Department of Health

Office Hours
Monday to Friday, 8:15 am to 4:45 pm, except District holidays

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899 North Capitol Street NE, Washington, DC 20002
Phone: (202) 442-5955
Fax: (202) 442-4795
TTY: 711
Email:doh@dc.gov

Ask the Interim Director

Agency Performance

Saul M. Levin, M.D., M.P.A.

Interim Director, DC Department of Health

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DOH Notice of Discharge Transfer or Relocation Form

NOTICE OF DISCHARGE OR TRANSFER FROM A NURSING FACILITY OR RELOCATION WITHIN A NURSING FACILITY

Health Regulation and Licensing Administration

Name of Nursing Facility

Address of Nursing Facility

City

State

Zip

Nursing Facility

Resident's Name

Resident's Representative

Representative's Email

Date

Month

Day

Year

Resident's representative" means (A) Any person who is knowledgeable about a resident's circumstances and has beendesignated by that resident to represent him or her; (B) Any person other than a facility who has been appointed by a courteither to administer a resident's financial or personal affairs or to protect and advocate for a resident's rights; or (C) The Long-Term Care Ombudsman or his or her designee, if no person has been designated or appointed in accordance withsubparagraphs (A) and (B) of this paragraph.

Both DC Law 6-108 and Federal regulations require that this facility provide you with specific information, and because this facility is licensed in the District of Columbia and is a participant in the Medicare and/or Medicaid program(s), all such requirements must be met.

WHO SHOULD RECEIVE THIS NOTICE: This notice must be delivered to you, the resident, and your representative.

WHEN SHOULD YOU RECEIVE THIS NOTICE: You should receive this notice at least thirty (30) days prior to the date oftransfer or discharge from the facility. You should receive this notice at least seven (7) days prior to a relocation within the facility.The time periods for notification may be changed by physician order, consent by the resident or the resident's representative or adetermination by the Long-term Care Ombudsman.

REQUIRED CONTENTS: The following should be completed by the provider.

(1) This proposed action is a

a) Transfer

b) Discharge

c) Relocation

(2) The specific reason(s) for this action is as follows:

(3) You are scheduled to be discharged, transferred or relocated on or by (date)

(4) Your destination is

(5) If you are being transferred to a hospital or the transfer is for therapeutic leave, attached is this facility's bed-holdpolicy.Your available number of bed-hold days is

(6) The following person from the facility is responsible for supervising the discharge, transfer or relocation:

Name:

Address:

Telephone:

Email *

(7) You may contact the DC Long-Term Care Ombudsman as follows:
     DC Long-Term Care Ombudsman Program
     Legal Counsel for the Elderly
   601 E Street, NW, Building A-4th Floor
     Washington, DC 20049
     Tel. (202) 434-2190, Fax (202) 434-6595

(8) If you have a developmental disability, you may also contact:
      Laura Nuss, Director
   Department of Disability Services
    1125 15th Street, N.W.Washington, D.C. 20005
   Attn: Transfer/Discharge of Resident from Nursing Home
    Tel. (202)730-1700, Fax (202)730-1843

(9) If you have a mental health issue, you may also contact:
    Stephen T. Baron, Director
    Department of Mental Health
    64 New York Avenue, N.E., 4th Floor
    Washington, D.C. 20002
    Attn: Transfer/Discharge of Resident from Nursing Home
    Tel. (202) 673-7440, Fax (202) 673-3433

(10)Please find attached a Hearing Request Form and a statement of your hearing rights, together with a postage paidenvelope preaddressed to the appropriate District official or agency.

Provider's signature:(INITIALS)

Date:

Resident's signature:

Date:

Resident's Representative:

Date:

Continued Compliance with DC Law 6-108 Required

When a resident is transferred or discharged from a nursing facility the nursing facility is required to comply with standards set forth in the Nursing Homes and Community Residence Facilities Residents' Protection Act , DC Law 6-108 (DC Official Code § 44-1003.01 et seq.). Evidence that the resident and/or family member and/or responsibleparty have been given the reasons for, procedures for contesting and proposed effective date of discharge, transferor relocation must be maintained in the resident’s record. Documents must be written in accordance with District of Columbia Official Code §44-1003.02 through §44- 1003.08.

Enclosures:

DC Long-Term Care Ombudsman Program
Legal Counsel for the Elderly
601 E Street, NW, Building A-4th Floor
Washington, DC 20049

Appeal Rights Request for Hearing Form:

Sharon Lewis, DHA, RN-BC, CPM
Program Manager
Health Regulation and Licensing Administration
Department of Health
899 North Capitol Street, NE, 2nd Floor
Washington, DC 20002

Wayne Turnage, MPH, Director
DC Department of Health Care Finance
Medical Assistance Administration
899 North Capitol Street, NE, 6th Floor
Washington, DC 20002

YOUR APPEALS RIGHTS

In Accordance with the Nursing Home and Community Residence Facility Residents' Protection Act of 1985, DC

Law 6- 108

(Transfer, Discharge, Relocation)

You have a right to challenge this facility's decision to discharge, transfer, or relocate you. If the decision is to discharge you from the facility or to transfer you to another facility and you think you should not have to leave, you or your representative have 7 days from the day you receive this notice to inform the Administrator [Residence Director, if a community residence facility] or a member of the staff that you are requesting a hearing and to complete the enclosed hearing request form andmail it in the preaddressed envelope provided. If you are mailing the hearing request form from the facility, the day you placeit in the facility's outgoing mail or give it to a member of the staff for mailing shall be considered the date of mailing forpurposes of the time limit. In all other cases, the postmark date shall be considered the date of mailing. If, instead, thedecision is to relocate you within the facility and you think you should not have to move to another room, you or your representative have only 5 days to do the above.

If you or your representative request a hearing, it will be held no later than 5 days after the request is received in the mail,and, in the absence of emergency or other compelling circumstances, you will not be moved before a hearing decision isrendered. If the decision is against you, in the absence of an emergency or other compelling circumstances you will have at least 5 days to prepare for your move if you are being discharge or transferred to another facility, and at least 3 days toprepare for your move if you are being relocated to another room within the facility.

To help you in your move, you will be offered counseling services by the staff, assistance by the District government if you are being discharged or transferred from the facility, and, at your request, additional support from the Long-Term Care Ombudsman program. If you have any questions at all, please do not hesitate to call one of the phone numbers listed below for assistance.

DC Long-Term Care Ombudsman Program
Legal Counsel for the Elderly
601 E Street, NW, Building A-4th Floor
Washington, DC 20049
el. (202) 434-2190, Fax (202) 434-6595

Laura Nuss, Director
Department on Disability Services
1125 15th Street, NW
Washington, DC 20005
Attn: Transfer/Discharge of Resident from Nursing Home
Tel. (202) 730-1700, Fax (202) 730-1843

Stephen T. Baron, Director
Department of Mental Health
609 H Street, NE, 5th Floor
Washington, DC 20002
Attn: Transfer/Discharge of Resident from Nursing Home
Tel. (202) 673-2200, Fax (202) 673-3422