Discharge Planning: Compliance with CMS Hospital and CAH CoPs 2021

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.

The regulations apply to all hospitals, and for the first time will apply to critical access hospitals.  CMS scaled back many of the proposed rules that hospitals had expressed concern about but there are still a lot of changes. CMS has section 1335 waivers during the COVID-19 pandemic and the discharge planning waivers will be discussed.

This program will discuss the Impact Act and how it affects hospital discharge planning. It requires standardized assessment, quality data, and resource data requirements. It requires hospitals to assist patients with post-discharge care such as home health, skilled nursing facilities, long-term care hospitals, and inpatient rehab facilities. Patients have freedom of choice and now information on all four must be provided to the patient except for CAHs.

The new regulations cover sections on patient timely access to medical records, the discharge planning process, discharge instructions, discharge planning requirements. It will cover transfers to other facilities, assessment of readmission within 30 days, caregiver rights and recommendations, reduction of factors that lead to preventable readmissions, timely discharge planning, and more. CMS has changed the email address to ask questions and the website to get all the manual and this information will be provided.

This program will briefly discuss the final surveyor worksheet for assessing compliance with the CMS hospital Conditions of Participation (CoPs) for discharge planning. This worksheet is used by State and Federal surveyors on all survey activity in hospitals assessing compliance with the discharge planning standards. CMS will revise the worksheet to reflect the revised discharge planning standards.

Every hospital that accepts Medicare and Medicaid must comply with the CMS discharge planning guidelines. These standards must be followed for all patients and not just Medicare or Medicaid. CMS requires several discharge planning policies and procedures so come learn which ones are required and why.

• Discuss the CMS has revised the discharge planning requirements that apply to all hospitals and critical access hospitals
• Recall patients and physicians can request a discharge planning evaluation
• Discuss that information about the hospitalization must be provided to the physician or provider before the first post-hospital visit
• Describe that the patient has a right to get medical records timely including a copy of their discharge plan

• CMS revised hospital & CAH Discharge Planning requirements
• How changes impact the discharge planning worksheet (to be amended)
• CMS Deficiency Memo and how to access deficiency/citation reports
• Discharge planning process and required planning
• Identification of patients in need of discharge planning
• Discharge planning evaluation
• RN, social worker, or qualified person to develop evaluation
• Timely evaluation
• Discussion of evaluation with patient or individual acting on their behalf
• Discharge evaluation must be in the medical record
• Documentation of the discharge process
• Discharge plan
• Physician request for discharge planning
• Implementation of the patient’s discharge plan
• Reassessment of the discharge plan
• Freedom of choice for post-acute care providers
• Document list to provide except CAHs
• Transfer or referral

• Discharge planners
• Transitional care nurses
• Social workers
• RN discharge planners
• All staff nurses who discharge patients in a hospital setting
• ED nurses
• Chief nursing officer
• Compliance officer
• Nurse educators
• Chief operation officer
• Chief medical officers
• Physicians
• Risk managers
• Regulatory officer
• Physician advisor
• UR nurses
• Joint Commission coordinator
• Chief executive officer
• Nurse managers
• PI director
• Health information director
• Billing office director
• Patient safety officer
• Any person serving on a hospital committee to redesign the discharge process to prevent unnecessary readmissions