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guardian for the transfer or discharge (except in emergencies).

Guidance §483.440(b)(4)(ii)

The client and their family or the client and their legal guardian are involved in planning for any

transfer or discharge and receive the services necessary to assist in preparing for movement,

unless an emergency (medical) situation prevents that involvement. If the client has an

advocate, the advocate should participate in the decision-making process.

Orderly, planned transfers and discharges usually take place over an extended period of time.

The IPP should reflect objectives or interventions which prepare the client for transfer or

discharge. Transfers or discharges executed on short timeframes (e.g. less than 30 days) without

“good cause” would not comply with the “reasonable” intent of the regulations.

“Reasonable” time is the time required to provide clients and their families with planned steps

and established timeframes to facilitate the successful transition. Time frames are modified

based on client needs and emergent situations.

Preparation of the client for transfer may include orientation or trial visits to the new location.

Staff should take steps to minimize potential anxiety or any behavioral reactions which could

result from the client’s transfer.

§483.440(b)(5) At the time of the discharge, the facility must-