By Toni Cesta, PhD, RN, FAAN


In the last two issues, we reviewed the areas of compliance in the Conditions of Participation (CoP) for utilization review and began our discussion on the CoP for discharge planning. In this issue, we will continue our discussion of the areas of compliance for discharge planning.

CoP and Patient Choice

In section c(6) of the discharge planning CoP is the explanation of the requirements related to post-discharge services and patient choice. Many hospitals either have overinterpreted this section or underinterpreted it. This is one area that can easily be audited by any surveyor and can affect the hospital’s recertification. The hospital must include in the discharge plan a list of home health agencies (HHAs) or skilled nursing facilities (SNFs) that are available to the patient, meaning that they provide the services that the patient needs and have an available bed. In addition, they must be participating in the Medicare program, and must serve the geographic area (as defined by the HHA) in which the patient resides. In the case of a skilled nursing facility, it must be in the geographic area requested by the patient.

At this time, home health agencies and skilled nursing facilities are the only two post-acute services that must be listed and provided to the patient. While you may give your patients choices for other services, you are not legally required to do so.

It also is required that the hospital documents in the medical record that the list was presented to the patient or an individual acting on the patient’s behalf. It does not require that you put the list in the medical record, only that you document that it was given to the patient.

For patients enrolled in managed care organizations, the hospital must indicate the availability of home health and post-hospital extended care services through individuals and entities that have a contract with the managed care organization.

When providing the list to the patient, the hospital is required to inform the patient, or his or her representative, of the freedom to choose among participating Medicare providers of post-hospital services and must, when possible, respect the patient and family’s preferences. If their preference is not available, the hospital can move on to their next choice. Of course, it always is best to give the patient his or her first choice, but if there is a delay in availability, the hospital cannot allow this delay to extend the length of stay. When this happens, the case manager should explain the issue to the patient and family so that they clearly understand the situation and select their second choice if they haven’t already done so.

Interpretive Guidelines

Listed below are guidelines that can be used to interpret discharge planning regulations. By following these guidelines, you and your department can ensure that you are compliant with them. (Compiled from Medicare’s Conditions of Participation: Discharge Planning, CMS, 2014.)

§482.43: Discharge Planning

The hospital must have in effect a discharge planning process that applies to all patients. The hospital’s policies and procedures must be specified in writing.

This CoP applies to all types of hospitals and requires them to conduct appropriate discharge planning activities for all patients who are admitted to the hospital as inpatients, except for those who are cared for in the ED but are not admitted as hospital inpatients. The written discharge planning process must reveal a thorough, clear, comprehensive process that is understood by the hospital staff.

Adequate discharge planning is essential to the health and safety of all patients. Patients may suffer adverse health consequences upon discharge without benefit of appropriate planning. Such planning is vital to mapping a course of treatment aimed at minimizing the likelihood of readmission that could have been prevented.

• §482.43(a): Identification of Patients in Need of Discharge Planning. The hospital must identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning.

The hospital must set the criteria for identifying patients who are likely to suffer adverse health consequences upon discharge without adequate discharge planning, considering factors such as functional status, cognitive ability of the patient, and family support. Patients at high risk of requiring post-acute services must be identified through a screening process.

The hospital should re-evaluate the needs of the patients on an ongoing basis, and prior to discharge, as they may change based on the individual’s status.

There is no set time frame for identification of patients requiring a discharge planning evaluation, other than it must be performed as early as possible. The timing is left up to the hospital and its staff.

§482.43(b): Discharge Planning Evaluation

The post-discharge needs assessment can be formal or informal and generally includes an assessment of the patient’s post-discharge needs. These may include assessment of psychosocial needs, the patient’s and caregiver’s understanding of discharge needs, and identification of post-hospital care resources.

• §482.43(b)(1): The hospital must provide a discharge planning evaluation to the patients identified in paragraph (a) of this section, and to other patients upon the patient’s request, the request of a person acting on the patient’s behalf, or the request of the physician.

The purpose of a discharge planning evaluation is to determine continuing care needs after the patient leaves the hospital setting.

• §482.43(b)(2): A registered nurse, social worker, or other appropriately qualified personnel must develop, or supervise the development of, the evaluation.

