Discharge Planning Worksheet and Standards: Ensuring Compliance with the CMS Hospital CoPs and Proposed Changes

Event Information
Product Format
Prerecorded Event
Sue Dill Calloway, RN, MSN, JD
Conference Date
Wed, Oct 11, 2017
90 minutes
Product Description

Comply with CMS Hospital CoPs and Proposed Changes to Discharge Planning Standards


The final surveyor worksheet, used by State and Federal surveyors on all survey activity for assessing hospital compliance with the CMS hospital Conditions of Participation (CoPs) for discharge planning, will be revised in 2017 to reflect the proposed discharged planning guidelines when finalized. Every hospital that accepts Medicare and Medicaid must be in compliance with the CMS hospital 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 and you must learn which ones are required and why.

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, 2,597 hospitals forfeited $528 million in 2017.

The CMS rewrote all of the interpretive guidelines on the hospital discharge planning standards in July 19, 2013, to match what is in the current worksheet. The memo consolidated the prior 24 standards into 13. The CMS proposed changes to discharge planning include 5 things to include in the admission assessment, 5 data things to measure, 5 things that must be in the discharge instruction, changes to the discharge planning evaluation, and 21 things in the transfer form. The CMS memo includes new elements, such as “blue boxes” that contain advisory practices recommended for improving patient outcomes, and a crosswalk between the prior tags and revised tags. Medical reconciliation has been added along with providing written information on side effects of medications.

According to the proposed changes, medical record information such as the discharge summary and discharge instruction sheet will need to be in the hands of the primary care physician (PCP) or other physician within 48 hours of discharge. In addition, the hospital will need to amend the discharge planning evaluation form, which must be done on all inpatients. Is your hospital familiar with the interpretive guidelines and the worksheet information?

Join this session with expert speaker Sue Dill Calloway, RN, MSN, JD, to learn about the final surveyor worksheet for assessing compliance with the CMS hospital Conditions of Participation (CoPs) for discharge planning. This session will discuss what has changed based on the IMPACT Act and the proposed discharge planning standards which are significant. You will learn what other important things CMS has in their final worksheet which addresses preventing hospital readmissions.

Sue will also cover the CMS hospital discharge planning standards. You will learn about what your hospital has to do to be in compliance with the discharge planning standards. CMS has published showing the number of deficiencies that hospitals have already received in the discharge planning standards and this data will be provided.

Session Objectives

This session will discuss:

  • The worksheet on discharge planning published by CMS
  • The changes for hospitals as a result of the IMPACT Act and the CMS proposed changes to discharge planning
  • CMS discharge planning standards that every hospital must follow
  • That one in every five Medicare patients is readmitted within 30 days of discharge and many suffer adverse events

Session Highlights

  • CMS issues discharge planning memo
  • Transmittal issued and into final manual
  • IMPACT Act and the CMS proposed changes to discharge planning
  • How this will impact the discharge planning worksheet
  • CMS deficiency memo shows this is a problematic area
  • Introduction
  • Blue box or advisory boxes
  • CMS crosswalk to old tags
  • Discharge planning
    • Discharge planning process
    • Discharge planning P&P required
    • Transition planning or community care transitions
    • Reducing number of hospital readmission
    • Causes of preventable readmissions
    • Inpatients verses outpatients
    • Four stage discharge planning process
    • Discharge planning evaluation
  • Identification of patients in need of discharge  planning
    • Discharge plan for every patients; optional or mandatory?
    • Important four factors in discharge planning
    • P&P must include criteria and screening process
    • Identification at early stage for discharge planning
    • 48 hour rule
    • Patient transfers
  • Discharge planning evaluation
    • Evaluation of likelihood of needing post hospital services
    • Self-care assessment
    • Screening verses evaluation
    • Evaluation requirements
    • Returns to the LTC facility
    • Developing collaborative partnerships with post hospital providers
    • Ability to pay out of pocket expenses must be discussed
    • Right to participate in the development of their plan of care
    • 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
  • Discharge plan
  • Physician request for discharge planning
  • Implementation of the patient’s discharge plan
  • Reassessment of the discharge plan
  • Freedom of choice for LTC or home health agencies
  • Transfer or referral
  • Crosswalk

Discharge Planning Worksheet

  • Completion of intake form; name, CCN number, deemed status
  • Complete form in advance of survey
  • Discharge planning policies for all inpatients
  • Discharge planning for certain outpatients
  • Preparation of discharge plan for all inpatients
  • Discharge planning policy requirements
  • Process to notify patients and doctors can request an evaluation
  • Interview of patients and questions asked
  • Interview questions for physicians
  • Reassessment of the discharge plan
  • Feedback process from post-acute hospital providers (LTC, home health)
  • Criteria and screening process for discharge planning evaluations
  • Qualified social workers and discharge planners
  • Self-care evaluation
  • Assessment of ADL
  • Medical equipment for home
  • Patient representative involvement
  • Medication reconciliation
  • Written and legible discharge instructions
  • Referrals and transfers
  • Readmissions within 30 days
  • Any tests pending when patient discharged and process
  • Changes for 2017

Who Should Attend

  • Discharge planners
  • Transitional care nurses
  • Chief nursing officer
  • Compliance officer
  • Chief operation officer
  • Chief medical officers
  • Chief executive officer
  • Physicians
  • PI director
  • Health information director
  • Billing office director
  • Nurses with direct patient care
  • Risk managers
  • Regulatory officer
  • Physician advisor
  • UR nurses
  • Joint Commission coordinator
  • Nurse educators
  • Staff nurses
  • Nurse managers
  • Patient safety officer
  • Social workers
  • Anyone involved with the discharge planning
  • Personnel serving on a hospital committee to redesign the discharge process to prevent unnecessary readmissions

Ask a question at the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker.

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About Our Speaker

Sue Dill Calloway - Hospital Coding Expert

Sue Dill Calloway, RN, MSN, JD, is the president of Patient Safety and Healthcare Consulting and Education company with a focus on medical-legal education especially Joint Commission and the CMS hospital CoPs regulatory compliance. She also lectures on legal, risk management and patient safety issues. She was a director for risk management and patient safety for five years for the Doctors Company. She was the...   More Info
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