(b) Standard: Form and retention of record. Broadly, the changes are part of CMS’s efforts to make patients a more active part of their care transitions out of the hospital and into other settings. With the release of the Final CoPs, CMS is finalizing the significant changes they proposed to make to the home health CoPs in October 2014. ... and laboratory reports, and vital signs and other information necessary to monitor the patient's condition. (3) To the extent permissible under applicable federal and state law and regulations, and not inconsistent with the patient's expressed privacy preferences, the system sends notifications directly, or through an intermediary that facilitates exchange of health information, at the time of: (i) The patient's registration in the hospital's emergency department (if applicable). Discharge Planning Process (Proposed § 482.43(c)) 6. The hospital must discharge the patient, and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient's follow-up or ancillary care. The hospital must have a medical record service that has administrative responsibility for medical records. The system must allow for timely retrieval by diagnosis and procedure, in order to support medical care evaluation studies. On May 17, 2013, the Centers for Medicare & Medicaid Services (CMS) released an update of Appendix A of the State Operations Manual (SOM) revising its interpretive guidelines for hospital Discharge Planning. Home health services are covered for the elderly and disabled under the Hospital Insurance (Part A) and Supplemental Medical Insurance (Part B) benefits of the Medicare program, and are described in section 1861(m) of the Social Security Act (the Act). Design (Proposed § 482.43(a)) 4. §482.61(e) Standard: Discharge Planning and Discharge Summary §482.62 Condition of Participation: Special Staff Requirements for Psychiatric Hospitals §482.62(a) Standard: Personnel §482.62(b) Standard: Director of Inpatient Psychiatric Services; Medical Staff §482.62(c) Standard Availability of Medical Personnel Final rule. (c) Standard: Requirements related to post-acute care services. We proposed to implement the discharge planning requirements mandated in section 1899B(i) of the Act by modifying the discharge planning or discharge summary CoPs for hospitals, CAHs and HHAs. Between reimbursement cuts, Pre-Claim Review, Probe & Educate, Value-Based [...] Select Conditions of Participation Revisions Under new Conditions of Participation for Medicare effective since 2018, agencies must complete an informational discharge or transfer summary within specific timeframes even when the discharge or transfer was not expected. It is considered a legal document and it has the potential to jeopardize the patient’s care if errors are made. This tool, adapted from the CMS Conditions of Participation (COPs), provides a checklist of discharge elements that CMS states should be provided to all Medicare and Medicaid patients. (2) The system sends notifications that must include at least patient name, treating practitioner name, and sending institution name. Final rule. (iv) Ensures that such orders and protocols are dated, timed, and authenticated promptly in the patient's medical record by the ordering practitioner or by another practitioner responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. Describe the three mandatory Conditions of Participation components for physician order completion. Clinical records are retained for 5 years after the month the cost report to which the records apply is filed with the intermediary, unless State law stipulates a longer period of time. Medicare Conditions of Participation (42 CFR Part 482) Joint Commission (discharge summary standards) State No state specific discharge requirements until this legislation . CONDITIONS OF PARTICIPATION FOR HOSPITALS. Review of the New Home Health Conditions of Participation – Patient Rights (part 2). Medicare discharge planning is a Condition of Participation for hospitals, including psychiatric hospitals. (1) Any discharge planning evaluation must be made on a timely basis to ensure that appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. October 20, 2020. These health and safety standards are the foundation for improving quality and protecting the health and safety of beneficiaries. Under section 484.50, you listed the only reasons a patient can be discharged. Which of the following is a function of the discharge summary? (4) To the extent permissible under applicable federal and state law and regulations and not inconsistent with the patient's expressed privacy preferences, the system sends notifications directly, or through an intermediary that facilitates exchange of health information, either immediately prior to, or at the time of: (i) The patient's discharge or transfer from the hospital's emergency department (if applicable). A reference to the Patient Resource. CMS Conditions of Participation in Discharge Planning ... • Hospital must send the discharge summary within 48 hours of patient discharge to the practitioner following up, must have pending test results within 24 hour of their availability §482.43(d)(3)(i&ii) Documentation of the updated examination must be placed in the patient's medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. Despite all of the changes in healthcare, the 30‐day requirement for discharge summary completion has persisted, often as a medical staff requirement. A medical record must be maintained for every individual evaluated or treated in the hospital. § 484.110 Condition of participation: Clinical records. It is nearly impossible to avoid receiving any standard deficiencies during a survey. (7) The hospital must assess its discharge planning process on a regular basis. •Explain how to navigate compli This section describes the basis and scope of the conditions and provides definitions for terminology introduced in the new standards. The hospital will need to get the discharge summary in the hands of the primary care physician within 48 hours. •What is the "penalty" for non-compliance? admission, discharge, and transfer event