2. If a resident is transferred to a general hospital or acute psychiatric care in this facility, the Bed Hold Procedure must be followed.

Transcription

1 Would anyone be willing to share their bedhold policy Brown Columbia Dane LaCrosse Lakeview Outagamie St Croix Saul Sheboygan Trempealeau Walworth Winnebago See separate PDF BROWN BED HOLD POLICY: It is the policy of the Brown County Community Treatment Center to ensure a systematic method whereby all residents have the right to continue to stay in Bayshore Village after acute care here or someplace else. SPECIAL INSTRUCTIONS: Performed By: Registered Nurse General Considerations: 1. If a resident is transferred to the community, another nursing home or a residential facility, the medical record will be closed and sent to the HIM Department. This is a direct discharge and the RN Manager will discharge him/her on the computer. 2. If a resident is transferred to a general hospital or acute psychiatric care in this facility, the Bed Hold Procedure must be followed. PROCEDURE: 1. Indicate bed hold in electronic record. 2. Chart resident transfer in the electronic progress notes. Include name of receiving facility, date, time, condition of resident, how transported, and any other pertinent information. 3. Give Notice of Transfer/Therapeutic Leave to guardian/resident. 4. Replace the chart in the chart rack. 5. If the resident returns, the household staff may pull the record and record even after the 15-day bed hold is up. 6. It is necessary to make an entry on return, much as you would for a new admission. 7. If gone from the facility longer than 24 hours, they will be treated as a new admission. A physical is required five (5) days prior or within 48 hours after, PPOC, and need to staff within 15 days. REFERENCES:

2 HFS 132; BCMHC Policy: Provision of Nursing Care; Nursing Care Standard: Discharge Planning. FORMS/ATTACHMENTS: None _ Director of Nursing Bayshore Village _ Hospital and Nursing Home Administrator Date Date DANE BADGER PRAIRIE HEALTH CARE CENTER SUBJECT: Bedhold I. PURPOSE: To establish a method of maintaining a temporarily vacant resident bed consistent with Wisconsin Administrative Code and Federal law. II. POLICY: A. A resident who has an absence from the facility for a period of fifteen (15) days or less shall have his/her bed held in anticipation of his/her return. B. Residents whose bedhold exceeds fifteen (15) days may be discharged on the sixteenth day. C. Residents are informed of this policy in the admission packet. D. Nursing staff shall ensure that a copy of the Bedhold Notification Form will be sent with residents as they are transferred to hospital or leave the facility on a therapeutic leave. E. A copy of the bedhold notification will be provided to the resident s financial representative within 24 hours of a transfer or pass. III. REFERENCES: Wisconsin Administrative Code Chapter HFS (5) State Operations Manual IV. FORMS: Bedhold Notification Form BPHCC Census V. PROCEDURES: A. Bedhold status exists when a resident temporarily leaves the facility for medical or other therapeutic reasons and their return is anticipated. Hospitalizations, home visits, preplacement visits, and vacations are examples of therapeutic absences. The facility will hold the resident's bed until the resident returns, until the resident waives his or her right to have the bed held, or up to fifteen (15) days following the temporary leave or discharge, whichever is earlier. B. Any resident whose hospitalization or therapeutic leave exceeds the bedhold period will be readmitted to the facility into the first available appropriate room if the resident: 1. Requires the services provided by the facility; and 2. The facility is able to meet their needs; and 3. Has a source of payment. Residents whose bedhold exceeds fifteen (15) days must be formally readmitted to Badger Prairie. At the discretion of the Administrator, the length of a bedhold may extend beyond fifteen (15) days. Any exception must be communicated in writing to the Night Nurses by the Administrator, Nursing Supervisors, or the Social Services Supervisor. C. When the facility reaches 94% or greater average occupancy rate for the preceding month, the facility may charge for bedhold as explained in the Admission Agreement. If a private pay resident chooses not to pay to have their bed held, they will be readmitted to the first available appropriate room if the resident meets the criteria in (B) above.

