CMS SOM App. B, Tag G454

[…The HHA may only transfer or discharge the patient from the HHA if:]

(1) The transfer or discharge is necessary for the patient’s welfare because the HHA

and the physician or allowed practitioner who is responsible for the home health plan

of care agree that the HHA can no longer meet the patient’s needs, based on the

patient’s acuity. The HHA must arrange a safe and appropriate transfer to other

care entities when the needs of the patient exceed the HHA’s capabilities;

Interpretive Guidelines §484.50(d)(1)

When a patient’s care needs change to require more than intermittent services or require

specialized services not provided by the agency, the HHA must inform the patient,

patient representative (if any), and the physician or allowed practitioner who is

responsible for the patient’s home health plan of care that the HHA cannot meet the

patient’s needs without potentially adverse outcomes. (As noted in §484.2, “allowed

practitioner” means a physician assistant, nurse practitioner, or clinical nurse specialist

as defined at this part.) The HHA should assist the patient and his or her representative

(if any) in choosing an alternative entity by identifying those entities in the patient’s

geographic area that may be able to meet the patient’s needs based on the patient’s acuity.

Once the patient chooses an alternate entity, the HHA must contact that entity to facilitate

a safe transfer. The HHA must ensure timely transfer of patient information to the

alternate entity to facilitate continuity of care, i.e., the HHA must ensure that patient

information is provided to the alternate entity prior to or simultaneously with the

initiation of patient services at the new entity.

Also see the discharge planning requirements at §484.58 and the requirements at

§484.110(a)(6)(ii) regarding time frame for the transfer summary.