospitalized person”, “at the same level of care” and “at the same level of care as the resident so absent”, effective July 1, 2001; June Sp. Sess. P.A. 01-9 revised effective date of June Sp. Sess. P.A. 01-2 but without affecting this section; P.A. 11-236 amended Subsec. (b)(2) and (4) by adding requirement that resident be admitted to next available bed in accordance with Subsec. (e), amended Subsec. (b)(4) by replacing reference to Department of Social Services requiring nursing home to reserve a bed with “nursing home is required to reserve the bed”, amended Subsec. (c) by replacing “patient” with “resident”, amended Subsec. (e)(1) by adding requirement that nursing home provide a resident with first bed available in a semiprivate or private room, if medically necessary, added Subsecs. (f) to (i) re readmission to a nursing home, and made technical changes, effective July 13, 2011.