3 D. Reception staff will be responsible for monitoring the daily census for temporary absences and providing financially responsible parties a copy of the Bedhold Notification form by mail, fax, or . Reception staff will maintain a log to prove that notifications were provided. VI. ATTACHMENTS: Bedhold Notification Form Badger Prairie Health Care Center Bedhold Notification Form Resident Name: Date: Dear Resident/Guardian/POA/Responsible Party, We are required to provide you and the resident with a notice of our bedhold policy whenever a resident is temporarily away from the facility overnight with the intent to return. We have informed the resident by giving them a copy of this form as they were leaving the facility. A resident who is temporarily out of the facility for overnight or longer has the right to have their bed held until they return. We will hold the resident s bed for 15 days or until they or their responsible party waives the right to have their bed held, whichever is earlier. If a resident or responsible party chooses to have the bed held, the resident will be allowed to return to their bed unless they no longer require the services of a nursing home or their needs exceed our ability to provide their care. If the facility is at 94 percent or greater occupancy, a resident who pays privately for their stay will be charged $100 per day to hold their bed. Badger Prairie will bill Medical Assistance for bedhold if the resident is receiving Medical Assistance. If a private pay resident chooses not to pay to hold their bed, the resident will be discharged and readmitted to the next available appropriate bed. Should the resident s temporary absence exceed 15 days, the resident may be discharged. To be readmitted the resident will need to meet all criteria for a new admission. Residents returning under these circumstances have priority for admission. Please contact Cindy Richmond at or richmond.cindy@countyofdane.com to let us know whether or not you want us to hold the resident s bed during this temporary absence OUTAGAMIE Brewster Village Bedhold Policy Before a resident is transferred to a hospital or allowed to go on therapeutic leave, Brewster Village must provide written information regarding the following: 1. When hospital transfers occur, the social worker (or nurse if social worker is unavailable) will provide the resident and family member or legal representative with a copy of the bedhold policy and have the resident or legal representative sign the bedhold authorization form. In the event of an emergency transfer, a copy of the bedhold policy will be sent with other papers accompanying the resident and the copy for the resident s family member or legal representative will be mailed the next business day. The social worker (or nurse) will document in the Release of Information folder under the face sheet tab in ECS that the bedhold policy was given or sent to the resident and family member or legal representative. The completed and signed bedhold authorization will be filed in the resident s health record. A copy will be given to the business office. a. In case of an emergency transfer, the social worker will follow up with a phone call to the responsible party the next business day to discuss the bedhold policy. The resident s condition at the time may influence the timing of the call. This conversation is to be documented in the Consent Folder stating who was contacted and the decision regarding the bed hold status. 2. When a therapeutic leave occurs, the social worker will provide the resident and family member or legal representative with a copy of the bedhold policy and have the resident or legal representative sign the bedhold authorization indicating bedhold during all therapeutic leaves. The completed and signed bedhold authorization form will be filed in the resident s health record to serve as documentation for future therapeutic bedholds. Each therapeutic leave will be documented by a nurse or a social worker in the Discharge/Transfer Leave folder under the Nurse charting tab in ECS. a. Residents who wish to have therapeutic leaves must first be evaluated by the treatment team and rationale, goals, duration and frequency of therapeutic leave will be documented in the care plan by the

4 social worker. The treatment team must obtain documentation of physician approval prior to therapeutic leave in the Physician s Orders in the resident s health record. 3. Permitting a resident to return to facility: a. In situations where hospital bedhold is 15 days or less, or a therapeutic pass is equal to or less than the number of days ordered by the physician, or in the case of a private pay resident, the responsible party/resident has agreed to continue and pay for a bedhold pass, the resident will be readmitted to the facility. Readmission would be subject to facility s ability to provide necessary care as required and the resident s need for nursing facility services. b. The facility will ensure equal access and will not discriminate against applicants for readmission based upon their pay source. Bedhold/Therapeutic Leave for Private Pay: If the resident pays for their own stay at Brewster Village or utilizes private commercial insurance benefits, the responsible party will be billed for the private pay daily room charge each day of hospital or therapeutic bedhold. Please refer to daily room charge information, which is available in the business office and the rate brochure. Bedhold/Therapeutic Leave for Medicare: Medicare does not pay for hospital bedhold. Upon transfer to the hospital, the