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Discharge Planning Beyond the Day of Discharge – Part 2

By October 1, 2019C&A Blog

The Discharge Planning process and actual Discharge Plan have often been overlooked or at least have become one of those processes that most staff just go through the motions on.  Surveyors are digging deep into these processes to ensure that patients truly understand the discharge plan and have received appropriate planning activities to meet their ongoing needs.  The deficiency most often cited is one where an organization cannot provide a Discharge Plan in a written format that includes: assessment, reassessments, criteria used for assessments, discharge instructions that are legible, culturally sensitive, in a language the patient prefers and is specific to the level of care they are receiving (LTC, Home Health, etc.).

CMS surveyors utilize a worksheet as a tool to determine compliance with discharge planning activities within an acute care facility.  Compliance is based on many factors within the Condition of Participation and associated standards. The CMS Condition of Participation (CoP) can be found at §482.43 Condition of Participation: Discharge Planning.

There is a distinct difference between Discharge Planning, Discharge Education and the actual Discharge Plan.  Discharge planning is an ongoing process that must be re-assessed when patient condition changes, when their post-discharge needs may have changed or when circumstances would suggest the need for additional/updated planning activities.  Planning is the arrangement for services, medical equipment, follow-up appointments and other assistance necessary for Daily Living Activities. Discharge education is teaching the patient ‘how’ to perform certain task within the discharge plan. The discharge plan is the actual document provided to the patient, in a manner they prefer, that outlines post-hospital care instructions and follow-up appointment information.

Acute Care Organizations should have effective processes to ensure this CoP is met “The hospital must have in effect a discharge planning process that applies to all patients. The hospital’s policies and procedures must be specified in writing.

In addition to the policies and procedures being in writing, hospitals must also address: “Patients not initially identified as in need of a discharge plan: a) Does the discharge planning policy address circumstances where changes in patient condition would call for a discharge planning evaluation in patients not previously identified as needing one? and b) Are inpatient unit staff aware of how, when, and whom to notify of such changes in patient condition in order to trigger a discharge planning evaluation?”

Discharge Planning is and must be an ongoing process that begins as early in the admission as possible, include an identification of patients in need of discharge planning and have the capabilities to implement discharge planning criteria once a patient’s condition changes to necessitate these planning activities.

Discharge Planning activities must be conducted by qualified personnel (§482.43(b)(2)A registered nurse, social worker, or other appropriately qualified personnel must develop, or supervise the development of, the evaluation) and must be completed on a timely basis (§482.43(b)(5) – The hospital personnel must complete the evaluation on a timely basis so that appropriate arrangements for post-hospital care are made before discharge, and to avoid unnecessary delays in discharge).

All surveyors understand that discharge planning begins at admission (in most cases), but often find that these activities do not continue with the patient as the patient needs change, their level of care changes or their home circumstances change.  The most often missing piece from discharge planning activities is found at §483.43(e) Standard: Reassessment; “The hospital must reassess its discharge planning process on an on-going basis. The reassessment must include a review of discharge plans to ensure that they are responsive to discharge needs”.  This ongoing basis may appear in nursing notes, in progress notes, in care team meetings, in multidisciplinary meetings or in other medical record documents.  It is beneficial to the organization to educate staff on where these on-going assessments / re-assessments can be found during medical record review.

The ultimate result of all discharge planning activities is to develop a comprehensive discharge plan that identifies the patients needs for medical equipment, daily living activities, need for home health services or other barriers that if not effectively addressed may lead to a readmission for the patient.  Discharge plans must be presented to the patient before discharge, in a language they prefer, in a manner they understand and contain follow-up or additional appointment information.  An additional component that is often sought after by surveyors include: instructions to the patient on how to care for a wound, what to do in the event of a fever or who to call in the event that their condition worsens.

The CMS worksheet is a wonderful tool in assisting hospitals assess their discharge planning processes.  Surveyors are now looking beyond the discharge plan and discharge planning process to determine compliance – discharge planning activities must be included in the organizations QAPI program.

  • Does the hospital review the discharge planning process in an ongoing manner, e.g. through QAPI activities?
  • Does the hospital track its readmissions as part of its review of the discharge planning process?
  • Does the hospital’s assessment of readmissions include an evaluation of whether the readmissions were potentially due to problems in discharge planning or the implementation of discharge plans?
  • If the hospital identified preventable readmissions and problems in the discharge planning process were identified as a possible cause, did it make changes to its discharge planning process to address the problems?


There is no magical solution for or ways around the Discharge Planning process, Discharge Plan, Assessment and Re-assessment components of the Condition of Participation.  The Joint Commission requires the same elements for discharge planning.  Surveyors interpret regulations literally.  When a standard states “Hospitals MUST” do something, something must be evident.  Each CMS standard for discharge planning indicates a ‘must’.  That means surveyors are looking for ‘something’ that (evidence) that indicates the ‘must’ has been performed.  Remember – discharge planning must begin early in the admission, be in a language the patient prefers and must cover the assessed needs of the patients to whatever level of care they are moving towards.

CMS Discharge Planning Worksheet link: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15-12-Attachment-3.pdf


James Ballard

Author James Ballard

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