Discharge Planning: Compliance with the New CMS Hospital & CAH CoPs

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Every hospital, including critical access hospitals, needs to attend this important webinar. This program will cover the new changes to the discharge planning standards that became effective November 29, 2019. These were published in the Federal Register on September 30, 2019. CMS will publish revised interpretive guidelines and survey procedures to match the new regulations. These apply to all hospitals, and for the first time will apply to critical access hospitals. Hospitals will be happy to find out that CMS scaled back on many of the proposed rules that hospitals had expressed concern about. 

This program will discuss the impact act and how if affects hospital discharge planning. It requires the standardized assessment, quality data, and resource data requirements. It requires hospitals to assist patient with post-discharge care such as home health, skilled nursing facilities, long term care hospitals and inpatient rehab facilities. Patients have freedom of choice and now information on all four must be provided to the patient except for CAHs. 

The new regulations cover sections on patient timely access to medical records, the discharge planning process, discharge instructions, discharge planning requirements. It will cover transfers to other facilities, assessment of readmission within 30 days, caregiver rights and recommendations, reduction of factors that lead to preventable readmissions, timely discharge planning, and more. CMS has changed the email address to ask question and the website to get all of the manual and this information will be provided.

This program will also cover what was not adopted by CMS. In many sections that were not adopted, CMS made recommendations to hospitals. This includes the prescription drug monitoring program, the 24 hour requirement to initiate a discharge plan, 8 things to be in the discharge planning assessment, 21 things to be included in the transfer form, medication reconciliation, the discharge summary and instructions must be sent within 48 hours of discharge and more.

This program will briefly discuss the final surveyor worksheet for assessing compliance with the CMS hospital Conditions of Participation (CoPs) for discharge planning. This worksheet is used by State and Federal surveyors on all survey activity in hospitals assessing compliance with the discharge planning standards. CMS will revise the worksheet to reflect the revised discharge planning standards.

Come join this important webinar to learn about what your hospital has to do to be in compliance with the revised discharge planning standards. CMS has published data showing the number of deficiencies that hospitals have already received in the discharge planning standards and this data will be provided.

CMS has included in the memo information about blue boxes. The blue boxes contain advisory practices which are recommendations to improve patient outcomes. Blue box recommendations are not required for hospital compliance and if a hospital does not follow they are not to be cited.

Discharge planning is not only important to ensure compliance with the CMS standards but also for reimbursement. Optimal discharge planning can help prevent unnecessary readmissions. Hospitals that have a higher readmission rate can be financially penalized. In fact, 2,573 hospitals forfeited $564 million.

Every hospital that accepts Medicare and Medicaid must be in compliance with the CMS discharge planning guidelines. These standards must be followed for all patients and not just Medicare or Medicaid. CMS requires a number of discharge planning policies and procedures so come learn which ones are required and why.

Detailed Agenda: 

• CMS issues revised hospital & CAH Discharge Planning requirements

• Transmittal and into final manual

• Revisions of the interpretive guidelines and survey procedure in 2020

• How this will impact the discharge planning worksheet which will be amended

• CMS Deficiency Memo shows this is a problematic area

• Introduction

• Blue box or advisory boxes

• Discharge planning

        1. Discharge planning process

        2. Discharge planning P&P required

        3. Transition planning or community care transitions

        4. Reducing number of hospital readmission

        5. Causes of preventable readmissions

        6. Timely Discharge planning evaluation

•  Identification of patients in need of discharge  planning

       1. Discharge plan for every patients; optional or mandatory?

       2. Important  factors in discharge planning

       3. P&P must include criteria and screening process

       4. Identification at early stage for discharge planning

       5. Patient transfer requirements

• Discharge planning evaluation

        1. Evaluation of likelihood of needing post hospital services

        2. Self care assessment

        3. Screening verses evaluation

       4. Evaluation requirements

       5. Returns to the LTC facility

       6. Right to participate in the development of their plan of care

       7. Interviews of patients to show awareness of right to request discharge planning

• RN, social worker or qualified person to develop evaluation

• Timely evaluation 

• Discussion of evaluation with patient or individual acting on their behalf 

• Discharge evaluation must be in the medical record

• Documentation of the discharge process

• Discharge plan

• Physician request for discharge planning

• Implementation of the patient’s discharge plan

• Reassessment of the discharge plan

• Freedom of choice for LTC, LTCH,  home health agencies and inpatient rehab

• Document list give except CAHs

• Transfer or referral


  • Discuss the CMS has revised the discharge planning requirements that apply to all hospitals and critical access hospitals
  • Recall patients and physicians can request a discharge planning evaluation 
  • Discuss that information about the hospitalization must be provided to the physician or provider before the first post hospital visit
  • Describe that the patient has a right to get medical records timely including a copy of their discharge plan

Who Should Attend?

Discharge planners, transitional care nurses, social workers, RN discharge planners, all staff nurses who discharge patients in a hospital setting, ED nurses, chief nursing officer, compliance officer, nurse educators, chief operation officer, chief medical officers, physicians, all nurses with direct patient care, risk managers, social workers, regulatory officer, physician advisor, UR nurses, compliance officer, Joint Commission coordinator, chief operating officer, chief executive officer, staff nurses, physicians, nurse managers, PI director, health information director, billing office director, patient safety officer, and anyone else involved with the discharge planning. Any person serving on a hospital committee to redesign the discharge process to prevent unnecessary readmissions should also attend.

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