resident will be discharged from Brewster Village unless he/she chooses to pay privately to hold the bed. A bedhold authorization form must be completed and the resident will be billed the private pay daily room charge for the entire duration of each hospital bedhold period. The bedhold authorization form should be completed as private pay. Generally, there is no therapeutic leave during a Medicare Part A covered nursing home stay, due to the Medicare requirement for daily skilled care. In most cases being absent from the facility overnight will result in the resident s being discharged from Medicare, and the bedhold policy for the secondary pay source of private payment or Medical Assistance payment will apply. An exception to the general rule that Medicare does not pay for therapeutic leave is when therapeutic leave is part of the treatment plan in a circumstance such as an overnight trial at home. In this situation Medicare could be contacted to determine whether the bedhold would be Medicare billable, or if the resident would be personally responsible to pay the bedhold rate so that the room would be held. A special bedhold authorization form generated in the business office would be used in this unusual circumstance. Bedhold/Therapeutic Leave for Medicaid Pending: If a resident s pay source is Medicaid pending, they are treated as private pay for purposes of the bedhold policy. If the Medicaid eligibility date is later determined to include the bedhold dates, Medicaid will be billed for the bedhold charges and any payments received from the resident for the related bed hold will be refunded. Bedhold/Therapeutic Leave for Medicaid: See note above for Medicaid Pending Hospital bedhold payment by Medicaid is a maximum of 15 days per leave. For persons covered by Medicaid, Medicaid will cover therapeutic bedholds of any length. The resident s physician must approve therapeutic bedholds and identify the frequency and number of days the resident can utilize. For persons covered by Medicaid, the monthly liability established by the County Department of Health and Human Services will still be due to the facility while that person is on therapeutic or hospital bedhold. In the event a Medicaid covered resident s hospital bedhold would exceed the state covered 15 days, the responsible party/resident may continue to hold the room as long as they desire to pay the private pay daily room charge. Please refer to daily room charges information, which is available in the Business Office and the Rate Brochure. Protectively placed residents for whom OCHHS has no alternate placement may be extended additional bedhold days without payment from the responsible party/resident. In situations where hospital bedhold exceeds 15 days for a Medicaid covered resident and the resident opts not to continue bedhold; or private paying resident opts not to continue bedhold, the resident may be readmitted to the facility immediately upon the first availability of a bed subject to this facility s ability to provide necessary care as required and the resident s need for nursing facility services. BREWSTER VILLAGE - BEDHOLD AUTHORIZATION ********************************************************************* RESIDENT NAME RESIDENT NUMBER_

5 AFTER REVIEWING BREWSTER VILLAGE S BEDHOLD POLICY AND THE INFORMATION CONCERNING RESOURCES AVAILABLE TO CONSUMERS, I INDICATE MY HOSPITAL OR THERAPEUTIC BEDHOLD CHOICE BY PLACING MY INITIALS BEFORE THE BEDHOLD STATEMENT I CHOOSE: (* BECAUSE MEDICARE DOES NOT COVER MOST BEDHOLDS, VILLAGERS ARE CONSIDERED TO BE PRIVATE PAY OR MEDICAID DEPENDING ON THEIR BACK UP PAY SOURCE.) HOSPITAL BEDHOLD: A. Private Pay I understand I will be billed the private pay daily room charge for the entire duration of my hospitalization. I am requesting direct discharge without a bedhold period. B. Medicaid: Covers a maximum of 15 days for each hospital stay. I understand that beginning on day 16, I will be billed the private pay daily room charge for the duration of my hospitalization. I request to be discharged from Brewster Village on day 16 should my hospitalization exceed the maximum covered by Medicaid. I am requesting direct discharge without a bedhold period. THERAPEUTIC BEDHOLD: A. Private Pay I understand I will be billed the private pay daily room charge for each day of therapeutic leave. I am requesting direct discharge without a bedhold period. B. Medicaid: Covers when approved by a physician stating the purpose and specifying the frequency and number of days to be utilized. Therapeutic bedhold for _ days as ordered by my physician. I understand I will be discharged following this bedhold period if I have not been readmitted. I understand the therapeutic leave policy and will follow the leave(s) as granted by my physician and I will be discharged from the facility if I have not been readmitted by the end of the specified leave, I agree to pay the private pay daily room charge for each additional day I choose to extend the bedhold. I am requesting direct discharge without a bedhold period. NOTE: IF THIS FORM OR VERBAL NOTIFICATION IS NOT RECEIVED WITHIN 1 BUSINESS DAY AFTER TRANSFER AND IF PAYMENT FOR BEDHOLD DAYS IS NOT RECEIVED, BREWSTER VILLAGE HAS THE RIGHT TO RELINQUISH YOUR BED. IF YOU HAVE ANY QUESTIONS PLEASE CONTACT THE BILLING CLERK AT SIGNATURE OF RESIDENT DATE:_ SIGNATURE OF LEGAL REPRESENTATIVE DATE: RELATIONSHIP TO RESIDENT 6/02 9/10 9/ /11/ SHEBOYGAN Policy: Rocky Knoll HCC shall inform resident/legal representative upon admission and at time of a transfer for hospital or therapeutic leave of the bed hold policy.

