US · guidance
CMS SOM App. U, Tag R153
(2) If the patient assessment indicates a need for a discharge plan, the discharge
plan must include instructions on post-RNHCI care to be used by the patient or the
caregiver in the patient’s home, as identified in the discharge plan.
Interpretive Guidelines: §403.736(a)(1-2)
Determine whether the assessment was timely and evaluated on a case-by-case basis. If
the patient assessment indicates a discharge plan is needed, has the facility provided
written instructions to the patient or the caregiver on post-care in the patient’s home?
Assessments completed after discharge are not timely.
Survey Procedures:
• If a patient is determined to need a discharge plan, is one developed? Is a
discharge plan developed if the patient or legal representative requests one?
• Are discharge plans modified to reflect current patient status and needs?
• Do discharge plans address necessary post-discharge care?
• How does the facility inform patients or legal representatives about post-RNHCI
care requirements?
History
Rev. 239; Issued: 04-24-26; Effective: 04-24-26; Implementation: 04-24-26
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
1a5549d287bfdbffe3a1e9d83bcee4907f370faee53aeb2dfe8930bb612087f5
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