CMS SOM App. A, Tag A-0806

(1) Any discharge planning evaluation must be made in a timely basis to ensure the

appropriate arrangements for post-hospital care will be made before discharge and to avoid

unnecessary delays in discharge.

Interpretive Guidelines §482.43(a)(1)

After a patient has been identified as needing a discharge planning evaluation, or after a request

for an evaluation has been made by the physician, patient and/or patient’s representative, the

evaluation must be completed timely. This means there must be sufficient time after completion

to allow arrangements for post-hospital care to be made, without having to delay the patient’s

discharge in order to do so, and without unnecessarily transferring the patient to a different

setting than that from which he/she was admitted primarily due to the delay in making

appropriate arrangements. Acute care hospital inpatients frequently have short lengths of stay,

which necessitates prompt attention to patients’ discharge planning needs in acute care

hospitals. Failure to complete the evaluation in a timely manner could make it more difficult to

implement the patient’s final discharge plan, and/or may cause an unnecessary delay in the

patient’s discharge from the hospital.

There may be citations if the hospital does not identify patients likely to need discharge planning

at least 48 hours in advance of the patient’s discharge, and there is 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) that 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 the arrangement of appropriate community services.

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

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 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.

Survey Procedures §482.43(a)(1)

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

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

the patient’s discharge.