CMS SOM App. A, Tag A-1569

[Note: The regulations at §483.20(l) setting forth the requirements for a nursing

home resident discharge summary was revised and re-designated as §483.21(c)(2)

in 2016 (81 FR 68858, Oct. 4, 2016) which provides, “When the facility anticipates

discharge a resident must have a discharge summary that includes, but is not

limited to:

(i) A recapitulation of the resident’s stay that includes, but is not limited to,

diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and

consultation results.

(ii) A final summary of the resident’s status to include items in paragraph (b)(2) of

§483.20, at the time of the discharge that is available for release to authorized

persons and agencies, with the consent of the resident or legal representative.

(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).

(iv) A post-discharge plan of care that is developed with the participation of the

resident and, with the resident’s consent, the resident representative(s), which will

assist the resident to adjust to his or her new living environment. The post-discharge

plan of care must indicate where the individual plans to reside, any arrangements

that have been made for the resident's follow up care and any post-discharge

medical and non-medical services.”]