CMS SOM App. A, Tag A-0803

(7) The hospital must assess its discharge planning process on a regular basis. The

assessment must include ongoing, periodic review of a representative sample of discharge

plans, including those patients who were admitted within 30 days of a previous admission,

to ensure that the plans are responsive to the patient post-discharge needs.

Interpretive Guidelines §482.43(a)(7)

Hospitals must provide evidence of an ongoing review of their discharge planning process to

evaluate whether the patient’s discharge plans are meeting the discharge needs of the patient.

The ongoing review must include a representative sample of discharge plans, including patients

that have been readmitted to the hospital within 30 days of the previous discharge. This

requirement is important because an effective discharge plan should prevent avoidable hospital

readmissions.

Additionally, this ongoing assessment must be on a periodic basis as determined by hospital

policy.

Survey Procedures §482.43(a)(7)

• Verify that the hospital reviews a representative sample of patient discharge plans at

regular intervals of time, as per hospital policy, including those patients who were

readmitted within 30 days of a previous admission.