The responsibility for discharge planning is multidisciplinary and not restricted to a particular discipline. The hospital has flexibility in designating the responsibilities of the registered nurse, social worker, or other appropriately qualified personnel for discharge planning. The responsible personnel should have experience in discharge planning, knowledge of social and physical factors that affect functional status at discharge, and knowledge of community resources to meet post-discharge clinical and social needs.

• §482.43(b)(3): The discharge planning evaluation must include an evaluation of the likelihood of a patient needing post-hospital services, and of the availability of the services.

The hospital is responsible for developing and implementing the discharge plan. The hospital’s ability to meet discharge planning requirements is based on the following:

- implementation of a needs assessment process with identified high-risk criteria;

- evidence of a complete, timely, and accurate assessment;

- maintenance of a complete and accurate file on community-based services and facilities, including long-term care, sub-acute care, home care, or other appropriate levels of care to which patients can be referred;

- coordination of the discharge planning evaluation among various disciplines responsible for patient care.

• §482.43(b)(4): The discharge planning evaluation must include an assessment of the likelihood of a patient’s capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital.

The capacity for self-care includes the ability and willingness for such care. The choice of a continuing care provider depends on the self-care components, availability, willingness, and ability of family/caregivers, and the availability of resources. The hospital must inform the patient or family of their freedom to choose among providers of post-hospital care. Patient preferences also should be considered; however, preferences are not necessarily congruent with the capacity for self-care.

Patients should be evaluated for return to the prehospital environment, but also should be offered a range of realistic options to consider for post-hospital care. Hospital staff should incorporate information provided by the patient and/or caregivers to implement the process.

• §482.43(b)(5): Hospital personnel must complete the evaluation in a timely manner so that appropriate arrangements for post-acute care are made before discharge, and to avoid unnecessary delays in discharge.

The timing of the discharge evaluation should be relative to the patient’s clinical condition and anticipated length of stay. Assessment should start as soon after admission as possible and be updated periodically during the episode of care.

Information about the patient’s age and sex could be collected on admission while functional ability data is best collected closer to discharge, indicating more accurately a patient’s continuing care requirements.

The hospital must demonstrate its development of discharge plan evaluation for patients in need and discuss the results of the evaluation with the patient or individual acting on his or her behalf.

• §482.43(b)(6): The hospital must include the discharge planning evaluation in the patient’s medical record in order to create an appropriate discharge plan, and must discuss the results of the evaluation with the patient or individual acting on his or her behalf.

The discharge plan evaluation should be documented in the patient’s record. The hospital is expected to document its decision about the need for a plan and indicate what steps were taken to implement the plan. Evidence of an ongoing evaluation of discharge planning needs is an important factor of documentation.

Documented evidence of discussion of the discharge planning evaluation with the patient, if possible, and interested persons should exist in the medical record. It is preferable that the hospital staff seek information from the patient and family to make the discharge planning evaluation as realistic and viable as possible.

The hospital CoP at §482.13(b): Patients’ Rights states that “The patient has the right to participate in the development and implementation of his or her plan of care.” CMS views discharge planning as part of the patient’s plan of care. “The patient or his/her representative (as allowed under state law) has the right to make informed decisions regarding his/her care” and “The patient’s rights include ... being involved in care planning and treatment.”

§482.43(c): Discharge Plan

The hospital must ensure that the discharge plan requirements are met. It is a management function of the hospital to ensure proper supervision of its employees. Existing training and licensing requirements of a registered nurse and social worker in discharge planning are sufficient. “Other appropriately qualified personnel” may include a physician.

• §482.43(c)(1): A registered nurse, social worker, or other appropriately qualified personnel must develop, or supervise the development of, a discharge plan if the evaluation indicates a need.

The hospital should determine who has the requisite knowledge and skills to develop the plan. However, because post-hospital services and, ultimately, the patient’s recovery and quality of life can be affected by the discharge plan, the plan should be supervised by qualified personnel to ensure professional accountability.

• §482.43(c)(2): In the absence of a finding by the hospital that a patient needs a discharge plan, the patient’s physician may request a discharge plan. In such a case, the hospital must develop a discharge plan for the patient.