6 DEFINITIONS: Hospital Leave A resident who is on leave or temporarily discharged to a hospital and has expressed an intention to return to the facility under the terms of the admission agreement for bed hold, shall not be denied readmission unless at the time readmission is requested the resident requires services unavailable at the facility and/or does not meet admission criteria. Therapeutic Leave A resident who is on leave for non-medical reasons such as visit with family/friends or a trial home stay in anticipation of discharge. PROCEDURE: 1. Medical Assistance (MA) Title XlX: For leave due to hospitalization, MA will pay as per the current Wisconsin Medicaid State Plan to hold the bed for 15 days, unless during this time the resident/legal representative informs the facility to discontinue bed hold or a condition of involuntary removal is met. If the hospitalization exceeds the bed hold limit as allowed by MA, resident/legal representative may elect to either: --pay for any days in excess of the State s plan at a charge of 75% of the current room rate and thus ensure return to the same bed that was occupied prior to hospitalization OR --be discharged on the 16 th day and be readmitted to the first appropriate available bed. Resident must also continue to meet admission criteria of the facility. For absence due to therapeutic leave, MA will pay to hold the resident s bed until the resident/legal representative informs the facility to discontinue the bed hold. 2. Private Pay: Resident/legal representative may elect to hold the bed during a therapeutic or hospital leave to guarantee the same placement upon return. The facility will hold the bed for 48 hours at no charge. After the 48 hours the facility will hold the bed indefinitely as long as the resident/legal representative makes the appropriate payment of 75% of the current room rate until the resident/legal representative informs the facility to discontinue bed hold. Any unauthorized, unpaid absences from the facility will be considered a discharge and the room must be cleared within 24 hours. 3. Residents Eligible for Medicare Part A: Medicare does not make bed hold payments for hospitalizations or therapeutic leave. Medicare A eligible residents may choose to make bed hold leave payments in accordance with the policy above for private pay or medical assistance. 4. VA (Veteran s Administration) Contract: Bed hold charges are only covered for 48 hours except with prior approval of the placing VA facility. After the VA bed hold expires the facility will hold the bed for 48 hours at no charge. After the 48 hours the facility will hold the bed indefinitely as long as the resident/legal representative makes the appropriate payment of 75% of the current room rate until the resident/legal representative informs the facility to discontinue bed hold. Any unauthorized, unpaid absences will be considered a discharge from the facility and the room must be cleared within 24 hours. The client will require a new authorization agreement from the placing VA facility to be readmitted. 5. Notification A. Resident or Legal Representative will be notified of the bed hold policy at the time of admission via the admission agreement. B. Nursing designee will send one carbon copy of the bed hold notification with the resident going on therapeutic leave or with the other papers accompanying the resident to the hospital. The original and remaining carbon copy will be forwarded to the Health Information Services department as soon as possible. C. Health Information Service staff will forward the original bed hold form to the legal representative and file the remaining carbon copy in the resident s file. D. As soon as is practicable, the Social Service Department will call the guarantor for all private pay residents, for MA residents prior to day 16 of hospital bed hold and for VA residents prior to the second 48 hours of leave to discuss the bed hold policy and clarify any bed hold decision. Social Services will then notify Health Information Services of decisions made.

