CMS SOM App. A, Tag A-0811

individual acting on his or her behalf.

Interpretive Guidelines §482.43(b)(6)

The results of the discharge planning evaluation must be discussed with the patient or the

patient’s representative. Documentation of this communication must be included in the medical

record, including if the patient rejects the results of the evaluation. It is not necessary for the

hospital to obtain a signature from the patient (or the patient’s representative, as applicable)

documenting the discussion.

The patient or the patient’s representative must be actively engaged in the development of the

plan, so that the discussion of the evaluation results represents a continuation of this active

engagement. It would not be appropriate for a hospital to conduct an evaluation without the

participation of the patient or the patient’s representative, and then present the results of the

evaluation to the patient as a finished product, since this would place the patient in a passive

position that is not consistent with the requirements of the patients’ rights CoP at §482.13(b).

Survey Procedures §482.43(b)(6)

• Review a sample of cases to determine if the discharge planning evaluation results were

discussed with the patient or the patient’s representative.