In this Question of the Week, Jennifer Osburn, Clinical Consultant answers a question related to Discharge Planning Requirements.
Q: I have a question regarding what surveyors are looking for in the form of discharge planning, demonstrating this has occurred, and what the patient’s response is. I am wondering if I should develop a short care plan with an intervention or two on this. What if anything have you heard on this, and what do you suggest?
A: Pertinent to discharge planning, the surveyor will be looking for information in the record that shows discharge planning has occurred throughout the patient’s care period. Discharge planning, evidenced throughout the patient’s clinical record, includes many Conditions of Participation standards, including but not limited to those found at §484.110 and §484.58.
The patient’s record must include:
- Patient-specific, individualized, measurable goals and the patient’s ongoing progress toward reaching them
- All interventions, including medication administration, treatments and services and responses to them
- Contact information for the patient, patient’s representative, and the patient’s primary caregiver
- Contact information for the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA
- This provider must be sent a completed discharge summary within 5 business days of the patient’s discharge
Ideally, the patient’s discharge plan and instructions would address the patient’s support needs, the location of the patient following agency discharge, and specific discharge instructions to follow including a current, reconciled mediation profile in patient-friendly language. For specific information on DC Planning, see the Home Health Surveyor’s Guidance Manual, State Operations Manual, Appendix B, interpretative guidance at §484.58 regarding Home Health Agency Discharge Planning.
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