7 WALWORTH Bed Hold If resident is temporarily absent from Lakeland Health Care Center for hospital treatment, therapeutic treatment or to participate in a therapeutic rehabilitative program, Lakeland Health Care Center will hold resident s bed in accordance with the following provisions: A. Private Pay: The bed will be held indefinitely for any absence from the facility due to hospitalization or therapeutic leave/home visit. Charges during the absence will be our normal daily rate. A resident/family member/legal representative may choose to waive their right to the bed hold by contacting the Social Work Supervisor and giving notice not to hold the bed. The resident then will be discharged and will need to re-apply for admission should he/she wish to return to Lakeland Health Care Center. The Social Work Supervisor or designee will phone the first contact person on the Permission for Notification form when a private pay resident is hospitalized for a decision on whether to hold the bed or discharge resident from the facility. The phone conversation will be documented in the resident s medical record and the follow up form sent for the contact person s signature. B. Medicare: Medicare does not pay for a bed hold. Charges will be billed at our private pay rate or through Medical Assistance for eligible residents. The Social Work Supervisor or designee will phone the first contact person on the Permission for Notification form when the Medicare resident is admitted to the hospital for a decision on bed hold or discharge. The Social Work Supervisor or designee will document the decision in the resident s medical record and a follow up form will be sent to the contact person for his/her signature. C. Medical Assistance: The bed will be held for fifteen (15) days for hospitalization. During the fifteen (15) day period, the Medical Assistance program will be billed at the bed hold rate. After fifteen (15) days, the resident will be discharged and will need to re-apply for admission. The resident will be re-admitted to Lakeland Health Care Center immediately upon the first available and appropriate bed. At the expiration of the fifteen (15) day bed hold period, the Social Work Supervisor or designee will contact the first contact person for the resident and request a decision on a bed hold or discharge. Charges to the resident will be at the private pay rate if the decision is to hold the bed. The phone conversation will be documented in the resident s medical record and the follow up form sent to the contact person for his/her signature St. Croix Health Center Bed Hold Policy Policy: When the facility transfers a resident to a hospital or a resident goes on therapeutic leave, the facility will provide written information of the bed hold policy to the resident and / or family member, legal representative. 1. Under the Medical Assistance Program, if a resident leaves the facility for hospitalization, or therapeutic leave, his/her bed will be held for 15 days per hospitalization and 15 days per calendar year for therapeutic leave, with payment made by the Medical Assistance Program. 2. If a resident exceeds the Medical Assistance bed hold period, he/she will be given the opportunity to maintain the bed hold by paying the appropriate daily rate. Arrangements can be made by contacting the Social Worker or designee. 3. If a resident chooses to not extend their bed hold beyond the 15 day Medical Assistance Program, they will be readmitted to the facility immediately upon the first availability of a bed, if the resident requires the service provided by the facility and is eligible for Medicaid nursing facility Services. 4. Private pay, Medicare and third party payers can choose to hold their bed and pay the appropriate charges, the facility will hold the bed for the time that is indicated on the bed hold form. Procedure: 1. Before a resident leaves for hospitalization or therapeutic leave, he/ she are given a copy of the bed hold policy. A copy of the bed hold policy will be attached to the patient transfer form, which accompanies each resident. 2. For therapeutic leaves, available copies of the bed hold policies are kept on the resident s sign in / sign out board located at the nurse s station.

8 3. The Nursing or Social Service designee will contact the resident/ responsible party to inquire about bed hold. If the resident/ responsible party chooses to pay bed hold, the agreement to pay changes form will be completed. 4. The completed bed hold signature form will be kept in the resident s financial file. St. Croix Health Center BED HOLD POLICY A. MEDICAID RESIDENTS A vacant bed will be held for you while you are in the hospital or on therapeutic leave. Medicaid pays for the following: Hospital Days 15 days per hospitalization Therapeutic Leave Days 15 days per year During this time you are permitted to return and resume residency in the facility. If your hospitalization or therapeutic leave exceeds the number of days indicated above, you can choose to maintain the bed by following the private pay policy, you will be readmitted immediately upon the availability of a bed in an appropriate room, if: 1. You require the services provided by the facility; and 2. You are eligible for Medicaid nursing facility services. B. PRIVATE PAY, MEDICARE & THIRD PARTY PAYOR RESIDENTS A vacant bed will be held for you while you are in the hospital or on