Can nursing home residents leave for the day? Outings, holiday visits, and the ride there

A nursing home resident can leave for a family meal, a holiday or an afternoon outing, and the home is expected to help. Federal rules protect the resident’s right to take part in activities outside the building. For a Medicare resident, an outing that ends before midnight changes nothing about coverage. This page is for families and nursing home staff planning an outing, and it ends with the part that trips people up: the ride.

The home’s duty to arrange rides to medical appointments is a separate subject, covered in do nursing homes provide transportation. Below is what applies when the destination is a dining room table instead of a doctor’s office.

Can a resident go out for the day?

Yes. A resident has the right to take part in community activities inside and outside the home, and to choose activities and schedules that fit his or her interests, assessments and care plan (42 CFR 483.10(f)). CMS’s guidance to inspectors goes further. It says a resident’s choices about how to spend time outside the facility should be supported “including making transportation arrangements,” and its example is a resident who wants to attend family gatherings, whose goal should be accommodated to the extent possible.

The outing belongs in the resident’s care plan. CMS calls an absence for any reason other than a required hospital stay “therapeutic leave,” and says it has to be consistent with the resident’s goals, assessed in the comprehensive assessment and written into the care plan. It also says leave cannot be used as a way to discharge a resident against their wishes.

The resident’s assessments and care plan shape how an outing works. The home may have its own procedure, and a state’s rules can add requirements, such as a doctor’s approval or a record of where the resident is going. Ask the nurse for the home’s leave policy at least a few days before a holiday, when many families ask at once.

Does a day out change Medicare coverage?

A day out does not change Medicare coverage when the resident is back before midnight. The rule that matters is midnight. Medicare counts days of nursing home care from one midnight to the next, and the home keeps billing as usual for a resident who leaves and returns before the following midnight. An outing that ends at 9 p.m. is an ordinary day. These rules come from Medicare’s manuals for original Medicare. For a Medicare Advantage plan, ask the plan and the home how a leave is handled.

An overnight stay is a leave of absence, and Medicare treats it differently:

• The days away. The day the leave starts is not counted as an inpatient day unless the resident is back by midnight, and the day of return counts only if the resident is in the building at midnight. The home reports the leave days with zero charges.
• The stay itself. An overnight leave does not end the covered stay. Medicare’s billing manual draws its line at 30 consecutive days: if an absence runs longer, the resident has to meet the three-day hospital stay and 30-day transfer rules again.
• The bed. Medicare does not pay to hold the bed during the leave. The home may offer to hold it for a daily fee, but only if it told the resident about the option and the amount in advance and the resident chose it. A home cannot treat silence as a yes and bill when the resident leaves.

Medicare’s manual also speaks to the fear behind the question. It says a pass or short leave for a religious service, holiday meal, family occasion, car ride or trial visit home is not, by itself, evidence that the resident no longer needs skilled care. If outings become frequent or long, the Medicare contractor can ask whether the care can be given outside the home. The manual says a home should not warn residents that leaving will cost them coverage, because that notice is not appropriate.

What does a Medicaid resident need to know?

The state’s Medicaid plan decides how many leave days it pays the home to keep the bed, so the rules vary. Federal regulations do not require states to pay for bed-holds at all, and CMS tells inspectors that state plans differ in both payment and number of days. Three examples:

• New York. Medicaid pays to reserve the bed during a leave to visit friends or relatives, but only for a day the resident is away overnight, meaning past the time the home takes its census. The resident must have lived in the home at least 30 days, and the home’s vacancy rate on the first day of leave can be no more than 5 percent. The first 18 reserved bed days in any 12-month period need no prior authorization, and a home must reserve the same bed and room when the care plan provides for leave, unless a medical reason makes that unwise. A day trip that ends before the census does not use any of the 18.
• California. Medi-Cal pays for up to 18 days of leave a calendar year for most residents, and up to 12 more when the extra days fit the care plan. Leave for a visit with relatives or friends qualifies. The attending physician has to approve it in writing with instructions, and the home’s record has to show the address the resident is going to and the dates.
• Washington. The state pays for up to 18 days of social or therapeutic leave per resident per calendar year, and more only with prior authorization. The home has to document in the clinical record any leave longer than 24 hours, and the resident keeps nursing home resident status while away.

A resident who goes over a state’s limit can still go out. The days beyond the limit are ones the state does not pay for, and CMS says the resident could use his or her own income to hold the bed. A resident who does not pay can still return, to the previous room if it is open or to the first available bed in a semi-private room, as long as the resident still needs nursing facility services and is eligible for Medicare or Medicaid coverage of them (42 CFR 483.15(e)).

What notice should the home give before the outing?

A nursing facility must give written bed-hold information before a resident goes on therapeutic leave (42 CFR 483.15(d)). CMS describes two notices. The first can be handed over well in advance, for example in the admission packet, and it has to be reissued if the state or the home changes its policy. The second goes to the resident and, if there is one, the resident’s representative when the leave begins.

The notice has to state how long the state will hold the bed, how reserve bed payments work, the home’s own bed-hold policy, and the conditions for returning. CMS says homes must give this information to every resident regardless of who pays. A family planning the first holiday can ask the social worker for the notice a week ahead, so there are no surprises about a daily charge.

Signing out, medications and timing

Check three things with the nurse before the day: whether the doctor needs to approve the outing, which medications fall due while the resident is out and how they will be handed over, and the time the resident is expected back. Each home sets its own sign-out steps, and states can add rules, as California’s destination-and-dates record shows.

If the resident is on Medicare and the outing might run late, build in a cushion to be back before midnight. That one decision is what separates an ordinary day from a leave day.

A late return is not a discharge. CMS tells inspectors that a home must not treat a resident who comes back from therapeutic leave later than agreed as discharged. The resident has to be allowed to return, checked for any ill effects of being away longer than expected, and given any medications or treatments that were missed.

How does the resident get there and back?

The ride for a holiday or a family dinner is not a Medicaid trip. Medicaid transportation pays for expenses to reach medical examinations and treatment (42 CFR 440.170(a)), and a social outing is neither. The choice is between the family car and a private-pay ride, and the home may help with the arrangement because CMS expects it to support residents’ outings.

• The family car. It works when the resident can move into a car seat safely and the wheelchair or walker folds into the trunk. Ask a nurse or therapist how much help the transfer takes, and whether it takes one person or two, before the day, not at the curb.
• A wheelchair van. A private-pay wheelchair van is the usual answer when the resident stays in the wheelchair or needs more than one person to transfer. Prices for these rides are in wheelchair transportation cost.

When you book a private ride, tell the company:

• The type of wheelchair or walker, whether it folds, and the weight of the resident with the chair.
• Whether the resident needs help from the room door to the vehicle, and from the vehicle to the family’s door.
• Any oxygen or other equipment that must travel with the resident.
• Who will ride along, and who at the home signs the resident out and in.
• The time to pick up and the time the resident must be back, with a note if the return must be before midnight.

How a driver handles the pickup at the nurse’s station is covered in nursing home pickups and returns.

For ride companies asked to take a resident out for the day

A family outing ends when the family says it does, so the return time is a guess. In HealthRide a return trip can be booked as a will-call trip, which waits on the dispatch board and becomes an active trip the moment the resident is ready to go. The dispatcher can also see which vans fit the resident’s wheelchair, because wheelchair, stretcher and oxygen needs are matched when the trip is booked. See the dispatch board.