CMS Sends Up Warning Flare on Discharge Planning

Back in June, the Centers for Medicare & Medicaid Services (CMS) released a memo titled “Requirements for Hospital Discharges to Post-Acute Care Providers,” which was sent to survey agencies that received no notice at all. Fortunately, I came across it and can now share it with everyone.

But a bit of background first.

We all know that CMS has regulations about discharge planning, as found in 42 CFR 482.43. These regulations were modified in 2019. Most notable was the requirement to provide information on post-acute care providers’ resource use and quality of care. CMS also expanded the requirement to offer choices, to include long-term acute-care hospitals (LTACHs) and inpatient rehabilitation facilities (IRFs), in addition to home care and skilled nursing facilities (SNFs), although they continue to note that patients should always be offered choices for any provider to which they are being referred.

CMS also publishes interpretive guidelines that accompany every section of the Conditions of Participation that guide survey organizations when scrutinizing a facility for compliance with the regulations. These are very helpful in that they outline what the surveyors will do. But in the case of the 2019 changes to the discharge planning rules, CMS still has not released the interpretive guidelines, leaving the survey organizations to make things up as they go.

With that background, according to this memo, CMS has received reports of patients being transferred to post-acute care providers without adequate information – and they are not happy. As a result, they are alerting survey organizations to address some specific deficiencies.

So, what are the issues?

First, not telling the post-acute provider that the patient had behavioral issues that required additional care. While at the time of transfer, the patient may not have needed a sitter, the use of the sitter during the stay would alert the post-acute provider that there is a potential for behavioral issues.

Next, CMS called out poor medication reconciliation, especially omitting the patient’s use of psychotropics and opioids during a hospital stay. They note that in some instances, patients with ongoing opioid medications were not sent with a hard copy of the prescription, resulting in inability of the facility to obtain the medication in a timely manner. CMS also noted that post-acute providers were not informed about skin issues that required treatment in the hospital.

CMS went on to note that some post-acute providers were not informed that the patient had durable medical equipment (DME), such as BiPAP or a wound vac. In this case, the patient would arrive with the immediate need for DME, but the post-acute provider would not have had time to arrange the delivery to the facility. Next was lack of communication about the patient’s home environment that would be relevant to the post-acute provider when planning for discharge from their facility, including omitting information that the patient was homeless or had no caregiver.

Now, just reading the list of issues, the pessimist in me sees a pattern of hospitals that omitted crucial information, perhaps in order to get a post-acute provider to accept a patient who was challenging or costly. Obviously, this is not acceptable. No hospital likes to have a patient who is stable for discharge but has no safe destination – but the solution is not to deceptively transfer the patient so they become someone else’s problem. Of course, many of these errors may have been inadvertent, with perhaps the discharging staff unaware that the patient required a sitter when the patient was on another hospital unit or unaware of the extent of skin breakdown, because the wound care nurse was managing that aspect of the patient’s care.

CMS also noted that hospitals have been omitting information about the patient’s goals of care and treatment preferences. CMS is very big on ensuring that medical decisions are made in collaboration with the patient, so we need to ensure that we are asking patients about their goals of care and treatment preferences – and documenting their preferences. They also called out patient preferences for end-of-life care, suggesting that some patients who did not want resuscitation were resuscitated anyway, because that information was not conveyed to the facility.

So, what do you do?

Download this document and read it, then assess your discharge program. CMS even provides a link within the document to a discharge checklist. They do not endorse this form, but if they link to it, you know they like it.

Finally, it is crucial to note that this memo was addressed to survey agencies. CMS is telling them to focus their reviews on these issues. If that’s not a red flag to be sure that your processes are in order, I don’t know what is.