therapeutic leave if you sign the Agreement to Pay Charges for Bed Hold (shown below) and pay the applicable charges when billed. A bed will be held for the number of days indicated on the agreement. During this time you are permitted to return and resume residency in this facility. The facility will not hold a bed for you beyond the number of days indicated. You may extend the number of days at any time by signing another agreement or by making arrangements with the facility. AGREEMENT TO PAY CHARGES FOR BED HOLD (To be signed when Medicaid does not apply and resident wishes to pay privately for bed hold) Resident s Name St. Croix Health Center Facility Name I, the above named resident, agree to pay the established rate for Bed Hold to St. Croix Health Center. I agree to pay for days from _ to _ unless resident returns to the facility prior. Date Date I understand that the current rate for Bed Hold for hospitalization or therapeutic leave is $98.00 /day. Resident/Authorized Agent Legal Representative Responsible Party Date Date Date SAUK COUNTY HEALTH CARE CENTER SUBJECT: BED-HOLD PURPOSE: Frequently home visits or general hospitalization of residents are needed or desired. To hold these beds for the residents that request this, the following policy is in effect at the Sauk County Health Care Center. DEFINITION: A resident who will be temporarily absent from the facility due to hospitalization, therapeutic leave or those that wish a trial discharge may arrange for the resident's bed to be held (bed-hold). PROCEDURE: The rate charged for bed-hold is 85% of the daily rate prior to the leave. The resident (if the resident does not have a guardian or activated POA/HC) will be informed of the rate prior to the leave and given the opportunity on the

9 Bed-Hold Authorization Form to reserve their bed. A designee will be advised of the resident's decision regarding bed-hold if the resident desires or in any cases where the resident's condition has altered the ability to completely understand the consequences of the decision. Unless there is a legal representative the designee/family can not overrule the resident's decision, unless they are willing to accept financial responsibility in writing. If the resident/designee agrees to bed-hold and expects to return, the facility shall hold the bed for a period of up to fifteen (15) days, unless during that time the resident or legal representative informs the SCHCC Business Office to discontinue the bed-hold, or continue it for a longer period of time. SCHCC will determine from the resident/legal representative orally and in writing before the absence whether or not the resident requests bed-hold. The original bed-hold form will be filed in Medical Records and a copy sent with the resident/legal representative. If it is an emergency transfer, and the resident is unable to receive/understand the bed-hold information, the resident's legal representative or designee assigned by resident upon admission (i.e. husband, wife, financial POA) will be informed of the opportunity to hold the bed. The original bed-hold form will be sent within 24 hours to the legal representative/designee for signature. A resident who is receiving Medicaid (MA) benefits is entitled to 15 days of bed-hold. They may elect to pay privately for any days after this by notifying the SCHCC Business Office. If they choose not to pay privately beyond the 15 days, the facility will readmit the resident immediately upon the first availability of a bed in a semiprivate room TREMPEALEAU Bed Hold Highlights Policy Statement Trempealeau County Health Care Center informs residents/clients upon admission and prior to a transfer for hospitalization or therapeutic leave of our bed-hold policy. Policy Interpretation and Implementation TCHCC will hold a resident/client bed up to 15 days following the first day of a hospital stay or a therapeutic visit. After 15 days, TCHCC will neither hold nor charge for the bed. If a resident/client exceeds the 15 day bed hold limit, still requires services provided by the facility and is eligible for Medicaid services, the resident/client will be placed on the facility waiting list and will be given priority for admission to the first available bed in a semi-private room. Before or at the time, a resident/client is transferred to a hospital or goes on a therapeutic visit/leave; TCHCC will provide written information to the resident/client and immediate family member. The information will review the provisions of the State Medicaid plan regarding the period of time during which the resident/client is permitted to return and resume residence in the facility and the duration of time allowed. For a copy of the Bed Hold form, refer to the Forms file. Regulatory Reference Sources and Revision Dates OBRA Regulatory Reference Numbers 42 CFR (b)(1)-(3); (d)(3)

