Discharge Planning from a Skilled Nursing Facility 

The Discharge Planning Process
Under the Illinois Nursing Home Care Act and federal regulations, the facility’s interdisciplinary team must create an effective, individualized discharge plan. This plan must ensure a safe transition to the next care setting by assessing and addressing the residents’ medical, functional, and social needs.

During this process, the facility must:

• Involve key individuals: The residents and their representatives must participate in developing the plan.
• Evaluate the support system: The team must assess the availability and capability of family members or caregivers who will assist the resident.
• Provide necessary training: If family members are taking over care, the facility should arrange education for tasks like wound care, medication administration, or safe physical transfers.
• Coordinate post-discharge care: The facility must arrange required services and equipment, including durable medical equipment (DME), home health services, follow-up medical appointments, transportation, and medication management.
• Perform medication reconciliation: Federal law requires a thorough comparison of the residents’ pre-discharge medications against their post-discharge prescriptions.

Notice Requirements
There are two separate notice processes that residents and families must understand:

1. Involuntary Facility Discharge Notice (Illinois Law): To legally remove a resident against their will, the facility must provide at least 30 days' written notice (subject to limited statutory exceptions). This notice must state the reason for discharge, the effective date, the new location, and instructions on how to appeal the decision through the Illinois Department of Public Health (IDPH).

2. Medicare Non-Coverage Notice (Federal Law): When Medicare-covered skilled services are ending, the facility must issue a Notice of Medicare Non-Coverage (NOMNC) at least two days before coverage terminates. Note: This only stops Medicare payment; it is entirely separate from an involuntary discharge from the building itself.

Protections and Appeal Rights
If a resident or family member believes a proposed discharge is unsafe, inappropriate, or medically unsound, they should immediately exercise their appeal and grievance rights.

Families can seek immediate assistance from:

• The Illinois Department of Public Health (IDPH)
• The State Long-Term Care Ombudsman
• The resident's primary physician
• Legal Counsel

To protect the residents, families should submit a written request to the facility demanding the proposed discharge plan, the clinical basis for the discharge, the destination, a list of arranged services/equipment, and documentation proving how the resident's post-discharge needs will be met.