Discharge Planning: Compliance with CMS Hospital & CAH CoPs 2021

Laura A. Dixon

Laura A. Dixon

Laura A. Dixon served as the Director, Facility Patient Safety and Risk Management, and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consulting and training to facilities, practitioners and staff in multiple states. Such services included the creation of and presentations on risk...
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90 Mins
Laura A. Dixon

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 comply with the CMS discharge planning guidelines. These standards must be followed for all patients and not just Medicare or Medicaid. CMS requires several discharge planning policies and procedures so come learn which ones are required and why.

This webinar by industry expert Laura A. Dixon, BS, JD, RN, CPHRM, is a must-attend session for every hospital, including critical access hospitals. This webinar covers the new changes to the discharge planning standards that became effective November 29, 2019, and published in the February 21, 2020 manual. It is anticipated CMS will publish revised interpretive guidelines and survey procedures to match the new regulations in 2021. These apply to all hospitals, and for the first time will apply to critical access hospitals. CMS scaled back many of the proposed rules that hospitals had expressed concern about but there are still a lot of changes. CMS has section 1335 waivers during the COVID-19 pandemic and the discharge planning one will be discussed.

This webinar will focus on the impact act and how it affects hospital discharge planning. It requires a standardized assessment, quality data, and resource data requirements. It requires hospitals to assist patients 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 questions and the website to get all the manuals and this information will be provided.

This webinar will also cover a brief description of what was not adopted by CMS but did recommend 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.

During the webinar, Laura will also 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.

Please join this important webinar to learn about what your hospital must comply 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.

Webinar Objectives

  • Discuss the CMS revised 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

Webinar 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
    • Discharge planning process
    • Discharge planning P&P required
    • Transition planning or community care transitions
    • Impact of COVID-19 reporting requirements on care transitions
    • Reducing the number of hospital readmission
    • Causes of preventable readmissions
    • Timely Discharge planning evaluation
  • Identification of patients in need of discharge planning
    • Discharge plan for every patient; optional or mandatory?
    • Important factors in discharge planning
    • P&P must include criteria and screening process
    • Identification at the early stage for discharge planning
    • Patient transfer requirements
  • Discharge planning evaluation
    • Evaluation of likelihood of needing post hospital services
    • Self-care assessment
    • Screening verses evaluation
    • Evaluation requirements
    • Returns to the LTC facility
    • 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
  • 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 to provide except CAHs
  • Transfer or referral

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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