CMS SOM App. A, Tag A-0809

must be developed by or under the supervision of a registered nurse, social worker, or

other appropriately qualified personnel.

Interpretive Guidelines §482.43(a)(5)

The patient’s discharge planning evaluation must be developed by a registered nurse, social

worker, or other appropriately qualified personnel, or by a person who is supervised by such

personnel. State law governs the qualifications required to be considered a registered nurse or a

social worker. The hospital’s written discharge planning policies and procedures must specify

the qualifications for personnel other than registered nurses or social workers who develop or

supervise the development of the evaluation.

The qualifications should include such factors as previous experience in discharge planning,

knowledge of clinical and social factors that affect the patient’s functional status at discharge,

knowledge of community resources to meet post-discharge clinical and social needs, and

assessment skills. All personnel performing or supervising discharge planning evaluations,

including registered nurses and social workers, should have knowledge of clinical, social,

insurance/financial and physical factors that must be considered when evaluating how a

patient’s expected post-discharge care needs can be met. It is acceptable for a hospital to

include new staff who may not have had previous discharge planning experience, but who are

being trained to perform discharge planning duties and whose work is reviewed by qualified

personnel.

Survey Procedures §482.43(a)(5)

• Verify that patient discharge planning evaluations and discharge plans are developed by,

supervised by, and/or reviewed by qualified personnel.