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CMS Issues Memo to Hospitals About Requirement to Provide Information to Post-Acute Providers

Guest Article: Elizabeth E. Hogue, Esq.


On June 6, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a memo to hospitals to remind them of their obligation to provide all necessary information to post-acute providers (PACs) as part of the discharge process. “When a patient is discharged from a hospital, it is important to provide their post-acute provider and caregivers as applicable with the appropriate patient information related to a patient’s treatment and condition in order to decrease the risk of readmission or an adverse event,” CMS says in the memo.

CMS is especially concerned about missing or inaccurate information related to:

  • Patients with serious mental illness, complex behavioral needs and/or substance use disorder, especially information about patients’ underlying diagnoses and specific treatments that were implemented to help manage patients’ conditions while in the hospital, but discontinued prior to discharge
  • Medications, including an incomplete comprehensive list of all medications prescribed to patients during and prior to their hospital admissions. Common omissions also include diagnoses or problem lists, clinical indications, lab results and or clear orders for medications post-discharge, especially psychotropic medications, and narcotics.
  • Skin tears, pressure ulcers, bruising and lacerations, such as surgical sites, skin conditions noted upon admission and/or acquired during hospitalizations, including orders or instructions for cultures, treatments, and dressings
  • Durable medical equipment (DME), such as Trilogy, CPAP/BiPap or high-flow oxygen used for respiratory treatments and skin healing equipment, such as mattresses, wound vacuum machines for treatment of a variety of wounds
  • Patients’ preferences and goals for care, such as choices for treatment and advance directives for end-of-life care
  • Communications about patients’ needs at home or how their home environment may impact their ability to maintain their health and safety after discharge.

CMS says that failure to provide complete, accurate information upon discharge may put patients’ health at risk. The health and safety of other residents and staff may also be at risk. Incomplete and/or inaccurate information may also cause avoidable readmissions, complications, and other adverse events. Patients may also receive treatments that are unnecessary or inconsistent with their wishes.

CMS reminds state survey agencies, accrediting organizations, and hospitals in the memo that regulations of the Medicare Program require hospitals to “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.”

In addition, says CMS, “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.”

CMS concludes the memo by acknowledging that hospitals have discretion to develop their own policies and procedures to meet the above requirements. However, CMS makes the following recommendations to hospitals with regard to discharge planning:

  • Collaborate with PAC providers by, for example, agreement on standardized processes;
  • Conduct case reviews of previous discharges to improve outcomes of future discharges;
  • Enable access to patient information in electronic health records (EHRs) by PAC providers so necessary information can be accessed to improve transitions.

Discharge planners/case managers should be prepared for increased scrutiny regarding these issues during surveys.


©2023 Elizabeth E. Hogue, Esq. All rights reserved.

No portion of this material may be reproduced in any form without the advance written permission of the author.


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