On May 17, the Centers for Medicare & Medicaid Services (CMS) issued an update of Appendix A of the State Operations Manual (SOM), thus revising the interpretive guidelines for Medicare Conditions of Participation (CoP) for hospitals (42 CFR 482.43). The effective implementation date is “upon issuance,” so there is no grace period for compliance. Hospitals should check their current discharge planning processes, using this detailed 39-page document for reference.

The revision included information in “blue boxes” – material that is meant to be helpful to hospitals because it recommends best practices they may choose to use in meeting the requirements of the SOM. However, the instructions state clearly that surveyors are not to issue citations based on a facility’s failure to follow the “blue box” guidance; hospitals need to ensure that this is upheld by checking the source of any citations.

The condition of participation that addresses discharge planning states that a hospital must have a written discharge planning process that applies to all inpatients (not just Medicare patients). Observation patients are not included in this.The relevant statute states that discharge planning is a process that involves determining the appropriate post-hospital discharge destination for a patient; identifying what the patient requires for a smooth and safe transition from the hospital to his/her discharge destination; and beginning the process of meeting the patient’s identified post-discharge needs.”

The revision addresses the need to reduce hospital readmissions by acknowledging the factors that lead to avoidable readmissions.

“Multiple factors contribute to the high level of hospital readmissions in the U.S … they may result from poor quality care or from poor transitions between different providers and care settings,” it reads. “Such readmissions may occur if patients are discharged from hospitals or other health care settings prematurely; if they are discharged to inappropriate settings; or if they do not receive adequate information or resources to ensure a continued progression of services. System factors, such as poorly coordinated care and incomplete communication and information exchange between inpatient and community‐based providers, may also lead to unplanned readmissions.”

With an eye toward remedying this through an improved discharge process, the revised CoP describes a four-stage discharge planning process that must involve the patient and his or her family as required. The following tasks are involved:

  1. Screening all inpatients to determine which ones are at risk of adverse health consequences post-discharge if they lack discharge planning;
  2. Evaluation of the post-discharge needs of inpatients identified in the first stage, or of inpatients who request an evaluation (or whose physician requests one);
  3. Development of a discharge plan if indicated by the evaluation or at the request of the patient’s physician; and
  4. Initiation of the implementation of the discharge plan prior to the discharge of an inpatient.

It is a cliché that “discharge planning starts at admission,” but Standard 482.43(a) states that “the hospital must identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning.” A hospital will not be cited, however, if discharge planning started at least 48 hours prior to discharge and there is no evidence things were delayed due to a failure to start planning earlier in the stay. This doesn’t let the hospital off the hook for short stays, however. There also must be screening for inpatients discharged in less than 48 hours.

According to Standard 482.43(b), the hospital must evaluate “the likelihood of a patient needing post-hospital services and of the availability of the services” and “the likelihood of a patient’s capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital.” In most cases the goal should be for the patient to return to the setting from which he or she came prior to hospitalization – but if the care required cannot be delivered in that setting, evaluation must be performed for transfer to another healthcare facility. The hospital is expected to be aware of the capabilities and limitations of these facilities in order to avoid the “bounce back” phenomenon, whereby a patient is immediately sent back to the hospital ER when a facility receives a hospital transfer and determines that it cannot provide the level of care required for that patient.

Patients should be advised of the financial details of their post-discharge care and the possible need to pay out of pocket when there is no coverage through government programs or insurance.

§482.43(b)(2) addresses the qualifications of the person responsible for the discharge plan: “A registered nurse, social worker, or other appropriately qualified personnel must develop or supervise the development of the evaluation.” §482.43(b)(5) states that the discharge plan must be completed “on a timely basis,” and §482.43(b)(6) requires that the hospital “discuss the results of the evaluation with the patient or individual acting on his or her behalf.” To be specific, “the patient or the patient’s representative must be actively engaged in the development of the plan,” that provision indicates, and the discharge plan must be kept in the medical record.

Discharge planning doesn’t actually stop when the patient leaves. According to §482.43(c)(3), “the hospital must arrange for the initial implementation of the patient’s discharge plan,” and §482.43(c)(5) states that “as needed, the patient and family members or interested persons must be counseled to prepare them for post-hospital care.” These arrangements include transfers to facilities that will provide additional care (such as SNFs, rehab hospitals and long-term care facilities, as well as home health agencies and community providers). Services at those facilities may include the provision of medical equipment and “referrals to pertinent community resources that may be able to assist with financial, transportation, meal preparation, or other post-discharge needs.” Medication reconciliation is mentioned specifically: the patient is to receive “a list of all medications the patient should be taking after discharge, with clear indication of changes from the patient’s pre-admission medications.”

Patients who require the services of a home health agency (HHA) or skilled nursing facility (SNF) must be given a list of providers that can provide necessary care. The list should be appropriate to the patient’s payor and geographic area, and it technically is considered part of the discharge plan. HHAs must ask to be included in hospitals’ referral lists; listings are not offered automatically. The hospitals also must disclose any financial interest they have in any of the providers on the lists. In addition to containing the lists, the record must show that it actually was presented to the patient or representative. And the hospital “must, when possible, respect patient and family preferences when they are expressed.”

The SOM places an obligation on the hospital to provide necessary medical information to the next provider, whether it’s an acute-care hospital, an SNF or a private physician. The required information includes, but is not limited to, the reason for hospitalization (including principle diagnosis), a summary of the hospital course, the patient’s condition on discharge, pending test results, and a list of medications and allergies. A copy of the patient’s advance directive also should be included, if the patient has one.


Since a patient’s condition can change during the course of his or her hospital stay, the discharge plan cannot be a static document. §482.43(c)(4) requires that “the hospital must reassess the patient’s discharge plan if there are factors that may affect continuing care needs or the appropriateness of the discharge plan.”§483.43(e) states that the hospital must “reassess its discharge planning process on an on-going basis. The reassessment must include a review of discharge plans to ensure that they are responsive to discharge needs.”

This revision of the SOM provides a valuable resource for hospitals that they should use to assess the appropriateness, thoroughness and effectiveness of their discharge planning processes. It includes detailed procedures that will be used by CMS surveyors and helpful advice in the “blue boxes” (yes, in this case the government actually is here to help you.) The common goal is better and safer transitions for hospital patients. While a reduction in readmissions may be a metric to measure the discharge planning process, a healthier patient with less need for acute hospital care hopefully will be the outcome.

Download the revised State Operations Manual §482.43 Condition of Participation: Discharge Planning online at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-32.pdf.

About the Author

Steven J. Meyerson, MD, is vice president of the Regulations and Education Group (“the REGs group”) for AccretivePAS®. He is Board Certified in Internal Medicine and Geriatrics. Before joining Accretive Physician Advisory Services in 2010 he served as the medical director of care management at Baptist Hospital in Miami, Florida. He has distinguished himself by contributing to the development of innovative service lines and managing education on Medicare regulatory compliance for AccretivePAS®.

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