conferencepanel (1)

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Discharge Planning Compliance with CMS Hospital
and CAH CoPs 2021
Presented ByMs. Laura A. Dixon (BS, JD, RN,
CPHRM)
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Deficiency Data Discharge Planning
Tag Number Section March 5, 2021
799 Discharge Planning (DP) 103
800 DP Evaluation 99
806 DP Needs Assessment 146
808/809 Qualified DP Staff 33
810 Timely DP Evaluation 59
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Deficiency Data Discharge Planning
Tag Section
811 Documentation Evaluation 56
812 Discharge Planning 39
818 DP Personnel 19
819 MD Required DP 3
820 Implementation of DP 215
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Deficiency Data Discharge Planning
Tag Section
821 Reassess DP 148
823 List of HH Agencies 90
837 Transfer or Referral 149
843 Reassess DP Process 81 Total 1,240
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IMPACT Act

• Federal law Improving Medicare Post-Acute Care
  Transformation Act of 2014
• Passed to
• Standardize information collected between the
  four post-acute care providers (PACs)
• Improve quality of care across the provider
  settings and reduce readmissions
• Wanted to improve hospital and discharge planning
  
• Required CMS to revise the hospital CoPs
• Review every five years for with the interpretive
  guidelines

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Discharge Planning Overall

• The hospital must have an effective discharge
  planning process that focuses on
• Patient goals and
• Treatment preferences
• Example
• 88-year-old female who had significant surgery on
  her foot
• Physician wants her to go to LTC for a week to
  rehab
• Patient wants to go home and be cared for her
  daughter, a nurse

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Discharge Planning

• CMS best practice to give the caregiver hospital
  contact information to discuss early concerns
  about the discharge plan or discharge
  instructions
• Not required to give the patient/caregiver a copy
  of the discharge plan
• Some hospitals do regardless
• The patient can request a copy of the discharge
  plan

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Discharge Planning Process

• Discharge plan must ensure an effective
  transition from the hospital to post-discharge
• Generally process is started when the patient
  is first admitted
• The nurse will ask questions during the admission
  assessment process starts here
• Are they able to do activities of daily living at
  home like can they take their own shower or fix
  their own meals
• Include in the nursing assessment what are the
  patients goals of care and treatment preferences

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Discharge Planning Process

• The hospitals discharge planning must identify
  at an early stage those patients who are likely
  to suffer adverse health consequences when
  discharged
• High-risk patient in the emergency department
  with a history of COPD, diabetes, and depression
• Patient admitted for outpatient surgery who has
  many medical problems and a lack of a caregiver
  to help out
• Patient placed in an outpatient observation unit
  who is going to need home oxygen, medications, a
  walker or other equipment

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Discharge Information and Decision

• Discharge or transfer summaries should not be
  delayed to wait for the physician signature
• It can be sent and then updated later with the
  signature
• CMS HPs, progress notes and transfer summaries
  can be signed by the licensed practitioners
  responsible for the care of the patient
• Federal EMTALA law says a transfer decision can
  only be made by a physician
• If NP or PA are in the CAH emergency department
  they can sign it and the physician can sign later

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Assessment of Discharge Planning Process

• Hospital must assess its discharge planning
  process on a regular basis
• To determine any changes in the patients
  condition
• Assessment must include an ongoing, periodic
  review of a representative sample of discharge
  plans
• Includes patients readmitted within 30 days

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Discharge Planning 2020

• Standard The hospital must have a discharge
  planning (DP) process that applies to all
  patients (799)
• Include the caregivers/support person in the
  discharge planning for post-discharge care
• Focus on patient goals and treatment preferences
• Discharge process and plan must be consistent
  with the goals and preferences
• Must ensure an effective transition from hospital
  to post-discharge care and reduce factors for
  readmission
• Guidelines are pending

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CAH Policies and Procedures

• CAH must have an effective discharge planning
  process under Appendix W
• The requirements are very similar to those
  required for hospitals under Appendix A
• Are a few differences
• Discharge planning must focus on the patients
  goals and treatment preferences
• It must include patients and their
  representatives as active partners in the
  discharge planning process
• Patients have timely access to their medical
  records

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CMS Discharge Planning Worksheet

• CMS has three worksheets
• Discharge planning
• Infection Control
• QAPI
• Link has been attached as a resource
• No longer used by CMS
• Are an excellent self-assessment tool

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Thanks for Reading
Register for the Webinar
Discharge Planning Compliance with CMS Hospital
and CAH CoPs 2021
For more information, contact us and visit us
at- Visit - https//conferencepanel.com/ Call
- 1-800-803-7592 Email - cs_at_conferencepanel.com

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