CMS SOM App. A, Tag A-0800

(a) The hospital’s discharge planning process must identify at an early stage of

hospitalization those patients who are likely to suffer adverse health consequences upon

discharge in the absence of adequate discharge planning and must provide a discharge

planning evaluation for those patients so identified as well as for other patients upon

the request of the patient, patient’s representative, or patient’s physician.

Interpretive Guidelines §482.43(a)

The discharge planning process is expected to begin in the early stages in the hospitalization of

the patient. Identifying upon admission of the patient those patients who are likely to suffer

adverse health consequences upon discharge without adequate discharge planning would allow

sufficient time to complete discharge planning evaluations and develop appropriate discharge

plans that support the discharge needs, goals, and preferences of the patient and their

caregivers. The hospital’s discharge planning policies and procedures must document the

criteria and screening process it uses to identify patients likely to need discharge planning,

including the evidence or basis for the criteria and process. They should also identify which staff

are responsible for carrying out the evaluation to identify patients likely to need discharge

planning.

However, no noncompliance deficiency citations will be made if the identification of patients

likely to need discharge planning is completed at least 48 hours in advance of the patient’s

discharge and there is no evidence that (1) the patient’s discharge was delayed due to the

hospital’s failure to complete an appropriate discharge planning evaluation on a timely basis, or

(2) the patient was placed unnecessarily in a setting other than that from which he/she was

admitted primarily due to a delay in discharge planning. For example, a delay in identification

of a patient in need of discharge planning might result in discharging the patient to a nursing

facility, because such placements can be arranged comparatively quickly, when the patient

preferred to return home, and could have been supported in the home environment with

arrangement of appropriate community services.

If the patient’s hospital stay is for less than 48 hours, hospitals must nevertheless ensure that

they are timely screened so that, if needed, the discharge planning process is completed before

the patient’s discharge.

For patients that may not have been initially identified as in need of a discharge plan, there may

be changes in the patient’s condition that may warrant development of a discharge plan. The

hospital’s discharge planning policies and procedures must address how the staff responsible for

discharge planning will be made aware of changes in a patient’s condition that require a

discharge planning evaluation.

In the event that a patient is transferred to another hospital, any pertinent information

concerning the identification of the patient’s post-hospital needs should be in the patient’s

medical record that is transferred with the patient. The receiving hospital then becomes

responsible for the discharge planning process for the patient.

Survey Procedures §482.43(a)

• Identify the hospital’s discharge planning policies and procedures.

• Verify that patients are timely screened so that the discharge planning process is completed

before the patient’s discharge and to avoid unnecessary delays in discharge.