Guideline text:
(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)

§482.61(e) [The record of each patient who has been discharged must have a discharge summary that includes] . . . recommendations from appropriate services concerning follow-up or aftercare as well as …

## Interpretive Guidelines §482.61(e)

The patient's discharge summary should describe the services and supports that are appropriate to the patient's needs and that will be effective on the day of discharge.

## Examples include:

- A complete description of arrangements with treatment and other community resources for the provision of follow-up services. Reference should be made to prior verbal and written communication and exchange of information;
- A plan outlining psychiatric, medical/physical treatment and the medication regimen as applicable;
- Specific appointment date(s) and names and addresses of the service provider(s);
- Description of community housing/living arrangement;
- Economic/financial status or plan, i.e., supplemental security income benefits;
- Recreational and leisure resources; and A complete description of the involvement of family and significant others with the patient after discharge.

## Survey Procedures §482.61(e)

How does the discharge planning process verify appointment source(s), dates and addresses?

How was the patient involved in the discharge and aftercare planning process?

Were discharge related documents made available to the patient, family, community treatment source and/or any other appropriate sources?

Is there indication that the discharge planning process included the participation of multidisciplinary staff and the patient? Have the results been communicated to the posthospital treatment entity?

Is there evidence that contact with the post-hospital treatment entity included communication of treatment recommendations (including information regarding the patient's medications)?

Is a contact person named, and does the patient have a specific appointment date and time for the initial follow-up visit?

A-1672

(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)

§482.61(e) [The record of each patient who has been discharged must have a discharge summary that includes] … a brief summary of the patient's condition on discharge.

## Interpretive Guidelines §482.61(e)

The patient's discharge planning process should address anticipated problems after discharge and suggested means for intervention, i.e., accessibility and availability of community resources and support systems including transportation, special problems related to the patient's functional ability to participate in aftercare planning.

The discharge summary and/or plan should contain information about the status of the patient on the day of discharge, including psychiatric, physical and functional condition.

A-1680

(Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20)

## §482.62 Condition of Participation: Special Staff Requirements for Psychiatric Hospitals

The hospital must have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning.

## Interpretive Guidelines §482.62

The purpose of this Condition of Participation is to ensure that the psychiatric hospital is adequately staffed with qualified mental health professionals and supportive staff to carry out an intensive and comprehensive active treatment program and to protect and promote the physical and mental health of the patients.

Through observation, interview and record review determine if numbers and/or deployment of qualified staff is a concern. Review incident reports, medication error reports, patient and staff injury reports, for indications that staffing is an issue.

Adequate numbers are defined to mean the numbers, and deployment, of staff with qualifications to evaluate, plan, implement and document active treatment.

Do not look at numbers alone. The hospital is responsible for organizing its available staff and administrative duties along with patient appointments, treatment plan meetings, treatment sessions, activities, materials, equipment and patient assignments to wards and groups in such a way that results in patients achieving the maximum therapeutic benefit.

## Survey Procedure §482.62

Assess the adequacy of the Special Staffing Condition by:

1. Observing sampled patients and others during structured sessions and in unstructured settings. You should be able to observe behavioral evidence of a rational organization of resources.
2. Next, interview patients and staff to determine whether or not necessary treatment modalities and other services are being provided in a timely manner.
3. Next review the medical records of patients in the sample to ascertain if necessary active treatment assessments, treatments, evaluations and activities have been conducted and documented.
4. Also, review other records such as restraint and seclusion records, incident reports, medication error reports, reports of patient/staff injuries, etc., to determine the extent to which staffing levels or deployment contributed to negative patient outcomes.
5. Evaluate all outcome data in light of the success or failure observed during the survey relevant to each patient receiving active treatment, and achieving desired outcomes of care. This is the primary basis for evaluating the adequacy of the hospital's staffing under this Special Condition.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "discharge summary containing comprehensive follow-up and aftercare recommendations", "trigger_assertion": "patient discharged"}, "rule_type": "conditional_existence", "scope_tags": ["clinical", "legal"]}