In Part 1 of our CMSCG Ftag of the Week for F627, we reviewed key transfer and discharge requirements, including when a resident needs to be allowed to return to the facility. We discussed how what’s not in your medical record can be a problem with supporting your need to discharge a resident. Remember, you need to have evidence of everything that has been attempted by the facility to support a safe discharge – anything less is not going to cut it. That includes evidence of discharge planning, which we’ll review now.
Discharge Planning Process
As you’ve likely heard more times than you want to admit, discharge planning should begin on admission. The requirements for discharge planning are part of the consolidated and revised Ftag list, including the following regulatory guidance. Nursing homes are required to develop and implement a process for discharge planning which includes the interdisciplinary team and:
- Addresses the resident’s goals of care, treatment preferences and needs.
- Includes and considers the resident and/or representative in the discharge process. This includes evaluating the resident’s and/or caregiver’s “capacity and capability to perform required care.” That’s a small statement with a lot of impact. Unfortunately, sometimes it takes until it’s close to discharge to recognize that a resident’s spouse is not going to be able to participate in the way that was anticipated, or the children can’t take off from work as needed to participate the way the resident expected. Try to get to the bottom of all that as soon as possible to prevent a discharge from being postponed, overly complicated, or not going to happen as planned.
- Identifies the discharge needs of each resident and culminates in the development of a discharge plan where the resident can be effectively transitioned to post-discharge care. The plan should address potential risk factors which could lead to preventable readmission. The resident and/or representative need to be informed of the final discharge plan, which they should have been involved in developing.
- Ensures the resident is routinely re-evaluated to ensure that the discharge plan remains solid or is modified as needed to reflect changes. This is something we routinely find issues with on mock surveys – the lack of a “living” discharge plan which reflects changes to the resident’s discharge plan. An initial discharge plan which makes use of a care plan template library often lacks evidence of revision when changes to the plan occur.
- Includes documentation that the resident has been asked about his/ her interest in returning to the community. This is typically part of a Social Work or other routine assessment, so it’s unlikely this would be missed. However, not documenting referrals to local contact agencies (LCAs) made by the facility on the part of the resident could be a problem, particularly for those residents who would love to tell a surveyor how badly they want to leave your facility and how no one helps them. There should be evidence that the discharge care plan is updated based on the information and assistance provided via those referrals.
Remember, it’s the facility’s responsibility to assist the resident, whether it’s making referrals to an LCA or sending out PRIs for lateral transfers or whatever the resident needs to facilitate the discharge. Even if it’s unlikely that a resident will be successfully discharged via one of these means, the effort is still required. Can we force another nursing home to accept our problematic resident? No. Does not mean we shouldn’t try? Absolutely not. Ensure your staff are documenting their efforts in this regard.
As it pertains to F627 Inappropriate Transfers, the discharge plan and associated documentation is key evidence that you have indeed been following regulatory requirements and trying to safely discharge the resident. It’s unlikely a facility will win a discharge appeal when there isn’t sufficient evidence of what has been done to try to facilitate a discharge for a particular resident, so keep that in mind. A general care plan template with general interventions which could be applicable to any resident doesn’t really show that the facility was making the effort to address my unique circumstances, especially when your interventions indicate that someone’s goal is to return home – when they don’t have a home in the community.
Like we discussed in Part 1 of our Ftag of the Week for F627 Inappropriate Transfers, the medical record needs to have evidence which supports the basis for discharge – or should we not have transferred or discharged this resident at all? This is certainly one of those times when the age-old adage, “if it isn’t documented it didn’t happen” really applies. In fact, when you are dealing with an extremely difficult discharge, it’s a good plan to hold an extra care plan meeting to discuss with the resident and their representative the roadblocks to achieving entrance to the discharge location of choice, access to services desired by the resident/representative not being available, including when the resident does not meet eligibility criteria to have such services paid for at the level requested, etc. The 24×7 assistance that the family wants may not happen unless the family is willing to pay privately for care services – do they really “get” that and work with you on an alternate option? Document, document, document as no one is going to be able to remember a year’s worth of discharge efforts. In Part 3 of this Ftag guidance series, we’ll review some additional requirements.
CMS Compliance Group, Inc. is a regulatory compliance and quality improvement consulting firm. We work with post-acute providers, including nursing homes on a variety of initiatives, including survey readiness. To learn more about our mock survey and other SNF/LTC consulting services, please visit the CMSCG website or contact us to discuss.
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