CMS SOM App. A, Tag A-1717

participating in discharge planning, arranging for follow-up care, and developing

mechanisms for exchange of appropriate, information with sources outside the

hospital.

Interpretive Guidelines §482.62(f)(2)

Social services contact with the patient, family, patient representative and significant

others should occur during admission or as soon as possible after the admission. A high-risk psychosocial case finding should result in supporting information from patient,

patient representative, and/or any other reputable source being available for early

integration into the patient’s treatment plan and subsequent social service action as

indicated. The treatment team should consider, for possible inclusion into the patient’s

treatment plan, the anticipated social services role and expected interventions as

recommended in the psychosocial assessment. Treatment and discharge planning

activities as well as liaison/follow-up efforts should be based upon the goals, including

discharge goals, and staff responsibilities specified in the treatment plan.

Communicating appropriate information to healthcare providers and community

resources outside the psychiatric hospital assists in providing continuity of care,

provision of a safe discharge, and the provision of community care.

Survey Procedures §482.62(f)(2)

• Review the hospital’s policy to determine the role(s) of social services staff.

• Review medical records to verify when the social worker had contact with patient,

patient representative and significant others; e.g., occurred during admission or

soon after admission.

• Observe treatment plan meetings to assess how social workers participate in the

development of a discharge plan.

• Interview social work staff and ask them to describe discharge planning processes

including how patients are provided options for continuity of care after discharge.

• Interview patients and ask them to describe how social services staff are working

with them to plan their discharge; verify the patient is involved in the discharge

planning decision making through interviewing the patient and medical record

documentation. As per A-1624, the patient and/or significant other must be

involved in admission of the patient which includes care all the way through

discharge.

• Review medical record documentation to verify social services participation in

the assessment, development and implementation of the discharge plan including

the arrangement of follow-up care.

• Ask social worker to provide documentation of how they develop mechanisms for

exchange of appropriate information with organizations outside the hospital.

• Verify through interviews and reviews of a sample of medical records the extent

to which social work staff prepare patients for post-hospitalization treatment and

outpatient services.

• Determine whether social work staff act as the liaison between the patient and

community resource providers.

• Review a sample of medical records to verify documentation that social work staff

provided appropriate information to sources outside the hospital who will provide

aftercare, such as post-hospital patient service providers, community agencies,

the patient, family members, and anyone else significantly involved with the

patient who will provide care after hospitalization.