Accreditation & Regulatory Journal
April 2024


5 Tips for Discharge Planning

By: Connie Compton 3/5/2024 10:00:00 AM
CMS Condition of Participation §482.43 requires an effective discharge planning process that focuses on the patient’s goals and treatment preferences, but that’s not all. This Condition of Participation defines what the patient discharge evaluation must entail and how to respect the patient’s right to participate and make decisions in their care.
The discharge evaluation must be consistent with the patient’s goals for care, which may change throughout the patient’s stay in the hospital. Therefore, the discharge evaluations and plans should be considered working documents that require updating throughout the patient’s stay. The process must support and assist the patient’s decision-making rights by actively involving the patient and patient representatives, along with addressing the patient’s treatment preferences. By following these tips, you will be aligned with CMS’ expectations for discharge planning.
1. Timeliness
Get started early. Discharge planning evaluations must be completed timely. To avoid delays in the patient’s discharge, sufficient time is needed to allow for post-hospital care arrangements. Timely placement of the evaluation in the medical record facilitates communication among staff to develop and implement the discharge plan. A key requirement is that the evaluation results are included in the patient's medical record and are used in the development of the discharge plan.
2. The Right Personnel
A patient's discharge planning evaluation must be developed by a registered nurse, social worker, or qualified personnel. Be sure to review your organization’s policy. If your hospital has personnel performing discharge evaluations, who are not a registered nurse or social worker, the hospital’s policy must specify the qualifications that allow these individuals to perform discharge planning evaluations. Qualifications must include factors such as:
  • Previous experience in discharge planning
  • Knowledge of clinical and social factors that affect the patient's functional status at discharge
  • Knowledge of community resources to meet post-discharge clinical and social needs
  • Assessment skills
3. Involving the Patient
For discussion purposes, patient representatives include the patient’s family members, caregivers, and support persons. The hospital must include the patient, and as warranted the patient’s representatives, in the discharge planning process to determine appropriate post-discharge care. Documentation of this communication must be included in the medical record, including if the patient rejects the results of the evaluation. As an important note; CMS clearly states a process of developing an evaluation without the participation of the patient or patient representative, and then presenting the plan as a finished product is not permitted.
4. Decision-Making for Post-acute care (PAC) Providers
Commonly referred to as the “choice list,” hospitals must inform Medicare-participating patients and their representatives of their right to choose and provide a list of PAC providers that participate in Medicare. The patient has the right to choose their PAC provider. At a minimum, the hospital is required to provide a list of home health agencies in the geographic area where the patient resides, or a list of skilled nursing facilities in the geographic area the patient requests, from which the patient may select their PAC provider. For patients enrolled in managed care organizations, the hospital must provide a list of PAC providers contracted with that specific managed care organization. If the hospital has a disclosable financial interest, it must be stated on the list provided to the patient.
Lastly, the hospital must assist patients in selecting post-acute care providers. CMS defines assistance as providing the patient with quality measures for home health agencies, skilled nursing facilities, inpatient rehabilitation facilities, and long-term care hospitals. Hospitals have the flexibility either to develop their own lists or to print a list from the CMS websites, Nursing Home Compare ( and Home Health Compare ( If hospitals develop their own lists, they are expected to update them at least annually.
5. Documentation
The hospital must include the discharge planning evaluation in the patient's medical record to guide the development of the patient's discharge plan. Surveyors evaluate medical record documentation to determine if the patient and patient representative(s) are involved in the discharge planning process. Additionally, there must be documentation to demonstrate the “choice list,” was provided, with any required financial disclosures noted, and quality data provided to assist the patient and patient representative(s) in their decision-making.
Centers for Medicare and Medicaid Services. (2023). State Operations Manual, Appendix A – Survey Protocol, Regulations, and Interpretive Guidelines for Hospitals.