US · guidance
CMS SOM App. U, Tag R154
(3) If the RNHCI’s patient assessment does not indicate a need for a discharge plan,
the beneficiary or his or her legal representative may request a discharge plan. In
this case, the RNHCI must develop a discharge plan for the beneficiary.
Interpretive Guidelines: §403.736(a)(3)
Determine whether the facility notifies the patient or the patient’s legal representatives of
proposed transfers or discharges. If the patient or the patient’s legal representative has
requested a discharge plan, has the facility provided one to the requested individuals?
While the RNHCI may determine a patient is not likely to suffer adverse outcomes if no
discharge plan is provided, the patient and/or legal representative may request a
discharge plan be provided. The RNHCI must develop a discharge plan which at a
minimum consists of the following information:
• Post-care or self-care instructions;
• Instructions for the legal representative/caregiver, if necessary;
If neither the patient nor the patient’s family or informal caregiver(s) are able to address
all of the required care needs, then the evaluation should determine whether there are
community-based services that are available to meet the patient’s needs while allowing
the patient to continue living at home.
Survey Procedures:
• 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?
• Has the discharge plan been reassessed by the facility? Has the facility discussed
changes with the patient and/or legal representative?
• Did the RNHCI develop and provide a discharge plan when it was requested?
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
daf70c3d047b5ad0ace1296eb9c08d8e9dd1e64cfefd45d91e683b77847aec51
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