Centers for Medicare &MedicaidServices
HospitalDischarge PlanningWorksheet
Nameof StateAgency:
Instructions: The followingis a list of itemsthat must beassessedduring theon-site survey,in orderto determinecompliance with theDischarge Planning Conditionof Participation.Itemsareto beassessedby a combinationof observation, interviewswith hospital staff,reviewof thehospital’s discharge planning programdocumentation includingpolicies and procedures,and reviewof medical records.
The interviewsshould beperformedwith themost appropriate hospital staff person(s) for theitemsof interest,as well as with patients, family members,and support persons.
Section1HospitalCharacteristics
1. Hospital name:
2. CMS Certification Number(CCN):
3. Dateof site visit:
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Section2Discharge Planning–PoliciesandProceduresElementstobe assessed / Surveyor Notes
2.1 Implementation of dischargeplanning policies and proceduresfor inpatients:
2.1a Foreveryinpatient unit surveyedis thereevidenceof
applicable dischargeplanning activities? / Yes
No
2.1b Arestaff membersresponsible for discharge planning
activities correctlyfollowingthehospital’s discharge
planning policies and procedures? / Yes
No
If nofor either 2.1aor 2.1b,cite theapplicablestandardfor identificationof patientsneedingdischargeplanning,42CFR 482.43(a)(TagA-0800);
dischargeplanningevaluation,42CFR 482.43(b)(TagA-0806);and/ordevelopingandimplementingthedischargeplan,42CFR 482.43(c)(TagA-0818)
HFAP Standard 15.03.01; 15.03.02; 15.03.09
2.2 Does thedischarge planning process apply to certain
categoriesof outpatients? / Yes
No
If yes, check all that apply:
Same day surgery patients
Observation patients who are not subsequently admitted
ED patients who are not subsequently admitted
Other
2.3 Is a discharge plan preparedfor eachinpatient? / Yes, skip to question 2.8
No, go to question 2.4
NOTE:Nocitationriskrelatedtoresponsestoquestions2.2and2.3;for informationonly.
Elementstobe assessed / Surveyor Notes
2.4 For patients not initiallyidentified as in needof a discharge plan:
2.4a Does thedischarge planning policy address
circumstances wherechanges in patient condition would call fora discharge planning evaluationin patients not previously identified as needingone? / Yes
No
2.4b Areinpatient unit staff awareof how, when,and
whom to notify of such changes in patient condition in orderto triggera discharge planning evaluation? / Yes
No
If notoeither 2.4aor 2.4b,cite at42CFR 482.43(a)(TagA-0800) HFAP Standard 15.03.01
2.5 For patients who do not havea discharge planning evaluation:
2.5a Does thehospital havea standard process for
notifying patients (or their representativeif applicable)that theymayrequesta discharge
planning evaluation and that thehospital will conduct
an evaluation upon request? / Yes
No
2.5b Does thehospital havea standard process for
notifying physicians that theymayrequesta discharge planning evaluation and that thehospital will conduct an evaluation upon request? / Yes
No
2.5c Canboth dischargeplanning and unit nursing staff
personneldescribetheprocess for a patient orthe
patient’s representativeto requesta discharge planning evaluation,evenif thehospital’s screening concluded one wasnot needed? / Yes
No
Elementstobe assessed / Surveyor Notes
2.5d Interviewpatients (ortheir representativesif
applicable).If theysaytheywerenot awarethey could requesta discharge planning evaluation, can thehospital provide evidencethepatient or representativereceivednotice theycould requestan evaluation? / Yes
No
N/A
2.5e Interviewattending physicians.If theyarenot aware
theycan requesta discharge planning evaluation, can thehospital provide evidenceof howitinforms the medical staff about this? / Yes
No
N/A
If notoanypartof question2.5,cite at42CFR 482.43(b)(1)(TagA-0806) HFAP Standard 15.03.02
2.6 Interviewattending physicians.If theyarenot awarethey
can requesta discharge plan regardlessof theoutcome of thedischarge planning evaluation, can thehospital provide evidenceof how it informs themedical staff about this? / Yes
No
N/A
If noto2.6,cite at42CFR 482.43(c)(2)(TagA-0819) HFAP Standard 15.03.10
2.7 Can discharge planning personnel describea process for physicians to ordera discharge plan to becompleted on a patient, regardlessof theoutcome of thepatient’s evaluation? / Yes
No
If noto2.7,cite at42CFR 482.43(c)(2)(TagA-0819) HFAP Standard 15.03.10
2.8 Does thehospital discharge planning policy includea
process for ongoing reassessmentof thedischarge plan based on changes in patient condition, changes in available support, and/or changes in post-hospital care requirements? / Yes
No
If noto2.8,cite at42CFR 482.43(c)(4)(TagA-0821) HFAP Standard 15.03.12
Section3Discharge Planning–Reassessment andQAPI
Elementstobe assessed / Surveyor Notes
3.1Does thehospital reviewthedischarge planning process in
an ongoing manner,e.g. through QAPIactivities? / Yes
No
3.2 Does thehospital trackits readmissionsas partof its review
of thedischarge planning process?(Askto seesome
readmissions datato confirm trackingoccurs.) / Yes
No
3.3Does thehospital’sassessmentof readmissions include an
evaluation of whetherthereadmissions werepotentially due to problems in discharge planning orthe implementation of discharge plans? / Yes
No
N/A
3.4 If thehospital identified preventablereadmissionsand
problems in thedischarge planning process wereidentified as a possible cause,did it makechanges to its discharge planningprocesstoaddress theproblems? / Yes
No
N/A
If notoanyquestionfrom 3.1through3.4,cite at42CFR 482.43(e)(TagA-0843)andpossiblyQAPI42CFR 482.21(c)(TagA-0283) HFAP Standards 15.03.24; 12.00.02
3.5Does thehospital havea process for collecting and
considering feedbackfrompost-acuteproviders in the
communityabout theeffectivenessof thehospital’s
discharge planning process? / Yes
No
NOTE:Nocitationriskrelatedtoresponsestoquestion3.5;for informationonly.
