02/19/2026
Survey Tip of the Week: Discharge Planning
Survey deficiencies related to discharge planning commonly occur when the process is treated as an end-of-stay task rather than an ongoing, individualized component of the comprehensive care plan. The Long-Term Care Survey Process requires surveyors to review a discharge record. Under §483.21(c)(1), discharge planning is expected to begin at admission and continue throughout the resident’s stay, based on the resident’s assessed needs, goals for care, desire to be discharged, and capacity for discharge. Surveyors frequently cite facilities when discharge planning is incomplete, poorly documented, or not reflective of the resident’s current condition and goals.
According to the State Operations Manual (SOM) Appendix PP, discharge planning is an interdisciplinary process that requires active involvement of the resident and, when applicable, the resident representative. Surveyors evaluate whether the discharge care plan is integrated into the comprehensive care plan and whether it addresses the resident’s stated goals, treatment preferences, and anticipated post-discharge needs. Failure to demonstrate resident involvement or meaningful interdisciplinary input is a common area of noncompliance.
Surveyors also assess whether facilities identify and address barriers that must be resolved prior to discharge, such as the need for resident or caregiver education, rehabilitation services, or caregiver support and training. Discharge plans that do not account for changes in the resident’s condition or that are not updated when goals or needs change may be cited, particularly when avoidable complications occur. Inadequate discharge planning may lead to poor transitions, increased risk of rehospitalization, or other adverse outcomes following discharge.
The discharge care plan must document the resident’s interest in discharge and include evidence of referrals to the local contact agency, when applicable. Surveyors will review whether facilities have identified necessary post-discharge services and support, such as nursing or therapy services, medical equipment, home modifications, or assistance with activities of daily living.
During survey, reviewers will trace how discharge planning decisions were made and whether the facility proactively reassessed discharge readiness over time. Facilities are expected to demonstrate that discharge planning is a dynamic process designed to support a safe and successful transition, rather than a last-minute administrative step. When discharge planning is individualized, regularly reassessed, and clearly documented, it supports compliance and reduces the risk of adverse outcomes following discharge.
