This program will cover the new changes to the discharge planning standards that became effective November 2019 and published in the February 21, 2020 manual. It is anticipated CMS will publish revised interpretive guidelines and survey procedures to match the new regulations in 2021.

1. Discharge Planning: Compliance with
CMS Hospital and CAH CoPs 2021
Presented By
Ms. Laura A. Dixon (BS, JD, RN, CPHRM)

2. Deficiency Data Discharge Planning
Tag
Number
Section March 5, 2021
799 Discharge Planning (DP) 103
800 DP Evaluation 99
806 DP Needs Assessment 146
808/809 Qualified DP Staff 33
810 Timely DP Evaluation 59
2

3. Deficiency Data Discharge Planning
Tag Section
811 Documentation & Evaluation 56
812 Discharge Planning 39
818 DP Personnel 19
819 MD Required DP 3
820 Implementation of DP 215
3

4. Deficiency Data Discharge Planning
Tag Section
821 Reassess DP 148
823 List of HH Agencies 90
837 Transfer or Referral 149
843 Reassess DP Process 81
Total 1,240
4

5. “IMPACT” Act
 Federal law: “Improving Medicare Post-Acute Care
Transformation Act of 2014”
 Passed to:
 Standardize information collected between the four post-
acute care providers (PACs)
 Improve quality of care across the provider settings and
reduce readmissions
 Wanted to improve hospital and discharge planning
 Required CMS to revise the hospital CoPs
 Review every five years for with the interpretive guidelines
5

6. Discharge Planning – Overall
 The hospital must have an effective discharge
planning process that focuses on:
 Patient goals and
 Treatment preferences
 Example:
 88-year-old female who had significant surgery on her foot
 Physician wants her to go to LTC for a week to rehab
 Patient wants to go home and be cared for her daughter, a
nurse
6

7. Discharge Planning
 CMS: best practice to give the caregiver hospital
contact information to discuss early concerns about
the discharge plan or discharge instructions
 Not required to give the patient/caregiver a copy of
the discharge plan
 Some hospitals do regardless
 The patient can request a copy of the discharge plan
7

8. Discharge Planning Process
 Discharge plan must ensure an effective transition
from the hospital to post-discharge
 Generally – process is started when the patient is first
admitted
 The nurse will ask questions during the admission
assessment – process starts here
– Are they able to do activities of daily living at home like can they take their
own shower or fix their own meals
 Include in the nursing assessment what are the
patient’s goals of care and treatment preferences
8

9. Discharge Planning Process
 The hospital’s discharge planning must identify at
an early stage those patients who are likely to suffer
adverse health consequences when discharged
 High-risk patient in the emergency department with a
history of COPD, diabetes, and depression
 Patient admitted for outpatient surgery who has many
medical problems and a lack of a caregiver to help out
 Patient placed in an outpatient observation unit who is
going to need home oxygen, medications, a walker or
other equipment
9

10. Discharge Information and Decision
 Discharge or transfer summaries should not be
delayed to wait for the physician signature
 It can be sent and then updated later with the signature
 CMS: H&Ps, progress notes and transfer summaries can
be signed by the licensed practitioners responsible for the
care of the patient
 Federal EMTALA law says a transfer decision can
only be made by a physician
 If NP or PA are in the CAH emergency department they
can sign it and the physician can sign later
10

11. Assessment of Discharge Planning Process
 Hospital must assess its discharge planning
process on a regular basis
 To determine any changes in the patient’s condition
 Assessment must include an ongoing, periodic
review of a representative sample of discharge
plans
 Includes patients readmitted within 30 days
11

12. Discharge Planning 2020
 Standard: The hospital must have a discharge
planning (DP) process that applies to all patients
(799)
 Include the caregivers/support person in the discharge
planning for post-discharge care
 Focus on patient goals and treatment preferences
 Discharge process and plan must be consistent with the
goals and preferences
 Must ensure an effective transition from hospital to post-
discharge care and reduce factors for readmission
 Guidelines are pending
12

13. CAH Policies and Procedures
 CAH must have an effective discharge planning
process under Appendix W
 The requirements are very similar to those
required for hospitals under Appendix A
 Are a few differences
 Discharge planning must focus on the patient’s
goals and treatment preferences
 It must include patients and their representatives as
active partners in the discharge planning process
 Patients have timely access to their medical records
13

14. CMS Discharge Planning Worksheet
 CMS has three worksheets
 Discharge planning
 Infection Control
 QAPI
 Link has been attached as a resource
 No longer used by CMS
 Are an excellent self-assessment tool
14

15. 15
15
15
Thanks for Reading
Register for the Webinar
Discharge Planning: Compliance with CMS
Hospital and CAH CoPs 2021
For more information, contact us and visit us at:-
Visit :- https://conferencepanel.com/
Call :- +1-800-803-7592
Email :- cs@conferencepanel.com