August’s Compliance Tip of the Month
August’s compliance tip of the month is focused on the requirements around discharge planning evaluations. Specifically, the elements that need to be assessed during the evaluation and subsequently documented in the patient’s medical record. The CMS regulation is below for your reference.
Hospitals will frequently be cited during a survey for not adequately documenting a patient’s discharge evaluation. The evaluation must include:
- The likelihood of a patient needing post-hospital care/services
- The availability of those services
- The likelihood of a patient’s capacity for self-care or of the possibility of the patient being returned to the pre-hospital environment.
Organizations are required to perform the evaluation, document the results and then to share them with the patient or their representatives. The evaluation should occur early in the admission to allow adequate time for planning.
CIHQ encourages organizations to evaluate their documentation mechanisms to assure that they comply with the regulations in order to avoid a deficiency during survey.
CMS
§482.43 Condition of Participation: Discharge Planning
§482.43(a)(1) Standard: Discharge Planning Evaluation
§482.43(a)(1) Standard: Discharge Planning Evaluation
- Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge.
- A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-hospital services, including, but not limited to hospice care services, post-hospital extended care services, home health services, and non-health care services and community-based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services.
- The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative).
There are tools available to CIHQ accredited and ARS member organizations to assist with compliance:
Resource Library:
#1043 – Form – Patient Discharge Planning Evaluation & Plan
#3063 – Form – Selection of Post-Acute Care Hospitalization Provider
#2402 – Policy – Discharge Planning
#1043 – Form – Patient Discharge Planning Evaluation & Plan
#3063 – Form – Selection of Post-Acute Care Hospitalization Provider
#2402 – Policy – Discharge Planning
