CMS SOM App. J, Tag W205

the new living environment.

Guidance §483.440(b)(5)(ii)

The post discharge plan of care is a component of the discharge summary.

The facility utilizes the information from the discharge summary to prepare the discharge plan

of care. The post-discharge plan of care identifies the essential supports and services necessary

for the client to successfully adjust to the new living environment and describe necessary

coordination of services. It should incorporate the client’s preferences. It should identify

specific client needs after discharge such as personal care, physical therapy, client/caregiver

education needs, and the ability of the client or caregiver to meet those needs after discharge.

(c) Standard: Individual program plan