Section4Discharge PlanningTracers
Review 5 patient records in this section. The records selected should include a combination of patients admitted from home as well as from residential healthcare facilities.
Includeatleast1current inpatientwhoreceived adischargeplanningevaluationandhasadischargeplanunder development.
Donotincluderecords of anyinpatientwhowastransferred toanothershort-term acutecare hospital
Whenpossible,includetherecord of atleast1inpatientwhowasreadmittedwithin30daysof aprioradmission,butonlyevaluatethe current admission;
For closed records, only select records that include a discharge planning evaluation and a discharge plan.
Patient/Record #1
Open
Closed / Patient/Record #2
Open
Closed / Patient/Record #3
Open
Closed / Patient/Record #4
Open
Closed / Patient/Record #5
Open
Closed
Patientlocationpriortothisadmission,
or totheadmissionunderreview for
closedmedicalrecords: / Home
NH, SNF,
assisted living or other residential healthcare facility / Home
NH, SNF,
assisted living or other residential healthcare facility / Home
NH, SNF,
assisted living or other residential healthcare facility / Home
NH, SNF,
assisted living or other residential healthcare facility / Home
NH, SNF,
assisted living or other residential healthcare facility
4.1Whenwasthescreeningdone to
identify whethertheinpatient needed
a discharge planning evaluation?
a.Beforeorattimeof admission
b.Afteradmission but atleast 48 hours prior to discharge
c.N/A– all admitted patients receive a discharge plan
d.Noneof theabove / a.
b.
c.
d. / a.
b.
c.
d. / a.
b.
c.
d. / a.
b.
c.
d. / a.
b.
c.
d.
If response4.1disselected, cite at42CFR 482.43(a)(TagA-0800) HFAP Standard 15.03.01
4.2Can hospital staff demonstratethat
thehospital’s criteriaand screening process for a discharge planning evaluation werecorrectlyapplied?
NOTE:Only use N/Aif ALL inpatients receivea discharge plan. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
If noto4.2,cite at42CFR 482.43(a)(TagA-0800) HFAP Standard 15.03.01
Patient/Record #1 / Patient/Record #2 / Patient/Record #3 / Patient/Record #4 / Patient/Record #5
4.3Wasthedischarge planning evaluation
and, as applicable, thedischarge plan developed by an RN,Social Worker,or
otherqualifiedpersonnel, as defined in thehospital discharge planning policies and procedures,orsomeone theysupervise? / Yes
No / Yes
No / Yes
No / Yes
No / Yes
No
If noto4.3,cite at42CFR 482.43(b)(2)(TagA-0807- evaluation)and/or42CFR 482.43(c)(1)(TagA-0818- plan) HFAP Standards 15.03.03 & 15.03.09
4.4 Aretheresults of thedischarge
planning evaluation documented in themedical record? / Yes
No / Yes
No / Yes
No / Yes
No / Yes
No
If noto4.4,cite at42CFR 482.43(b)(6)(TagA-0812) HFAP Standard 15.03.07
4.5Did theevaluation include an
assessmentof thepatient’s post
discharge careneeds being metin the environment fromwhich he/she enteredthehospital? / Yes
No / Yes
No / Yes
No / Yes
No / Yes
No
4.6Did theevaluation include an
assessmentof thepatient’s ability to
performactivities of daily living (e.g. personal hygieneand grooming, dressing and undressing, feeding, voluntary control overbowel and bladder, ambulation, etc.)? / Yes
No / Yes
No / Yes
No / Yes
No / Yes
No
Patient/Record #1 / Patient/Record #2 / Patient/Record #3 / Patient/Record #4 / Patient/Record #5
4.7Did theevaluation include an
assessmentof thepatient’sand/or
support person’s ability to provide self-care/care? / Yes
No / Yes
No / Yes
No / Yes
No / Yes
No
4.8Did theevaluation include an assessmentof whetherthepatient will require:
4.8aspecialized medical equipment?
