Discharge Planning: Compliance with CMS Hospital & CAH CoPs

Hospitals and Critical Access Hospitals (CAHs) that participate in Medicare or Medicaid must adhere to the CMS discharge planning Conditions of Participation (CoPs). These regulations apply to all patients, regardless of payer source, and play a vital role in ensuring safe and effective transitions of care. In February 2020, CMS issued updates to discharge planning requirements; however, the corresponding interpretive guidelines and survey procedures are still pending publication. This essential program offers a comprehensive review of the updated discharge planning standards, focusing on compliance strategies and best practices that align with current expectations.

The session will also highlight the IMPACT Act and its influence on hospital discharge processes. Under this Act, hospitals must evaluate patients at admission using standardized data to guide discharge decisions and ensure appropriate post-acute care placement. Facilities must provide patients with information on various post-discharge options—such as home health agencies, skilled nursing facilities, long-term care hospitals, and inpatient rehabilitation centers. Documentation must clearly reflect the discharge planning process, patient education, and physician collaboration to ensure compliance and continuity of care.

Key topics include managing transfers to other facilities, addressing readmissions within 30 days, supporting caregiver involvement, reducing avoidable readmissions, and ensuring timely completion of discharge evaluations. The program will also review how discharge planning CoPs apply to Critical Access Hospitals, which largely mirror acute hospital requirements.

Participants will gain practical insights into meeting CMS expectations, maintaining accurate documentation, and fostering patient-centered discharge planning that supports compliance, safety, and quality outcomes.

Learning Objectives

• Explain how CMS revised the discharge planning requirements for hospitals and CAHs.

• Recognize that patients and physicians can request a discharge planning evaluation.

• Understand the requirement to share hospitalization details with the provider before the first post-discharge visit.

• Describe patient rights regarding timely access to medical records and discharge plans.

Areas Covered in the Session

• Overview and introduction to discharge planning regulations

• Common deficiencies and compliance data

• The IMPACT Act and its role in discharge planning

• Identifying patients who require discharge planning

• Involvement of the support person and handling incapacitated patients

• Development and documentation of discharge evaluations

• Role of RNs, social workers, and qualified personnel

• Timely evaluation and patient discussion

• Implementation and reassessment of the discharge plan

• Physician requests and documentation requirements

• Freedom of choice for post-acute care providers

• Transfers, referrals, and CAH discharge planning requirements

• Resources and appendices

• Live Q&A session

Suggested Attendees

• Discharge Planners

• Transitional Care Nurses

• Social Workers

• Staff Nurses involved in patient discharge

• Chief Nursing Officers and Nurse Managers

• Nurse Educators and Clinical Leaders

• Chief Operations and Medical Officers

• Physicians and Risk Managers

• Compliance and Regulatory Officers

• Chief Executive Officers and Administrators

• Patient Safety Officers

• Performance Improvement Directors

• Health Information and Quality Directors

• Members of Hospital Readmission Reduction Committees

About the Presenter

Laura A. Dixon, RN, JD, BSN, CPHRM
Former Regional Director of Risk Management & Patient Safety – Kaiser Permanente Colorado

Laura A. Dixon brings a unique blend of clinical, legal, and risk management expertise to healthcare compliance education. With over twenty years of hands-on clinical experience in acute care—including critical care, coronary care, perioperative services, and pain management—she bridges the gap between bedside practice and regulatory compliance. As a registered nurse and attorney licensed in Colorado and California, Laura has held key leadership roles, including Director of Risk Management and Patient Safety for Kaiser Permanente Colorado and Director of Facility Patient Safety and Operations for COPIC.

She has extensive experience providing consultation, training, and program development for hospitals, physicians, and healthcare organizations nationwide. Laura’s background in medical malpractice defense and patient safety risk management allows her to offer practical insights into CMS regulations, compliance strategies, and process improvement. A respected speaker and educator, she continues to guide healthcare professionals in building safer, more compliant discharge planning programs.