CMS SOM App. U, Tag R151

(1) Discharge instructions must be provided at the time of discharge to the patient

or the patient’s caregiver as necessary.

Interpretive Guidelines: §403.736(a)

The discharge planning process should begin upon the patient entering the RNCHI for

care and should be provided at or near the time of discharge or upon request of the

patient or legal representative. The discharge planning evaluation should include:

• An assessment of the possibility of a patient needing services after discharge;

• The patient’s capacity for self-care; and

• Information regarding the care in the environment from which he or she entered

the facility and where he or she is going to after discharge.

RNHCIs do not need to develop a discharge plan that includes medical care as doing so

is not in keeping with the religious tenets, goals of the facility or scope of the facility’s

practice. However, we believe that it is important for the RNHCI to discuss with the

caregiver/legal representative information about the patient’s post-discharge care and

needs, which may or may not include seeking care at a medical based facility.

RNHCIs must have policies and procedures that address their discharge processes. If the

RNHCI determines that a patient does or does not require discharge instructions, this

decision must be made based on the existing policies.

Although all patients must have a discharge planning evaluation, not all patients will

require a discharge plan. Review discharge planning evaluations and review discharge

plans as applicable. The RNCHI’s discharge planning policies and procedures must

address how the staff responsible for discharge planning will be made aware of changes

in a patient’s condition that require a discharge planning evaluation to reevaluate the

need for a discharge plan.

Additionally, the discharge planning evaluation should be conducted in a timely manner,

allowing for sufficient time after completion to allow arrangements for post-RNHCI care

to be made, without having to delay the patient’s discharge in order to do so, or

requiring the patient to transfer to a different setting from where he/she was admitted

from primarily due to the delay in making appropriate arrangements.

Survey Procedures:

• Review the RNHCI policies and compare them with the patient record to confirm that

either the existence or lack of discharge instructions is consistent with the policies.

• Verify documentation that the facility has a discharge planning process.

• Review discharge plans for patients and verify the discharge plan was provided to the

patient or patient representative/caregiver at the time of the discharge, as necessary.