If No,skip question 4.9a. / Yes
No / Yes
No / Yes
No / Yes
No / Yes
No
4.8bhome and/orphysical
environment modifications?
If No,skip question 4.9b. / Yes
No / Yes
No / Yes
No / Yes
No / Yes
No
4.9 Iftheassessmentdeterminedthepatient required specialized medical equipmentand/orenvironment modifications,did theevaluation include an
assessmentof whether:
4.9a theequipment is available?
NOTE:Only choose N/Aiftheassessment determinedthepatient did not need specialized medical equipment. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
4.9bif themodificationscan bemade
to safelydischarge thepatient to that setting?
NOTE:Only choose N/Aif theassessment determinedthepatient did not need environmentmodifications. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
Patient/Record #1 / Patient/Record #2 / Patient/Record #3 / Patient/Record #4 / Patient/Record #5
4.10If theassessmentdeterminedthat
thepatient orfamily/support persons areunable to meetallcareneeds ,did theevaluation include an assessment of available community-based services to meetpost-hospital needs?
NOTE:Only choose N/Aif theassessment determinedall careneeds couldbemetby thepatient and/orsupport persons. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
If notoanyquestionfrom 4.5- 4.10,cite at42CFR 482.43(b)(4)(TagA-0806) HFAP Standard 15.03.02
4.11Iftheassessmentdeterminedthe
patient would needHHAorSNF care,
did thehospital provide thepatient
with lists of Medicare-participating HHAsorSNFs that provide post- hospital servicesthat could meetthe patient’s medicalneeds?
If NoorN/A,skip to 4.12.
NOTE:Only choose N/Aif theassessment
determinedthepatientwouldnot need
HHAorSNF care. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
4.11aIf thehospital provided lists, weretheygeographically appropriate for thepatient?
NOTE:Only chooseN/Aif theassessment determinedthepatient wouldnotneed HHAorSNF care. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
If noto4.11or 4.11a,cite at42CFR 482.43(c)(6)(TagA-0823) HFAP Standard 15.03.14
Patient/Record #1 / Patient/Record #2 / Patient/Record #3 / Patient/Record #4 / Patient/Record #5
4.12If thepatient wasadmitted froma
residential facility, did theevaluation assess whetherthatfacility has the capability to provide necessarypost- hospital servicesto thepatient (i.e. is thesame,higher,orlowerlevelof
carerequired)and can those needs be
metin that facility?
NOTE:Only choose N/Aif thepatient was not admitted froma residential facility. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
4.13Did theevaluation include an
assessmentof thepatient’s insurance coverage(if applicable)and how that
coveragemight ormight not provide for necessaryservicespost- hospitalization? / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
If noto4.12or 4.13cite at42CFR 482.43(b)(4)(TagA-0806) HFAP Standard 15.03.02
4.14Wasthedischarge planning
evaluation completedin a timelybasis to allow for appropriate arrangements to bemadefor post-hospital careand to avoid delays in discharge(including to a post-acutecaresetting)? / Yes
No / Yes
No / Yes
No / Yes
No / Yes
No
If noto4.14,cite at42CFR 482.43(b)(5)(TagA-0810) HFAP Standard 15.03.06
4.15Wasthepatient(orthepatient’s
representative,if applicable)involved in a discussionof theevaluation results? / Yes
No / Yes
No / Yes
No / Yes
No / Yes
No
If noto4.15,cite at42CFR 482.43(b)(6)(TagA-0811)andpossibly42CFR 482.13(b)(1)Patient'sRights(TagA-0130) HFAP Standard 15.03.07 & 15.01.10
Patient/Record #1 / Patient/Record #2 / Patient/Record #3 / Patient/Record #4 / Patient/Record #5
4.16Did thedischarge plan match the
identified needs as determinedby the
discharge planningevaluation?
NOTE:Onlyuse N/Afor open recordsif thedischarge plan isn’t complete. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
If noto4.16,cite at42CFR 482.43(c)(1)(TagA-0818) HFAP Standard 15.03.09
4.17If any significant changes in the
patient’s conditionwerenoted in the medical recordthat changed post- discharge needs,wasthedischarge plan updated accordingly?
UseN/Afor open recordsorif no significant changes werenoted. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
If noto4.17,cite at42CFR 482.43(c)(4)(TagA-0821) HFAP Standard 15.03.12
Questions4.18through4.22canonlybe answered ontheclosedrecords, asselected inthePatient/RecordfieldspriortoQuestion4.1.