10 Survey Tag Numbers F205; F206; F208 Policy/Procedures Reviewed/Revised Date: Date: Date: Date: By: By: By: By: LACROSSE LAKEVIEW PROCEDURE: BEDHOLD NOTICE AND BILLING PROCEDURE NURSING HOME/FDD LICENSE POLICY STATEMENT: Lakeview Health Center shall comply with State and Federal requirements for bedhold when a resident is on therapeutic leave, hospitalized, or discharged. This bedhold period is mandated at 15 days, unless the resident or legally authorized representative waives their right to bedhold. Billing for bedhold will be done in accordance with regulatory standards. I. Bedhold Notice Procedure A. Hospitalization Upon hospitalization, the resident or legally authorized representative shall be provided the right to bedhold via LHC form 045. This form outlines bedholds and readmission rights. The form is filled out by the Nursing Home Living Area Social Worker or nurse. For the FDD the FDD Coordinator, Health Services Supervisor, or Building Supervisor fills out the form. The white copy goes to the resident, pink copy to Health Information for mailing or legally authorized resident representative (if available), and yellow copy to SW/Chart. All residents, regardless of pay source, have the right to bedhold of 15 days. If the resident or legally authorized representative waives their right to bedhold, this will be documented on the LHC form 045 and copies distributed as above. The Social Worker/FDD Coordinator will notify the case manager/county of the hospitalization per critical incident reporting standards for that entity. When the facility is able to charge for bedhold, the Social Worker/FDD Coordinator will authorize payment for bedhold with the payor (i.e. MCO, county pay, private pay), unless the facility is able to bill Medical Assistance. The Social Worker/FDD Coordinator will track the 15 day bedhold. If the resident remains hospitalized at the end of the 15 days, the Social Worker/FDD Coordinator will notify the resident/legally authorized representative and discuss whether an extension should be considered. If the resident/representative wishes the bedhold to be extended, Social Worker/FDD Coordinator will contact payor to authorize payment for an extension. If the payor denies authorization for payment, the Social Worker/FDD Coordinator will communicate this to the resident/legally authorized representative and other interested parties and the resident will be discharged. B. Therapeutic Leave Therapeutic Leave is any resident leave/pass that includes overnight stay out of the facility. Upon leaving the facility for therapeutic leave, the resident or legally authorized representative shall be provided the right to bedhold via LHC 045. This form is filled out by the Nursing Home Social Worker or nurse. For the FDD the FDD Coordinator, Health Services Supervisor, or Building Supervisor fills out the form. The white copy goes to the resident, pink copy to Health Information for mailing or legally authorized resident representative (if available), and yellow copy to Social Worker/Chart. If the resident or legally authorized representative waives their right to bedhold, this will be documented on the LHC form 045 and copies distributed as above. If the plan is for discharge from the therapeutic visit, the physician order must indicate that (i.e. discharge date at the end of the therapeutic leave). If the resident has a payor other than Medical Assistance (i.e. MCO, county pay, private pay), the Social Worker/FDD Coordinator will inform the payor of the resident s plan for therapeutic leave and gain authorization for payment for bedhold days. IF the payor does not grant authorization for payment, the Social Worker/FDD Coordinator will communicate this to the resident/legally authorized representative and other interested parties to determine the course of action. The Social Worker/FDD Coordinator will track bedhold days and if at the end of the 15 day bedhold the resident has not returned, will contact the resident/legally authorized representative and discuss whether an extension should be considered. If the resident/representative wishes the bedhold to be extended, the Social Worker/FDD Coordinator will contact payor to authorize payment for an extension. If the payor denies

11 authorization for payment, the Social Worker/FDD Coordinator will communicate this to the resident/legally authorized representative and other interested parties and the resident will be discharged. C. Discharge Upon discharge, the resident or legally authorized representative shall be provided the right to bedhold via LHC form 045. This form outlines bedholds and readmission rights. The form is filled out by the Nursing Home Social Worker or nurse. For the FDD the FDD Coordinator, Health Services Supervisor, for Building Supervisor. The white copy goes to the resident, pink copy to Health Information for mailing or legally authorized resident representative (if available), and yellow copy to Social Worker/Chart. If the resident or legally authorized representative waives their right to bedhold, this will be documented on the LHC form 045 and copies distributed as above. If the resident, legally authorized representative, county of responsibility, or payor voices potential for the resident to return to the facility, this will be considered a Therapeutic Leave. See Section B regarding Therapeutic Leave bedhold. D. Extension of Bedhold 1. Resident or legally authorized representative and MCO (if applicable) will be given the option to extend their bedhold when the 15 day mandated bedhold period has expired. 2. Documentation of the acceptance or refusal of a bedhold extension should be made by the Living Area Social Worker/FDD Coordinator in the resident s medical record. 3. If the resident or legally authorized representative wishes an extended bedhold, the Living Area Social Worker/FDD Coordinator will notify the facility business office for billing purposes. E. Readmission Rights 1. If a resident wishes to return to the facility during the bedhold period, they will be guaranteed readmission. 