notifications The Final Rule modifies the Conditions of Participation (CoPs) to require hospitals, including psychiatric hospitals and critical access hospitals (CAHs), to send electronic patient event notifications of a patient’s admission, discharge, and/or transfer (ADT) from the hospital to certain providers. The hospital must employ adequate personnel to ensure prompt completion, filing, and retrieval of records. § 482.24 Condition of participation: Medical record services. c. reported as a potentially compensable event. Staff. Transfer of Patients to Another Health Care Facility (Proposed § 482.43(e)) 8. Agency and Discipline Discharge Summaries must be completed at the time of Discharge DC summaries must include brief summary of Care Provided, patient Goal Status, the post DC plan, (d) Standard: Electronic notifications. (1) The system's notification capacity is fully operational and the hospital uses it in accordance with all State and Federal statutes and regulations applicable to the hospital's exchange of patient health information. If the hospital has information on which practitioners, providers or certified supplies are in the network of the patient's managed care organization, it must share this with the patient or the patient's representative. Discharge or transfer summary content. Case managers should use the worksheet as a self-assessment tool to make sure they are complying with the CMS Conditions of Participation for discharge planning, according to an expert. The hospital must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences. § 482.43 - Condition of participation: Discharge planning. An example is the definition of a branch that stresses oversight by the parent organization instead of geographical distances between the parent and the branch. (c) Standard: Content of record. As stated above, the IMPACT Act added section 1899B to the Act. (5) Any discharge planning evaluation or discharge plan required under this paragraph must be developed by, or under the supervision of, a registered nurse, social worker, or other appropriately qualified personnel. The hospital must have an effective discharge planning process that focuses on the patient's goals and treatment preferences and … Hospice Regulations, Conditions of Participation (CoPs) and Conditions of Payment Jennifer Kennedy, EdD, MA, BSN, RN, CHC National Hospice and Palliative Care Organization December 5, 2019 Learning Objectives •Describe the hierarchy of federal hospice regulatory requirements •What are they? (5) The hospital has made a reasonable effort to ensure that the system sends the notifications to all applicable post-acute care services providers and suppliers, as well as to any of the following practitioners and entities, which need to receive notification of the patient's status for treatment, care coordination, or quality improvement purposes: (i) The patient's established primary care practitioner; (ii) The patient's established primary care practice group or entity; or. A condition-level deficiencyis issued if a surveyor determines that an HHA is not i… This tool can be used to update existing processes and identify whether new processes and practices need to be implemented. PRESENTED BY . (iii) The hospital must document in the patient's medical record that the list was presented to the patient or to the patient's representative. Hospitals. 2 Speaker Sue Dill Calloway RN, Esq. Conditions of Participation: What You Need to Know February 26, 2015 Webinar Questions Following are answers to the questions that were asked in our webinar. § 482.53 - Condition of participation: Nuclear medicine services. Summary. (3) The discharge planning evaluation must be included in the patient's medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient's representative). (vi) All practitioners' orders, nursing notes, reports of treatment, medication records, radiology, and laboratory reports, and vital signs and other information necessary to monitor the patient's condition. The discharge summary is viewed as the synopsis of all events during the patient's stay. The CMS Conditions of Participation for Discharge Planning: Updates and Changes. The discharge summary must be a summary of the patient's stay, including the reason for referral to the HHA, the patient’s clinical, mental, psychosocial, cognitive, and functional condition at the time of the start of If the hospital utilizes an electronic medical records system or other electronic administrative system, which is conformant with the content exchange standard at 45 CFR 170.205(d)(2), then the hospital must demonstrate that -. CMS is finalizing certain standards for discharge planning for hospitals that outline the discharge planning process, the provision and transmission of the patient’s necessary medical information upon discharge, and requirements related to post-acute care (“PAC”) services. Often, the discharge summary is the only form of communication that accompanies the patient to the next setting of care. View all text of Subpart C [§ 482.21 - § 482.45] § 482.43 - Condition of participation: Discharge planning. § 482.24 Condition of participation: Medical record services. (6) The hospital's discharge planning process must require regular re-evaluation of the patient's condition to identify changes that require modification of the discharge plan. to be included in the transfer form, medication reconciliation, the discharge summary and more. (b) Standard: Discharge of the patient and provision and transmission of the patient's necessary medical information. It is often the primary mode of communication between the hospital care team and aftercare providers. (1) Medical records must be retained in their original or legally reproduced form for a period of at least 5 years. Below are key takeaways from the rule. (2) A discharge planning evaluation must include an evaluation of a patient's likely need for appropriate post-hospital services, including, but not limited to, hospice care services, post-hospital extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient's access to those services. 