Accreditation & Regulatory Journal
April 2024


Performance Improvement in Discharge Planning

By: Connie Compton 3/19/2024 10:00:00 AM
There are many reasons to assess and improve the performance of the hospital’s discharge planning processes, but did you happen to know it is also a CMS requirement? That’s right! Under CMS CoP Standard §482.43(e) hospitals are to conduct ongoing assessments of their overall process for discharge planning. But wait, there’s more! Now, CMS is aiming at CoP Standard §482.43(d) which requires hospitals to provide “necessary medical information” to post-acute care (PAC) providers; e.g., skilled nursing facilities or home health agencies. Let’s explore §482.43(e) and §482.43(d) Standard requirements and examine a new focus area for hospitals to prevent readmissions and maintain survey readiness.
Ongoing Assessments
Let’s start with §482.43(e) for ongoing assessments of the discharge planning process which begins with data. Under this standard, hospitals are expected to track their readmission rates and identify preventable readmissions. This includes tracking readmissions using a defined interval of time for the rate. Most hospitals align with CMS and utilize a 30-day readmission rate, but 7-day and 15-day intervals are permissible for short-term acute care hospitals. The chosen methodology for tracking their readmission rates, including how to identify patient cases must be documented. The medical records for identified readmissions need to be reviewed. As for volume, a review of at least 10% of potentially preventable readmissions, or 15 cases/quarter (whichever is larger is suggested) to determine whether the medical record contains an appropriate discharge planning evaluation, discharge plan, and if the discharge plan was implemented.
Post-acute Care (PAC) Provider Communication
The next step is do something with that data. However, before moving forward you should ask, what was audited in the medical records? Let’s dive deeper into what CMS has identified as a weak point in discharge planning that is believed to be fueling readmissions and consider when selecting process measures. As we all know, hand-off communications have always been a challenge in healthcare. CMS is calling for special attention in transitions of care, specifically PAC providers. In 2023, CMS reminded hospitals and encouraged surveyors to ramp up efforts when surveying CoP §482.43(d) which requires providing PAC providers with “necessary medical information.” Specifically, CMS states when a patient is discharged to a PAC provider, these providers must receive accurate and complete information related to the patient’s condition and treatment. CMS went as far as to encourage hospitals to collaborate with PAC providers to standardize discharge processes and forms used with a suggestion to use InterACT’s, “Hospital to Post-acute Care Transfer Form.” Necessary medical information shared with PAC providers includes, but is not limited to the following:
Course of Treatment:
  • A brief reason for hospitalization, including a principal diagnosis.
  • A brief description of the hospital's course of treatment, including results of laboratory tests. As a special note for patients with complex behavioral needs and/or substance abuse disorders, specific treatments to manage these conditions and any additional supervision required during the hospital stay should be included.
  • Patient’s condition at discharge, including cognitive and functional status and social supports needed.
Medications / Allergies / Skin Conditions
  • A comprehensive list of all medications prescribed to a patient (prior to and during their hospital stay that includes a list of food and drug allergies, along with any drug interactions). As an important note - an actual medication list must be provided, and referral to an electronic list is unacceptable. CMS states most commonly psychotropic medications and “hard” prescriptions for narcotics are missed.
  • Information about skin conditions, including skin tears, pressure ulcers, bruising, or lacerations, as well as instructions for cultures, treatments, or dressings.
Equipment / Home Environment
  • Durable medical equipment, such as high-flow oxygen, CPAP/BiPAP, ventilators, specialty mattresses, and wound vacuums.
  • The patient’s needs at home or home environment that may impact their ability to maintain health and safety, e.g., risk of falls, family involvement, homelessness, etc.
Care Planning
  • The patient’s preferences and goals for care. If the patient has one, include a copy of advance directives for end-of-life care.
Targeting Improvement
As part of the QAPI requirements, hospitals must identify factors that contribute to preventable readmissions and revise their discharge planning processes to address these factors. To do so, look for trends in readmissions related to post-surgical infections, discharges from a particular service line or unit, discharges to a particular extended care facility or home health agency, discharges with the same primary diagnosis as the first admission, etc.
By targeting these areas and focusing on standardizing communications with PAC providers, hospitals will be ready for their next survey.
Centers for Medicare and Medicaid Services. (2023). State Operations Manual, Appendix A – Survey Protocol, Regulations, and Interpretive Guidelines for Hospitals.
Centers for Medicare and Medicaid Services. (2023, June 6). Requirements for Hospital Discharges to Post-Acute Care Providers. Retrieved from:
Patel, P. R., & Bechmann, S. (2023). Discharge Planning. In StatPearls. Retrieved from:
Pathway Interact. (2021) Hospital to Post-Acute Care Transfer Form. Retrieved from: