Nursing Home Notice of
Involuntary Transfer or Discharge
To the Nursing Home: This notice is for an involuntary discharge or transfer. Fill out this notice for the resident you want to move. Give these pages to the resident – and to his or her representative. Also, send these pages to the State LTC Ombudsman, and the Local LTC Ombudsman. The federal rules at 42 CFR § 483.15 give more information.
Resident
Name ______Date of Birth ______
Resident Representative (if applicable)
Name ______Address ______
Phone ______
Place where resident is going (required)
Name ______Address ______
Phone ______
Current Nursing Home (and Contact Person)
Nursing Home ______Address ______Contact Person Name ______Contact Person Phone ______
Date Nursing Home Provided Notice and the Proposed Move
Nursing home gave the resident these pages on: ______
Nursing home wants to move resident on: ______
A nursing home can move a resident 30 days after it gives this page to the resident, provided a safe discharge has been arranged. The nursing home can move a resident before then if an exception applies. But the nursing home must document the exception. The resident can choose to move before the 30 days is up. This is up to the resident.
Reason for discharge or transfer: per Federal Nursing Home Regulations- CFR §483.15
The transfer or discharge is necessary to meet the resident’s welfare and the resident’s welfare 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*;
The health of individuals in the facility would otherwise be endangered*;
The resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility; or
The facility ceases to operate.
* A doctor must agree if the nursing home checks this box. The doctor must also sign the second page. Or the nursing home must attach the doctor’s written order. This could be your doctor – or the doctor at the nursing home. Or it could be a nurse practitioner or physician assistant who works for one of these doctors.
The nursing home must tell you why they want you to move. Here is what they said, about the situation, their efforts to resolve the situation and other important information:
______
______
______
You Can Get Help
You can appeal this. After following the steps of the grievance process, if you choose to continue the appeal, ultimately the State will have a hearing for your case. Also, you can get help with your appeal. See below. If you ask, the nursing home must help you with this. Talk to the Nursing Home Contact Person on the first page. And the nursing home must help you call the people below. Contact the local ombudsman if you have concerns about pursuing your appeal.
You Can Appeal
You have the right to appeal the nursing home’s decision to transfer or discharge you. If you think you should not be transferred or discharged, you may appeal to __ (staff designee). If you do not wish to handle the appeal yourself, you may use an attorney, relative or friend. If your appeal is not resolved to your satisfaction by the staff designee, you can continue your appeal to the nursing care facility’s grievance committee and, if necessary, the Colorado Department of Public Health and Environment at 4300 Cherry Creek Drive South, Denver, CO 80246; phone number 303-692-2000 or toll free 800-886-7689.
If you have questions or complaints about the transfer or discharge or would like help to appeal, call or write the State or Local Long-Term Care Ombudsman.
State LTC OmbudsmanLocal LTC Ombudsman
c/o Disability Law Colorado______
455 Sherman St., Suite 130______
Denver CO 80203______
303 722-0300 or 1 800 288-1376______
For Residents Who live with Developmental Disabilities or Residents who live with Mental Illness:
If you have questions or complaints about the transfer or discharge or would like help to appeal, call or write Disability Law Colorado, 455 Sherman St. #130, Denver, CO 80203; phone number 303-722-0300 or toll free 800-288-1376 or you can send an email request to
How to Appeal
If you want to appeal, you can submit an appeal to the nursing home administrator. If you need assistance with your appeal you can callyour local Long-Term Care Ombudsman at OR If contact information for your local Long-Term Care Ombudsman is not readily available, you can call Disability Law Colorado at 303-722-0300 or toll free at 1-800-288-1376 to get the contact information for your local Long-Term Care Ombudsman.
Procedure and timeline is applicable to appeals of 30-day discharge notices as well as general grievances.
-Grievances and Discharge notices: Resident, resident representative or Resident Council presents grievance orally or in writing within 14 days of incident or nursing home presents resident or resident’s representative with written 30 day notice of discharge.
-Staff designee confers with persons involved in incident or other relevant persons provides written findings to the complainant (resident or resident’s representative) within 3 days of receipt of the grievance or discharge notice.
The nursing home is required to have a Grievance Committee (comprised of the Nursing Home Administrator or his or her designee, a resident selected by the facility’s residents, and a 3rd person agreed upon by the Nursing Home Administrator and the facility’s resident representative).
-If complainant is dissatisfied with findings of staff designee, or disagrees with the facility’s decision to follow through with discharge, complainant/resident or resident’s representative may file an appeal to the Grievance Committee within 10 days of receipt of the staff designee findings.
-Grievance Committee confers regarding complaint or discharge notice and provides written explanation of the findings to the complainant/resident or resident’s representative within 10 days of the date of the appeal.
-If the complainant/resident or resident’s representative is dissatisfied with the findings of the Grievance Committee, he or she (or the resident’s representative) may file an appeal to the Executive Director of the Colorado Department of Public Health and Environment-Health Facilities Division within 10 days of the receipt of the Grievance Committee’s written findings.
-If the complainant/resident or resident’s representative is dissatisfied with the findings of the Executive Director of the Colorado Department of Public Health and Environment-Health Facilities Division the complainant/resident or resident’s representative may file an appeal within 30 days of receipt of the findings of the Department and ask that the Department set the matter for hearing which may be conducted by the Department, an administrative law judge from the Office of Administrative Courts or a hearing officer appointed by the Department.
I gave these completed pages to the resident:
______
Nursing Home Administrator/Designee Name Signature Date
______
Physician/Designee Name (When Required) Signature Date
I received these pages:
______
Resident or Representative Name Signature Date
Notice given to:
Resident / ______(Date)Resident’s Representative / ______(Date)
Resident Clinical Record / ______(Date)
Local LTC Ombudsman / ______(Date)
State LTC Ombudsman / ______(Date)
To the Nursing Home: Send these pages to the Colorado Department of Public Health and Environment designee, the State LTC Ombudsman, and the Local LTC Ombudsman at:
Local Ombudsman address
Name
Phone number
State Long-Term Care Ombudsman
Disability Law Colorado
455 Sherman St. #130
Denver, CO 80203
303-722-0300 FAX 303-722-0327
Email:
Contact information for each Local LTC Ombudsman is at
Revised 11/20171