Discharge Planning Worksheet and Standards: Ensuring Compliance with the 2019 CMS Hospital CoPs and Proposed Changes

Discharge Planning Worksheet and Standards: Ensuring Compliance with the 2019 CMS Hospital CoPs and Proposed Changes
Product Code: : AQ-9034
Speaker : Sue Dill Calloway
Date : 20th June 2019
Time : 10:00 AM PST | 01:00 PM EST
Duration : 120Min

This program will 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. The worksheet will be revised to reflect the proposed discharged planning guidelines when finalized. This webinar will discuss what has changed based on the IMPACT Act and the proposed discharge planning standards which are significant.

Objectives of the Presentation

  • Discuss the CMS has published a worksheet on discharge planning
  • Discuss that the IMPACT Act and the CMS proposed changes to discharge planning that will result in many changes for hospitals
  • Recall that CMS has discharge planning standards that every hospital must follow
  • Discuss when the discharge summary and discharge instructions will have to be provided to the primary care physician under the proposed rules

Why Should you Attend

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 on 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 another 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.

Areas Covered

  • CMS issues Discharge Planning memo issued
  • 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 the 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 patient; optional or mandatory?

                -Important four factors in discharge planning

                -P&P must include criteria and screening process

                -Identification at an 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 versus 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 with patients to show awareness of the 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 the survey
  • Discharge planning policies for all inpatients
  • Discharge planning for certain outpatients
  • Preparation of discharge plan for all inpatients
  • Discharge planning policy requirements
  • The process to notify patients and doctors can request an evaluation
  • Interview with 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 2019

Who will Benefit

  • 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

Speaker Profile

Sue Dill Calloway is a nurse attorney, a medical-legal consultant and the past chief learning officer for the Emergency Medicine Patient Safety Foundation. She is the immediate past director of Hospital Patient Safety and Risk Management for The Doctors Company. She is currently president of Patient Safety and Health Care Education and Consulting. She was a medical malpractice defense attorney for many years and a past director of risk management for the Ohio Hospital Association. She was in-house legal counsel for a hospital in addition to being the privacy officer and compliance officer. She has done many educational programs for nurses, physicians, and other healthcare providers. She has authored over 102 books and numerous articles. She is a frequent speaker and is well known across the country in the area of healthcare law, risk management, and patient safety. She has taught many educational programs and written many articles on compliance with the CMS and Joint Commission restraint standards.



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