2. If a resident wishes to return to the facility after the bedhold period has expired, they shall be admitted to the first available semi-private room if they are eligible for facility services and Medicaid nursing facility services. II. Bedhold Billing Procedure A. Medical Assistance Residents 1. Medical Assistance will allow billing for up to 15 days at the MA bedhold rate if Lakeview Health Center meets the bed occupancy requirements. Occupancy requirements are based on prior month patient days. 2. If Lakeview Health Center is below occupancy requirements, Medical Assistance cannot be billed, but the resident still has the right to a 15-day bedhold period. 3. If the resident or legally authorized representative and MCO/County (if applicable) wishes to extend bedhold beyond the 15-day bedhold period, they will be billed at 85% of the private pay rate. 4. Therapeutic leave bedhold shall be billed at the MA bedhold rate (if occupancy criteria were met) for up to 15 bedhold days per leave. There is no limit on the number of therapeutic leaves per year, provided physician documents necessity. B. Private Pay Residents 1. Private pay resident will be billed for up to 15 days at 85% of the private pay rate if Lakeview Health Center has met MA occupancy requirements. Occupancy requirements are based on prior month patient days. 2. If the resident or legally authorized representative chooses to extend bedhold beyond the 15-day bedhold period, they will be billed at 85% of the private pay rate. 3. Therapeutic leave bedhold rights shall apply as per MA residents, except that the resident/resident representative will be billed at 85% of the private pay rate. APPROVED Bedhold/Transfer/Discharge Notice form (Form LHC 045) is completed when a resident leaves the facility (i.e. therapeutic leave), is transferred to the hospital, or is discharged. 1. LHC 045 is filled out as resident leaves. 2. White copy is sent with the resident

12 3. Pink copy is taken to Health Information (H.I.) Department for immediate mailing to Guardian of Person/POA for Health Care. During normal work hours, Health Unit Clerks (HUCs) will bring pink copy to H.I. Department. When HUCs are not here, the person filling out the form will be responsible to get it to the H.I.Department or give to the Nursing Supervisor to put in H.I. Department. 4. Yellow copy will be folded and slid into facesheet sleeve and kept there until resident returns. HUC then will take yellow copy to H.I. Department and file in resident s overflow chart. If the resident returns on a weekend/after HUC hours, HUC will need to be sure to follow-up when returning to work. 5. A bedhold form is filled out on every resident who is transferred to the hospital, regardless of whether the resident is admitted. If resident returns the same day, the HUC notes on the yellow copy and files as above. APPROVED * * * * * PROCEDURE: BEDHOLD SOCIAL WORK TRACKING 1) Unit social worker will receive a copy of the bedhold notice at the time it is completed. Social worker will track only for hospitalization or discharge. 2) Social worker will contact responsible party/resident prior to expiration of the bedhold on day ) Social worker will notify building supervisor of the acceptance or refusal of bedhold. 4) Social worker will document in the Social Work Progress Notes the acceptance or refusal of bedhold notice. 5) Social worker will follow discharge planning procedure SW as needed. * * * * * APPROVED WINNEBAGO PARK VIEW HEALTH CENTER NOTICE OF TRANSFER Date of Notice First Contact Relationship Address Date of Transfer Destination Reason: Transferred for acute medical care (hospital) Transferred for acute psychiatric care (hospital) Other Facility Representative Date HOSPITAL BEDHOLD POLICY PRIVATE PAY: Beds are automatically held during hospitalizations at the full rate of care. Arrangements to terminate this bedhold can be made with the Business Office. Termination of bedhold cannot be made retroactively.

13 Residents choosing not to hold a bed can request to be readmitted. They will be readmitted to the next available bed as long as they require the services provided by Park View Health Center. MEDICAL ASSISTANCE RECIPIENTS: The Medical Assistance Program pays for fifteen (15) days of bedhold for hospitalization minus any income that has been determined to be available toward the cost of care. If the hospitalization is longer than 15 days, residents will be readmitted in the next available bed in a semi-private room as long as they require the services provided by Park View Health Center. Residents who anticipate being hospitalized longer than 15 days, may choose to pay for continued bedhold privately at the Medical Assistance Bedhold Rate by contacting the Business Office. You have a right to appeal this Transfer notice to the Wisconsin Division of Health, Bureau of Quality Compliance, Northeastern Regional Office, PO Box 5965, 1325 S. Broadway St., DePere, WI Telephone: Ombudsmen: Carol Kriemelmeyer, Ombudsman, Board on Aging & Long Term Care, 1045 Clark St., Suite 212, Stevens Point, WI Telephone: or For persons who are developmentally disabled or mentally ill: Wisconsin Coalition for Advocacy, 16 North Carroll St., Madison, WI Telephone: * white copy to resident * yellow copy to First Contact * pink copy - Clinical Record