Overview of 42 CFR 482.43: The Discharge Planning CoP
- The CMS discharge planning Condition of Participation at 42 CFR 482.43 was substantially revised by the final rule published in September 2019 (84 FR 51836), effective November 29, 2019. The revised CoP expanded requirements across four main areas: discharge planning evaluations, discharge planning processes, discharge instructions, and transfer of information to post-acute care providers.
- Under 42 CFR 482.43(b), hospitals must perform a discharge planning evaluation for any patient identified as likely needing post-discharge services and for any patient who requests an evaluation. The evaluation must be completed by a registered nurse, social worker, or other qualified clinical staff member within 24 hours of a request. Hospitals may not limit evaluations to patients meeting specified clinical criteria: any patient who requests an evaluation must receive one.
- The revised CoP introduced explicit patient choice requirements at 42 CFR 482.43(c)(7): when a patient is referred to a specific post-acute provider, the hospital must provide a list of Medicare-participating providers in the geographic area chosen by the patient, must not place restrictions on the providers the patient may choose, and must document in the medical record that the patient was given a list and chose their preferred provider.
- CMS surveyor guidance for the discharge planning CoP, published in the State Operations Manual Appendix A (Rev. 200, 2020), emphasizes that the discharge plan must be individualized based on the patient's clinical needs, goals, and preferences, not based on hospital convenience, average length of stay, or administrative factors.
Discharge Planning Evaluation Requirements
- The discharge planning evaluation under 42 CFR 482.43(b) must assess the patient's likelihood of needing post-hospital services and the availability of those services. The evaluation must consider the patient's goals and treatment preferences, clinical status, cognitive function, functional capacity, caregiver availability, financial resources, and home environment. A checklist that captures only clinical factors and omits social determinants of health does not satisfy the regulation.
- For Medicare patients, the IMPACT Act of 2014 (P.L. 113-185) added a requirement that hospitals provide quality data to patients when referring them to post-acute care providers. Hospitals must provide patients with standardized data on the quality and resource use measures of potential receiving providers, presented in a format the patient can use to make a meaningful comparison. This requirement supplements, but does not replace, the 42 CFR 482.43 discharge planning requirements.
- Discharge evaluations must be documented in the medical record regardless of whether the patient ultimately requires post-discharge services. A patient who is evaluated and determined not to need post-acute services should have documentation of that determination and its clinical basis. Absence of evaluation documentation is a common CoP deficiency finding.
- When a patient has advance directives, the discharge evaluation must take them into account in planning post-discharge care, including the types of services and settings consistent with the patient's expressed wishes. The State Operations Manual surveyor guidance specifically identifies failure to incorporate advance directives into discharge planning as a deficiency indicator.
Discharge Instruction and Patient Education Requirements
- Under 42 CFR 482.43(d), hospitals must provide discharge instructions in a form the patient can use. Instructions must include information about the patient's diagnosis, medications, dietary restrictions, physical activity limitations, follow-up care schedule, and symptoms or conditions that require immediate medical attention. The regulation does not specify a required format, but instructions must be written at a level the patient can understand.
- The discharge instruction requirement interacts with the patient rights CoP at 42 CFR 482.13(e), which requires hospitals to provide care in a language the patient understands. Discharge instructions in English provided to a patient whose primary language is not English do not satisfy either the discharge planning CoP or the patient rights CoP. Interpreter documentation and translated materials are both implicated.
- Hospitals must provide discharge instructions to both the patient and any designated caregiver involved in post-discharge care. The 2019 revision added caregiver involvement as an explicit element of discharge planning. If a patient identifies a caregiver who will assist with post-discharge care, the hospital must offer to include that caregiver in discharge planning and instruction, document whether the offer was accepted, and provide the caregiver with appropriate instruction.
- Standardized discharge instruction tools, when used, must be supplemented with individualized content reflecting the patient's specific clinical situation. CMS surveyors have cited hospitals that provide generic printed discharge forms without evidence that staff reviewed and individualized the content for each patient. The medical record should reflect a clinical interaction, not just the distribution of a pamphlet.
Transfer of Information to Receiving Providers
- The 2019 CoP revision added explicit requirements at 42 CFR 482.43(d)(4) for transferring information to receiving post-acute providers and practitioners. When a patient is transitioning to another care setting, the hospital must send a copy of the discharge summary or specific clinical elements within defined timeframes: a preliminary record within 24 hours of discharge and a complete record within 7 days.
- The required elements for transfer documentation include the patient's diagnosis, procedures performed, medications and dosing instructions, functional status, cognitive status, behavioral health status, advance directive status, patient goals and treatment preferences, and the name and contact information of the responsible practitioner. These elements align with the interoperability requirements under the 21st Century Cures Act rule.
- Hospitals must also notify the patient's primary care physician or other established practitioner of the discharge, including the diagnosis and whether a follow-up appointment is needed. This notification requirement is separate from the transfer documentation requirement. In many organizations, a single discharge summary serves both purposes, but the timing and recipient requirements differ.
- Documentation that a discharge summary was sent and received should be retained in the medical record. Fax confirmation pages, EHR transmission logs, or secure messaging delivery receipts serve as evidence of compliance. The absence of this documentation does not prove non-compliance, but its presence provides a defensible record during survey.