4.18Regardingtheinitialimplementation of thedischarge plan during thehospitalization,look for evidenceof thefollowing, if applicable, based on the discharge plan:
4.18aProviding in-hospital training to
patient and/orsupport persons, using recognizedmethods.
Examples include teach-backorrepeat- back,simulationlaboratories, etc.,but thesespecific methods arenot required.
NOTE:Only use N/Afor patients transferredto a post-acutecarefacility, or for patients for whom no home care training wasrequired. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
Patient/Record #1 / Patient/Record #2 / Patient/Record #3 / Patient/Record #4 / Patient/Record #5
4.18b Writtendischarge instructions
that arelegible and use non-
technical language.
NOTE:Only use N/Afor patients transferredto a post-acutecarefacility. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
4.18c Alist of all medications the
patient should betaking after
discharge,with clearindicationof changes fromthepatient’s pre- admission medications
NOTE:Only use N/Afor patients who have no medications prescribedpost-discharge. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
4.18dEvidence of education of
patient and/or support persons on admission vs. discharge medications, highlightingchanges.
NOTE:Only use N/Aif no changes from pre-admissionsmeds,no post-discharge meds,orif patient wastransferredto a post-acutecarefacility. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
4.18eReferralsfor follow-up careto
new/establishedprimarycare physician orhealth center.
NOTE:Only use N/Aif thepatient was transferredto a post-acutecarefacility, or if thepatient has a scheduled follow-up appointment with theattendingphysician. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
Patient/Record #1 / Patient/Record #2 / Patient/Record #3 / Patient/Record #4 / Patient/Record #5
4.18fReferrals,if applicable,to specializedambulatory services, e.g. PT,OT,HHA,hospice, mental health, etc. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
4.18gReferrals,if applicable,to community-based resourcesother than health services,e.g. Depts. of Aging,elderservices, transportation services,etc. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
4.18hArrangingessential durable
medical equipment, e.g.oxygen,
wheelchair,walker,hospital bed,
commode,etc.,if applicable. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
4.18i Sendingnecessarymedical informationto providers the patient wasreferredto prior to thefirst post-discharge appointment orwithin 7days of discharge,whichevercomesfirst.
NOTE:Only use N/Aif thepatient was transferredto a post-acutecarefacility or if thepatient has a scheduled follow-up
appointment withtheattending physician. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
If implementation of the discharge plan was not initiated, cite at 42CFR 482.43(c)(3)(TagA-0820) HFAP Standard 15.03.11
Patient/Record #1 / Patient/Record #2 / Patient/Record #3 / Patient/Record #4 / Patient/Record #5
4.19For patients transferredto a post-
acutecaresetting otherthan home, wasnecessarymedical information readyattimeof transferand sent to thereceivingfacility with thepatient orelectronically attimeof transfer?
NOTE:Only use N/Afor patients discharged to home. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
If noto4.19,cite at42CFR 482.43(d)(TagA-0837) HFAP Standard 15.03.23
4.20Werethereportions of theplan the
hospital failed to begin implementing,
resulting in delays in discharge?
NOTE:Only use N/Afor current inpatients. / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
If yesto4.20,cite at42CFR 482.43(c)(3)(TagA-0820) HFAP Standard 15.03.11
4.21For information only,indicateany of thefollowingservicesinitiated while thepatient washospitalized(selectall that apply):
a. Scheduling follow-up
appointments
b. Fillingprescriptions
c.Pharmacistmeetingwith patient and/or family/support persons to reviewmedication regimen
d. Pharmacistreviewingdischarge
medication ordersprior to hospital departure
e. Homesetting visitation by hospital staff
f.Transportation arrangedfor
follow-up appointments
g.Dischargeplanning checklists,e.g.
CMS, AHRQ,CAPSchecklists / a.
b.
c.
d. / a.
b.
c.
d. / a.
b.
c.
d. / a.
b.
c.
d. / a.
b.
c.
d.
NOTE:Nocitationriskrelatedtoquestion4.20;for informationonly.
Patient/Record #1 / Patient/Record #2 / Patient/Record #3 / Patient/Record #4 / Patient/Record #5
4.22Is theredocumentation in the
medical recordof providing theresults of tests,pending attimeof discharge, to thepatient and/or post-hospital provider of care,if applicable? / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A / Yes
No
N/A
If noto4.22,cite at42CFR 482.43(d)(TagA-0837) HFAP Standard 15.03.23
Question4.23shouldbe answered onallrecords.
4.23Is theinpatient admission record
being reviewed(whetheropen or closed)a readmissionwithin 30days of a prior admission to this hospital? / Yes
No / Yes
No / Yes
No / Yes
No / Yes
No
NOTE:Nocitationriskrelatedtoquestion4.23,for informationonly.
Page 1 of 16 Updated September 15, 2015