Hospital to Skilled Nursing Facility Virginia — How Transfers Work

The Transfer Is Not as Simple as Finding a Bed

When a Virginia hospital tells you that your parent needs to move to a skilled nursing facility for rehabilitation, the implication is that the process is routine. The discharge planner will make some calls, a facility will accept the patient, and the transfer happens within a day or two.

The reality involves at least three administrative systems that must align before the transfer can proceed — and if any one of them stalls, your parent either stays in an expensive hospital bed past their welcome or gets discharged to a destination that cannot provide the care they need.

Understanding these systems before the discharge planner starts making calls gives you the ability to track the process and catch gaps before they become crises.

PASRR Screening: The Federal Requirement

Before any patient can be admitted to a Medicaid-certified skilled nursing facility in Virginia — regardless of who is paying — the facility must complete a Pre-Admission Screening and Resident Review (PASRR). This is a federal requirement, not a state one, and it applies to Medicare patients, private-pay patients, and Medicaid patients alike.

The PASRR Level I screening is a brief evaluation that determines whether the patient has a serious mental illness, an intellectual disability, or a related condition that might require specialized services beyond what a standard nursing facility provides. If the Level I screen identifies a potential condition, a more detailed Level II evaluation is required before admission.

In practice, the hospital discharge team handles the PASRR paperwork. But it is one more item on a discharge planner's list, and delays in completing the screening can hold up the transfer. Ask the discharge planner directly whether the PASRR has been submitted and when they expect clearance.

LTSS Screening: The Medicaid Gate

If your parent will need long-term custodial care — not just short-term Medicare-covered rehabilitation — a separate screening is required. Virginia's Long-Term Services and Supports (LTSS) screening determines whether the patient meets the functional criteria for Medicaid-funded nursing home care or the CCC Plus home-based waiver.

This screening is different from the PASRR. It is conducted by a certified team that includes a Registered Nurse as the primary screener, and it must be entered into the state's electronic Medicaid LTSS Screening (eMLS) portal. The screening evaluates functional dependencies in activities of daily living — bathing, dressing, transferring, eating, toileting, and mobility.

Here is why this matters for the transfer timeline: under DMAS regulations, if a nursing facility admits a Medicaid or Medicaid-pending resident to a custodial bed without a valid LTSS screening marked "Accepted Authorized" in eMLS, the facility faces a mandatory six-month Medicaid reimbursement penalty. If the patient is transferring directly into a custodial bed, ask for the screening to be completed before transfer. When a patient enters under a non-Medicaid skilled stay, nursing-facility staff can perform certain post-admission screenings before the transition to custodial care.

Request the LTSS screening as soon as the clinical team indicates your parent may need long-term care. The hospital's screening team can perform it during the inpatient stay. If you wait until after discharge, the appropriate team depends on the setting: a community-based team may screen at home, while nursing-facility staff can perform certain post-admission screenings after a non-Medicaid skilled stay.

Choosing a Facility

The discharge planner will typically present a list of facilities with available beds. Three factors matter more than the facility's brochure:

Medicare certification and star rating. Check the facility's rating on Medicare's Care Compare tool. A one-star or two-star facility may have available beds precisely because families with options avoid it.

Cardinal Care MCO network. If your parent is enrolled in a Cardinal Care managed care plan — Anthem, Aetna, Humana, Sentara, or UnitedHealthcare — the SNF must be in-network with that specific MCO. An out-of-network facility may refuse to coordinate with the plan, creating billing complications that land on the family.

Medicaid acceptance. If the rehabilitation stay may extend beyond Medicare's 100-day coverage limit into long-term custodial care, verify that the facility accepts Medicaid and has beds designated for Medicaid-funded residents. Some facilities accept Medicare for short-term rehab but limit Medicaid admissions, which means your parent could face an involuntary transfer once Medicare coverage ends.

The Home Care Alternative

Not every patient needs to transfer to a facility. If the physician determines that the patient can recover at home with clinical support, two pathways exist:

Medicare home health covers short-term skilled services — registered nurse visits, physical therapy, occupational therapy — for patients who are homebound and need intermittent skilled care. The patient does not need a qualifying three-day inpatient stay for home health. Medicare covers the services directly through a certified home health agency.

The CCC Plus waiver covers long-term home and community-based services for patients who meet nursing facility level of care but choose to receive care at home. The LTSS screening determines eligibility, and services include personal care aides (subject to an approximately 56-hour-per-week soft limit), adult day care, home modifications, and respite care for family caregivers.

The decision between facility placement and home care depends on the clinical complexity of the care needs, the availability of a family caregiver, and the home's physical accessibility. The hospital discharge team should present both options — if they only mention facility placement, ask about home health and the CCC Plus waiver.

Coordinating the Transfer

The transfer itself has a specific sequence that the discharge planner should manage but that you should monitor:

1. Confirm inpatient status and the three-midnight count (for Medicare SNF coverage)
2. Verify PASRR clearance
3. Request LTSS screening if long-term care is anticipated
4. Contact selected facilities to confirm bed availability and insurance acceptance
5. Ensure the physician writes discharge orders that include the SNF admission, medication reconciliation, and therapy recommendations
6. Arrange medical transport if the patient cannot safely travel by private vehicle

Our Virginia hospital discharge guide includes a facility evaluation checklist, the LTSS screening request procedure, and a transfer coordination timeline that tracks each of these steps against your parent's discharge date.

See more Virginia guides →