Ftag of the Week – F628 Transfer and Discharge Process (Pt. 3)

To wrap up our CMSCG Ftag of the Week blog series for one of the newly added Ftags, F628 Transfer and Discharge Process, we will review the requirements for the discharge summary. In Parts 1 and 2 of this series, we reviewed the rest of the regulatory components for this tag, all of which were relocated from existing Ftags. The discharge summary regulation is also a current Ftag which will be going away on April 28, 2025 (maybe?) but the requirement will remain in place as part of F628.

Discharge Summary

F661 Discharge Summary is one of the tags that we didn’t get to do an “Ftag of the Week” for, so we’re covering it in more detail now as part of F628. The regulation requires that a discharge summary is provided for each resident when the facility anticipates his/her discharge. The purpose of this summary is meant to be a comprehensive overview of care provided by all members of the clinical team, including the physician, as well as summarizing the resident’s status at the time of discharge to guide the resident’s plan of care following discharge.

Here are the key definitions related to the discharge summary requirements:

These definitions are relevant because they explain two of the three key components required for the discharge summary. Per F628 in the advance copy of State Operations Manual Appendix PP, the contents of the discharge summary must include, minimally:

• Recap of the resident’s stay, including, but not limited to, diagnoses, course of illness, treatments or therapy and the results of any consultations and/or pertinent labs or radiology results.
• Pre-discharge and post-discharge medication reconciliation for all meds. Any identified discrepancies must be assessed and resolved. The resolution must be documented in the discharge summary, including a rationale for any changes made.
• Final summary of the resident’s status at the time of discharge which is available for release to authorized individuals or agencies, so long as the resident/ representative’s consent has been obtained.

To accurately describe the resident’s current status, the final summary must include information from the resident’s most recent comprehensive assessment. Required information which must be included in the discharge summary includes:

• Identification information
• Demographic information
• Communication
• Vision
• Cognitive patterns
• Mood and Behavior patterns
• Psychosocial well-being
• Customary routine
• Activity pursuit
• Physician functioning and structural problems
• Continent
• Dental status
• Nutritional status
• Disease diagnoses and health conditions
• Skin condition
• Medications
• Special treatments and procedures
• Discharge planning
• Documentation of additional assessments completed based on the triggered CAAs
• Documentation of who participated in the assessment

Don’t Forget

• If a resident is being discharged to home or another non-institutional setting, the discharge summary should be provided to the resident’s community-based providers so that there is continuity of care. Don’t forget to get consent to share this information.
• For a resident being discharged to another healthcare setting, the discharge summary must be provided at the time the resident leaves the facility to the receiving provider. The resident’s medical record must contain the discharge summary information and identify the recipient of the summary.
• If the resident does not have a continuing care provider, the medical record should include documentation regarding the facility’s efforts to help the resident locate a provider.
• Discharge instructions and medication prescriptions which are provided to the resident/ representative must reflect the reconciled medication list provided in the discharge summary.

The discharge summary requirements are also included in the new F627 Inappropriate Transfer or Discharge – a tag we’ll be reviewing in a future Ftag of the Week. Check back soon.

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