3 Objectives Recall that … “This delivers on President […] discharge; A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility. Readmission champion and day-to-day leader. DVD gives you the access to the webinar recording along with the pdf hand-outs, delivered to your shipping address. Original medical records must be released by the hospital only in accordance with Federal or State laws, court orders, or subpoenas. This tool can be used to update existing processes and identify whether new processes and practices need to be implemented. The Proposed Rule. (1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. (2) The hospital, as part of the discharge planning process, must inform the patient or the patient's representative of their freedom to choose among participating Medicare providers and suppliers of post-discharge services and must, when possible, respect the patient's or the patient's representative's goals of care and treatment preferences, as well as other preferences they express. Hospital discharge summaries serve as the primary documents communicating a patient’s care plan to the post-hospital care team. Discharge planning evaluations and discharge plans (applicable to hospitals and CAHs) While Medicare and Medicaid Conditions of Participation (CoPs) previously required hospitals to have discharge planning processes in place, the Final Rule extends this requirement to CAHs and makes several significant changes applicable to both hospitals and CAHs. A detailed summary will be posted here shortly in the compliance section. The discharge planning process and the discharge plan must be consistent with the patient's goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to preventable hospital readmissions. The medical history and physical examination must be placed in the patient's medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. §482.61(e) Standard: Discharge Planning and Discharge Summary §482.62 Condition of Participation: Special Staff Requirements for Psychiatric Hospitals §482.62(a) Standard: Personnel §482.62(b) Standard: Director of Inpatient Psychiatric Services; Medical Staff §482.62(c) Standard Availability of Medical Personnel If the hospital provides rehabilitation, physical therapy, occupational therapy, audiology, or speech pathology services, the services must be organized and staffed to ensure the health and safety of patients. The Conditions of Participation for Discharge Planning are the case manager’s guide as to how to correctly develop, implement and re-assess a hospital discharge planning program. (3) The hospital must have a procedure for ensuring the confidentiality of patient records. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were readmitted within 30 days of a previous admission, to ensure that the plans are responsive to patient post-discharge needs. discharge condition information is a concern and may affect patient safety. § 482.56 - Condition of participation: Rehabilitation services. “We believe that these final discharge planning requirements for hospitals, including LTCHs, IRFs, HHAs, and CAHs will improve transitions … The hospital must have an effective discharge planning process that focuses on the patient's goals and treatment preferences and includes the patient and his or her caregivers/support person(s) as active partners in the discharge planning for post-discharge care. Introduction . If this situation occurs, you would expect to see the circumstances of the leave a. documented in both the progress notes and the discharge summary. The organization of the nuclear medicine service must be appropriate to the scope and complexity of the services offered. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentification and protects the security of all record entries. These services, provided under a plan of care that is established and periodically reviewed by a physician, must be furnished by, or under arrangement with, a home health agency (HHA) that participates in the Medicare or Medicaid programs. 1 hour to review … 2015 … The hospital must not specify or otherwise limit the qualified providers or suppliers that are available to the patient. Conditions of Participation (CoP) –Discharge Planning Hospitals CMS is finalizing certain standards for discharge planning for hospitals that outline the discharge planning process, the provision and transmission of the patient’s necessary medical information upon discharge, and requirements related to post-acute care (“PAC”) services. A Plan of Correction is written and must be approved by the regulatory body. b. reported to the Executive Committee. Even though Case Management Week is not for two weeks (October 13 – 19, 2019), the release of the Discharge Planning Conditions of Participation (CoP) Final Rule is a reason for an early celebration as evidenced by the following quote from CMS in the Final Rule. Condition of participation: Medical record services. Applicability (Proposed § 482.43(b)) 5. (vii) Discharge summary with outcome of hospitalization, disposition of case, and provisions for follow-up care. SNFs must serve the geographic area requested by patient; HHAs must request to be listed by the hospital. It is important that the discharge summary is just that--a summary of events already chronicled in the patient's record. “Concepts related to patient preference, goals and needs of each patient along with patient participation in discharge planning are key concepts that are already part of the [home health Conditions of Participation] in overall care planning.” Discharge Planning Conditions of Participation Final Rule. CMS had initially issued the proposed regulations in November 2015 to update discharge planning requirements for hospitals, critical access hospitals (“CAHs”) and post-acute care (“PAC”) providers, such as home health agencies (“HHAs”), as part of CMS’s Conditions of Participation (“CoPs”). (ii) The patient's current plan of care. Delay in transfer of discharge summary Test results unknown No follow-up Medications not being reconciled correctly (Jack et al., 2013). 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