CMS SOM App. A, Tag A-0818

(1) - A registered nurse, social worker, or other appropriately qualified personnel must

develop, or supervise the development of, a discharge plan if the discharge planning

evaluation indicates a need for a discharge plan.

Interpretive Guidelines §482.43(c)(1)

The discharge plan that is based on the findings of the discharge planning evaluation must be

developed by a registered nurse, social worker, or other appropriate 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 plan.

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 development of discharge plans,

including registered nurses and social workers, must 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.

For Information – Not Required/Not to be Cited

A well designed discharge planning process uses a multidisciplinary team approach. Team

members may include representatives from nursing, case management, social work, medical

staff, pharmacy, physical therapy, occupational therapy, respiratory therapy, dietary, and other

healthcare professionals involved with the patient’s care. The team approach helps to ensure

all of the patient’s post-discharge care needs are addressed in the plan, increasing the

likelihood of successful recovery and avoidance of complications and readmissions.

The hospital CoP governing patients’ rights at §482.13(b) provides that “The patient has the right

to participate in the development and implementation of his or her plan of care.” (CMS views

discharge planning as part of the patient’s plan of care). “The patient or his/her representative (as

allowed under State law) has the right to make informed decisions regarding his/her care” and

“The patient’s rights include...being involved in care planning and treatment.” Accordingly,

hospitals are expected to engage the patient, or the patient’s representative, actively in the

development of the discharge plan, not only to provide them the necessary education and training

to provide self-care/care, but also to incorporate the patient’s goals and preferences as much as

possible into the plan. A patient will be more likely to cooperate in the implementation of a

discharge plan that reflects his/her preferences, increasing the likelihood of a successful care

transition and better health outcomes.

A patient’s goals and preferences may be, in the hospital’s view, unrealistic. A hospital is not

obligated to develop a discharge plan that cannot be implemented. However, the fact that a plan

incorporating the patient’s goals and preferences might be more time-consuming for the hospital

to develop and implement than another alternative does not make the patient’s preferred plan

unrealistic.

For Information – Not Required/Not to be Cited

If a patient exercises the right to refuse to participate in discharge planning or to implement a

discharge plan, documentation of the refusal in the medical record is recommended.

Survey Procedures §482.43(c)(1)

• Review a sample of cases to determine if the discharge plan was developed by an RN, Social

Worker, or other qualified personnel, as defined in the hospital discharge planning policies

and procedures, or someone they supervise? In order to assess this:

• Review the hospital’s written policy and procedure governing who is responsible for

developing or supervising the development of the discharge plan. Does the policy permit

someone other than a RN or social worker to be responsible for developing or supervising

development of such plans? If yes, does the policy specify the qualifications of the

personnel other than a RN or social worker to perform this function?

• Determine which individual(s) are responsible for developing or supervising the

development of discharge plans. Review their personnel folders to determine if they are

a RN, social worker, or meet the hospital’s criteria for developing/supervising the

discharge plan. If they are not, are they supervised by an individual who is an RN, social

worker or qualified according to the hospital’s policies? Are their discharge plans

reviewed by their supervisor before being finalized?

• Ask personnel who supervise or develop discharge plans to give examples illustrating

their knowledge of healthcare and other resources available in the community that could

be utilized to meet patients’ expected post-discharge care needs.

• Ask the discharge planner how the patient or patient’s representative is engaged to participate

in the development of the discharge plan. Does the discharge plan identify the patient’s or

patient’s representative discharge preferences?

• Does the discharge plan match the identified needs as determined by the discharge planning

evaluation?