CMS SOM App. A, Tag A-0843

The hospital must reassess its discharge planning process on an on-going basis. The

reassessment must include a review of discharge plans to ensure that they are responsive to

discharge needs.

Interpretive Guidelines §483.43(e)

The hospital must reassess the effectiveness of its discharge planning process on an ongoing

basis. Since the QAPI CoP at §482.21 requires the QAPI program to be hospital-wide, the

discharge planning reassessment process is considered an integral component of the overall

hospital QAPI program.

The hospital must have a mechanism in place for ongoing reassessment of its discharge planning

process. The reassessment process must include a review of discharge plans in closed medical

records to determine whether they were responsive to the patient’s post-discharge needs. One

indicator of the effectiveness of the discharge plan is whether or not the discharge was followed

by a preventable readmission. Accordingly, hospitals are expected to track their readmission

rates and identify potentially preventable readmissions.

Typically readmissions at 7, 15, 30 days, or even longer, after discharge are tracked by analysts

studying readmissions to short-term acute care hospitals. Hospitals must choose at least one

interval to track. Since there are National Quality Forum-endorsed readmissions measures that

use a 30-day interval, and since such measures are permitted by law to be used by CMS for

payment-related purposes, it might be prudent for a hospital to track its 30-day readmissions rate,

but other intervals are permissible. It is understood that information on post-discharge

admissions to other hospitals may not be not readily available to hospitals, but all hospitals are

expected to track readmissions to their own hospital, and to do so on an ongoing basis, i.e., at

least quarterly. Hospitals may employ various methodologies to identify potentially preventable

readmissions. There are proprietary products that, for example, use claims data to identify such

cases. Hospitals are expected to document their methodology for tracking their readmissions

rates.

Once the hospital has identified potentially preventable readmissions, it is expected to conduct an

in-depth review of the discharge planning process for a sample of such readmissions (at least

10% of potentially preventable readmissions, or 15 cases/quarter, whichever is larger is

suggested but not required) in order to determine whether there was an appropriate discharge

planning evaluation, discharge plan, and implementation of the discharge plan.

Hospitals are also expected to follow up on trends identified through analysis of their

readmissions, such as a concentration of readmissions related to post-surgical infections,

discharges from a particular service or unit, discharges to a particular extended care facility or

home health agency, discharges with the same primary diagnosis on the first admission, etc.

Such clustering or concentration may identify areas requiring more follow-up analysis and

potential remedial actions.

Having identified factors that contribute to preventable readmissions, hospitals are expected to

revise their discharge planning and related processes to address these factors. Consistent with

the requirements under the QAPI CoP, the hospital’s governing body, medical leadership and

administrative leadership are all expected to ensure that identified problems are addressed, with

further ongoing reassessment to achieve improvement.

Survey Procedures §482.43(e)

• Review hospital policies and procedures to determine whether the discharge planning process

is reassessed on an ongoing basis, i.e., at least quarterly.

• Does the hospital’s discharge planning reassessment policy include tracking and analysis of

readmissions?

• Do staff know how to obtain data on readmissions that enables them to review the

discharge plans for the initial admission? Ask them to identify medical records for

patients who were readmitted and to show you the documentation of the review of the

discharge planning process for the initial admission.

• Does the assessment of readmissions include an evaluation of whether the readmissions

were potentially preventable?

• Is there evidence of in-depth analysis of a sample of discharge plans in cases where

preventable readmissions were identified?

• Is there evidence that the hospital took action to address factors identified as contributing

to preventable readmissions?