Policy/Procedure Additional Comments/Special Instructions ...

1 Standard Met? Y or N Policy/Procedure Additional Locations Comments/Special Instructions DISCHARGE PLANNING ASSESSMENT TOOL According to Condition of Participation , the hospital must have in effect a discharge planning process that applies to all patients. The hospital policies and procedures must be specified in writing." Utilize this tool to help evaluate if your discharge planning meets COP standards. 2014 Executive Health Resources, Inc. All rights reserved. The content and analysis in this tool is solely for informational purposes. The analysis herein does not constitute legal advice. It is not a legal opinion and nothing contained in this tool should be used as a substitute for the advice of competent legal counsel. EHR makes no claims, promises or guarantees about the accuracy, completeness, or adequacy of the information contained in this tool.

2 You are responsible for the application of this tool and for any conclusions derived from your use of the tool. EHR, its employees, agents, and affiliates shall not be liable or responsible to for any claim, loss, injury, liability, or damages related to your use of this tool or reliance on the information contained therein. (a) Standard: Identification of Patients in need of Discharge PlanningDischarge Planning policy Job Description Discharge Planning staff. Must note how patients are identified for discharge planning evaluation. (b) Standard: Discharge Planning Evaluation.(1) The hospital must provide a discharge planning evaluation to the patients identified in paragraph (a) of this section and to other patients upon the patient s request, a person acting on the patient s behalf, or the request of the physician. DischargePlanning policy Must note how a patient, physician, or someone acting on patient s behalf can make a referral for a discharge plan.

3 (b)(2) A registered nurse, social worker, or other appropriately qualified person must develop or supervise the development of the evaluation. Discharge Planning policy Job Description and Signature / credentials are noted on the discharge plan. Describe how a qualified person is identified. If licensed staff is required, are credentials current? If the facility uses non licensed staff to evaluate and implement, how, where is their competency demonstrated. (b)(3) The discharge planning evaluation must include an evaluation of the likelihood of a patient needing post hospital services and of the availability of the services. Discharge Planning policy Discharge Planning Screens or other tool used to determine patients needing a discharge planning evaluation. What mechanism is used to identify which patients are at risk for discharge planning evaluation?

4 Screening criteria built upon what criterion? (b)(4) The discharge planning evaluation must include an evaluation of the likelihood of a patient s capacity for self care or the possibility of the patient being cared for in an environment from which they entered the hospital. Discharge Planning policy Discharge Planning Screens or other tool used to determine patients at risk needing a discharge planning evaluation. Assessment of capacity for self care or by others post hospitalization. How is each patient s capacity evaluated? (b)(5) The hospital personnel must complete the evaluation on a timely basis so that appropriate arrangements for post hospital care is made before discharge and to avoid unnecessary delays in discharge. Discharge Planning Screening Tool Screening tool demonstrates compliance. This is a 24/7 operation. If the patient is assessed as needing a discharge plan post acute, the staff (nursing/physician/case management) should be able to perform referrals according to policy whether the designated staff is present or not.

5 Delays due to insufficient discharge planning must be tracked, trended, and addressed in UR/QA committee and actions taken to correct the issues. (b)(6) The hospital must include the discharge planning evaluation in the patient s medical record for use in establishing an appropriate discharge plan and must discuss the results of the evaluation with the patient or individual acting on patient s behalf. Discharge Planning policy Documentation in the medical record. Documentation in the medical record should demonstrate conversations, education and discussions of the evaluation results with the patient, family, service providers, physicians, or other member of the interdisciplinary team. (c) Standard: Discharge Plan. (1) A registered nurse, social worker, or other appropriately qualified personnel must develop or supervise the development of a discharge plan, if the discharge planning evaluation indicates a need for a discharge plan.

6 Discharge Planning policy . Job Description. (c)(2) In the absence of a finding by the hospital that a patient needs a discharge plan, the patient s physician may request a discharge plan. In such a case, the hospital must develop a discharge plan for the patient. Discharge Planning policy (Medical Staff By Laws). Discharge policy should describe all manners in which a discharge planning evaluation may occur, , patient , family, physician, concerned person, etc. Standard Met? Y or N Policy/Procedure Additional Locations Comments/Special Instructions DISCHARGE PLANNING ASSESSMENT TOOL According to Condition of Participation , the hospital must have in effect a discharge planning process that applies to all patients. The hospital policies and procedures must be specified in writing." Utilize this tool to help evaluate if your discharge planning meets COP standards.

7 2014 Executive Health Resources, Inc. All rights reserved. The content and analysis in this tool is solely for informational purposes. The analysis herein does not constitute legal advice. It is not a legal opinion and nothing contained in this tool should be used as a substitute for the advice of competent legal counsel. EHR makes no claims, promises or guarantees about the accuracy, completeness, or adequacy of the information contained in this tool. You are responsible for the application of this tool and for any conclusions derived from your use of the tool. EHR, its employees, agents, and affiliates shall not be liable or responsible to for any claim, loss, injury, liability, or damages related to your use of this tool or reliance on the information contained therein. (c) (3) The hospital must arrange for the initial implementation of the patient s discharge plan.

8 Discharge Planning policy . (c) (4) 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. Discharge Planning policy . What does the policy address in terms of reassessing a patient s discharge plan: (1) How often? (2) What triggers a reassessment? (3) What does the hospital do if the discharge planning causes a delay in discharge? (c) (5) As needed, the patient, family memberor interested person, must be counseled to prepare for post hospital care. Discharge Planning policy . Documentation of conversations with patient, family, staff, physicians in the medical record. (c) (6) The hospital must include in the discharge plan the list of HHAs and SNFs that are available to the patient and are participating in the Medicare program and that serve the geographic area (as defined by the HHA) in which the patient resides or in the case of a SNF, in the geographic area requested by the patient.

9 HHAs must request to be listed by the hospital, as available. Patient Choice policy and Procedure. Patient Choice List. Each hospital should have a listing of services approved by Medicare available to hand to the patient/family. The facility should have on file a copy of the service provider and their current licensure. The facility should have a list of HHA who requested to be listed. The list should denote service areas and any managed care specifics or have a separate list. (c) (6) (i) The list must only be presented to patients for whom HH care or post hospital extended care services are indicated and appropriate as determined by the discharge planning evaluation. Patient Choice policy and Procedure. (c) (6) (iii) The hospital must document in the patient s medical record that the list was presented to the patient or to the individual acting on the patient s behalf.

10 Patient Choice policy and Procedure. (c) (7) The hospital, as part of the discharge planning process, must inform the patient or the patient s family of their freedom to choose among participating Medicare providers of post hospital care services and must, when possible, respect patient and family preferences when they are expressed. The hospital must not specify or otherwise limit the qualified providers that are available to the patient. Patient Choice policy and Procedure. Documentation in the medical record should indicate what information and to whom the information was shared. (c) (8) The discharge plan must identify any HHA or SNF to which the patient is referred, in which the hospital has a disclosable financial interest, in a hospital under Medicare. Financial interests that are disclosable under Medicare are determined in accordance with the provisions of Part 420, Subpart C, of this chapter.