The physician can make the final decision as to whether a discharge plan is necessary. The hospital will develop a plan if a physician requests one, even if the interdisciplinary team determined it is unnecessary.

• §482.43(c)(3): The hospital must arrange for the initial implementation of the patient’s discharge plan.

This includes arranging for necessary post-hospital services and care, and educating patient, family, caregivers, or community providers about post-acute care plans.

• §482.43(c)(4): The hospital must reassess the patient’s discharge plan if there are factors that may affect continuing care needs or the appropriateness of the discharge plan.

The discharge plan should be initiated as soon as possible after admission. As changes in the patient’s condition and needs occur, the discharge plan must be reassessed and updated to address those changes.

• §482.43(c)(5): As needed, the patient and family members or interested persons must be counseled to prepare them for post-acute care.

Records should show that the patient and/or family and/or caregiver were provided information and instructions in preparation for post-acute care and kept informed of the progress. It is important that the patient and caregivers know, and as appropriate, can demonstrate or verbalize the care needed by the patient.

Use of family caregivers in providing post-hospital care should occur when the family is both willing and able to do so. It is appropriate to use community resources with or without family support whenever necessary.

• §482.43(c)(6): The hospital must include in the discharge plan a list of HHAs or SNFs that are available to the patient, that are participating in the Medicare program, and that serve the geographic area (as defined by the HHA) in which the patient resides, or in the case of a SNF, in the geographic area requested by the patient. HHAs must request to be listed by the hospital as available.

The Social Security Act (SSA) at §1861(ee) requires Medicare participating hospitals, as part of their discharge planning evaluations to:

- Share with each patient, as appropriate, a list of Medicare-certified HHAs that serve the geographic area in which the patient resides and that request inclusion on the list. The SSA prohibits hospitals from limiting or steering patients to any particular HHA and must identify those HHAs to whom the patient is referred, in which the hospital has a disclosable financial interest, or which has such an interest in the hospital.

- Include an evaluation of the patient’s likely need for hospice care and post-hospital extended care services, and to provide a list of the available Medicare-certified hospices and SNFs that serve the geographic area requested by the patient. The discharge plan should not specify or limit qualified hospice or SNFs and must identify those entities to whom the patient is referred in which the hospital has a disclosable financial interest, or which has such an interest in the hospital.

- Develop and maintain its own list of hospices, HHAs, or SNFs; or in the case of SNF, simply print a list from the Nursing Home Compare site at based on the geographic area that the patient requests.

• §482.43(d): Transfer or Referral. The hospital must transfer or refer patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services as needed for follow-up or ancillary care.

The hospital must ensure that patients receive proper post-hospital care within the constraints of a hospital’s authority under state law and within the limits of a patient’s right to refuse discharge-planning services. If a patient exercises the right to refuse discharge planning or to comply with a discharge plan, documentation of the refusal is recommended.

“Medical information” may be released only to authorized individuals according to provision §482.24(b)(3). Examples of necessary information include functional capacity of the patient, requirements for healthcare services procedures, discharge summary, and referral forms. “Appropriate facilities” refers to facilities that can meet the patient’s assessed needs on a post-discharge basis, and that comply with federal and state health and safety standards.

• §483.43(e): The hospital must reassess its discharge planning process on an ongoing basis. The reassessment must include a review of discharge plans to ensure that they are responsive to discharge needs.

The hospital’s discharge planning process must be integrated into its quality assurance and performance improvement program. The hospital should have a mechanism in place for ongoing reassessment of its discharge planning process. Although specific parameters or measures that would be included in a reassessment are not required, the hospital should assure the following factors in the reassessment process:

- time-effectiveness of the criteria to identify patients needing discharge plans;

- the quality and timeliness for discharge planning evaluations and discharge plans;

- the hospital discharge personnel maintain complete and accurate information to advise patients and their representatives of appropriate options;

- the hospital has a coordinated discharge planning process that integrates discharge planning with other functional departments, including the quality assurance and utilization review activities of the institution and involves various disciplines.


This month, we completed our discussion of compliance with the Conditions of Participation for discharge planning. We will complete our compliance series next time with a review of other areas of compliance required by case managers and case management departments.