Executive Summary

The discharge planning worksheet that the Centers for Medicare & Medicaid Services developed for surveyors spells out what case managers should be doing to create an effective discharge plan.

  • Case managers should use the worksheet as a self-assessment tool to make sure they are complying with the CMS Conditions of Participation for discharge planning, according to an expert.

  • Surveyors will review discharge planning policies and procedures and check to make sure the discharge planning staff are following them.

  • They will look for evidence that the hospital is tracking readmissions, determining the reasons for readmissions, and making changes to address any problems.

  • They will review five patient records to determine if discharge planners are assessing patients for their needs after discharge, giving patients a choice of post-acute providers, ensuring a timely discharge, and forwarding information on the hospital stay to providers at the next level of care.

CMS issues final version for surveyors

The Centers for Medicare & Medicaid Services (CMS) has issued the final worksheets for state and federal surveyors to use when they assess hospitals’ compliance with the Medicare Conditions of Participation for quality assessment and performance improvement, infection control, and discharge planning.

The worksheets are designed to help the surveyors and the hospital staff to identify when they are in compliance. Surveyors will use the worksheet whenever a CMS survey is done.

“CMS has been pilot-testing the worksheets since 2011. The only difference before was that if you got something wrong, it couldn’t be held against you. Now, if hospitals don’t get it right, they could be cited for deficiencies,” says Sue Dill Calloway, RN, MSN, JD, CPHRM, CCM, CCP, president of Patient Safety Education and Consulting in Dublin, OH.

“Hospitals have to comply with the Medicare Conditions of Participation or they could be fined or lose their ability to bill for Medicare and Medicaid,” Dill Calloway says.

The discharge planning worksheet offers hospitals a guide to complying with the revised discharge planning standards that went into effect July 19, 2013, Dill Calloway says. She suggests that hospitals use the worksheet as a self-assessment tool.

“The worksheet is the gold standard of discharge planning. It’s a great tool that spells out what case managers should be assessing and what they should be doing to create an effective, comprehensive discharge plan, and ensure a smooth transition to the next level of care,” she says.

Dill Calloway recommends that everyone in the hospital who discharges patients review the worksheets and incorporate all the elements of them into their policies and practices.

“It’s not just the hospital case managers and social workers who should be familiar with the worksheets and the discharge planning standards. Every nurse who discharges patients and the staff in the emergency department and outpatient clinics need to be informed as well,” she says.

The worksheets will not be used by surveyors in critical access hospitals, but the staff in those hospitals should be familiar with them, Dill Calloway says.

The Conditions of Participation require hospitals to have discharge planning policies and procedures and to follow them. The surveyors will look for evidence of discharge planning activities and whether the staff are following the policies and procedures, Dill Calloway says.

If your hospital doesn’t conduct a discharge planning evaluation for every patient, there must be a process to notify patients, family members, and attending physicians that they can request a discharge planning evaluation, even if the patient doesn’t meet high-risk criteria, she says. The worksheet calls for surveyors to interview patients or their representatives and attending physicians to find out if they are aware that they can request a discharge planning evaluation, she says.

Surveyors also are going to check for policies on requesting a discharge planning evaluation when there is a change in a patient’s status and evaluate whether the inpatient unit staff are aware of how, when, and whom to notify if there is a change, according to Dill Calloway.

The best practice for hospitals is to conduct a discharge planning evaluation on every patient, Dill Calloway adds.

The surveyors will ask to see readmission data to confirm that hospitals are tracking readmissions as required by the standards, Dill Calloway says. If hospitals do not track their readmissions as part of discharge planning, they will be cited.

“Hospitals should be reviewing the charts of readmitted patients and analyzing why they were readmitted, then make changes to address any problems,” she adds.

The surveyors will check on compliance with requirements that hospitals track readmissions, assess patients who were readmitted, and change the discharge planning process to address the problems.

“CMS is putting a lot of emphasis on preventing readmissions. The agency just announced that 2,610 hospitals forfeited $428 million in reimbursement because of excess readmissions. With penalties rising to 3% of reimbursement, hospitals should already be working on reducing readmissions,” she says.

The surveyors will review five patient records, a combination of patients admitted from home and from residential healthcare facilities, to determine if patients have a timely discharge planning evaluation, and if the discharge planning assessment takes into account the patient’s ability to perform activities of daily living and support in the community, she says.

They will evaluate whether the five patients were given a choice of geographically convenient post-acute providers that could meet the patients’ needs, whether the patient’s caregiver was included in the discussions about post-acute care, and whether the discharge planning evaluation was completed early in the stay to avoid discharge delays, she says.

The surveyors will examine discharge instructions and medication lists for the five patients and look for evidence that the patient and/or caregiver were educated on admission versus discharge medications, she says.

If the patients were transferred to a post-acute setting, the surveyors will review the transfer form to ensure that it includes a brief reason for hospitalization, the course of treatment, the patient’s condition at discharge, a medication list, allergies, pending laboratory work, and a copy of the advance directives. “These items are mandatory, not optional,” she says.

Surveyors will check to ensure that the discharge summary was sent to the patient’s primary care physician before the first follow-up visit or within seven days of discharge, Dill Calloway says. “Case managers should document the appointment for the follow-up visit and make sure that the discharge summary gets into the hands of the primary care provider,” she says.