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CMS HOSPITAL CONDITIONS
OF
PARTICIPATION
Discharge Planning Standards
2023
2
Speaker
▪ Laura A. Dixon, Esq.
▪ BS, JD, RN, CPHRM
▪ President, Healthcare Risk
Education and Consulting, LLC
▪ 303-955-8104
▪ ldesq@comcast.net
▪ Email questions to CMS:
Critical Access Hospitals: qsog_CAH@cms.hhs.gov.
Acute hospitals: qsog_hospital@cms.hhs.gov.
2
2
Deficiency Data Discharge Planning
Tag
Number
Section June 2023
799 Discharge Planning (DP) 120
800 DP Evaluation 106
802 Re-Evaluation Patient’s
condition
25
806 DP Needs Assessment 147
808/809 Qualified DP Staff 33/10
3
Deficiency Data Discharge Planning
Tag
Number
Section June 2023
810 Timely DP Evaluation 60
811 Documentation &
Evaluation
58
812 Discharge Planning 43
813 Transmission of Patient
Information*
37
818 DP Personnel 20
4
Deficiency Data Discharge Planning
Tag Section June 2023
820 Implementation of DP 218
821 Reassess DP 150
823 List of HH Agencies 92
837 Transfer or Referral 151
843 Reassess DP Process 102
Total 1,372
5
CMS CoPs, Discharge
Planning
and the IMPACT Act
6
Changes to CoPs on
Discharge Planning
7
Discharge Planning
Condition of Participation
8
Discharge Planning
Process
Patient Rights
CAH Discharge Planning
Requirements
Hospital Performance Metrics on
the Discharge Planning Process
12
Key Takeaways
▪ Review your process
▪ Focus on patient’s goals and treatment preferences
▪ Involve the patient, caregivers, support person
involved in the planning and evaluation
▪ Ensure process provides a method to identify
patients who will need evaluation and a plan
▪ Prepare for physician, patient or representative to
request evaluation and plan development and
implementation
13
Key Takeaways – Process to Include
▪ Re-evaluation of patient’s condition and on timely
basis
▪ Evaluate for need for post-hospital services
▪ What and where and if available
▪ Evaluate for self-care
▪ Update plans as needed/indicated
▪ Have resources/data on PACs readily available
▪ Review overall process regularly
14
Key Takeaways – Documentation
▪ Evaluation, Plan, Patient engagement
▪ Referrals
▪ Implementation of the plan
▪ Resources provided
▪ Patient education
15
16
The End Questions???
▪ Laura A. Dixon, Esq.
▪ BS, JD, RN, CPHRM
▪ President, Healthcare Risk
Education and Consulting, LLC
▪ 303-955-8104
▪ ldesq@comcast.net
16
16
Register Now

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Ensuring CMS Hospital and CAH CoPs Compliance for Discharge Planning

  • 2. 2 Speaker ▪ Laura A. Dixon, Esq. ▪ BS, JD, RN, CPHRM ▪ President, Healthcare Risk Education and Consulting, LLC ▪ 303-955-8104 ▪ ldesq@comcast.net ▪ Email questions to CMS: Critical Access Hospitals: qsog_CAH@cms.hhs.gov. Acute hospitals: qsog_hospital@cms.hhs.gov. 2 2
  • 3. Deficiency Data Discharge Planning Tag Number Section June 2023 799 Discharge Planning (DP) 120 800 DP Evaluation 106 802 Re-Evaluation Patient’s condition 25 806 DP Needs Assessment 147 808/809 Qualified DP Staff 33/10 3
  • 4. Deficiency Data Discharge Planning Tag Number Section June 2023 810 Timely DP Evaluation 60 811 Documentation & Evaluation 58 812 Discharge Planning 43 813 Transmission of Patient Information* 37 818 DP Personnel 20 4
  • 5. Deficiency Data Discharge Planning Tag Section June 2023 820 Implementation of DP 218 821 Reassess DP 150 823 List of HH Agencies 92 837 Transfer or Referral 151 843 Reassess DP Process 102 Total 1,372 5
  • 7. Changes to CoPs on Discharge Planning 7
  • 12. Hospital Performance Metrics on the Discharge Planning Process 12
  • 13. Key Takeaways ▪ Review your process ▪ Focus on patient’s goals and treatment preferences ▪ Involve the patient, caregivers, support person involved in the planning and evaluation ▪ Ensure process provides a method to identify patients who will need evaluation and a plan ▪ Prepare for physician, patient or representative to request evaluation and plan development and implementation 13
  • 14. Key Takeaways – Process to Include ▪ Re-evaluation of patient’s condition and on timely basis ▪ Evaluate for need for post-hospital services ▪ What and where and if available ▪ Evaluate for self-care ▪ Update plans as needed/indicated ▪ Have resources/data on PACs readily available ▪ Review overall process regularly 14
  • 15. Key Takeaways – Documentation ▪ Evaluation, Plan, Patient engagement ▪ Referrals ▪ Implementation of the plan ▪ Resources provided ▪ Patient education 15
  • 16. 16 The End Questions??? ▪ Laura A. Dixon, Esq. ▪ BS, JD, RN, CPHRM ▪ President, Healthcare Risk Education and Consulting, LLC ▪ 303-955-8104 ▪ ldesq@comcast.net 16 16 Register Now