0
No
if there is not active discharge planning already occurring for the resident
to return to the community.
DiraChart MDS item reference
Q0400Section Qv1.20.1Manual page Q-8
Discharge Plan
Item Rationale
Quick coding
Answer Codes
Use the item-specific response choices below when structured codes apply.
Response format: Instruction / group heading
1
Yes
if there is active discharge planning already occurring for the resident to
return to the community.
Item-specific instructions
Coding Guidance
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Steps for Assessment
1. A review should be conducted of the care plan, the clinical
record, and clinician progress notes, including but not
limited to nursing, physician, social services, and therapy to
consider the resident’s discharge planning needs.
2. If the resident is unable to communicate their preference
either verbally or nonverbally, or has been legally
determined incompetent, the information can be obtained
from the family or significant other or guardian, as
designated by the individual.
3. Record the resident’s expectations as
expressed/communicated, whether NH staff believe that
they are realistic or not realistic.
4. The resident, their interdisciplinary team, and LCA (when a
referral has been made) should determine the services and
assistance that the resident will need post discharge (e.g.,
homemaker, meal preparation, ADL assistance,
transportation, prescription assistance).
5. Eligibility for financial assistance through various funding
sources (e.g., private funds, family assistance, Medicaid,
long-term care insurance) should be considered prior to
discharge to identify the options available to the individual
(e.g., home, assisted living, board and care, or group
homes).
6. A determination of family involvement, capability and
support after discharge should also be made. However,
support from the family is not always necessary for a
discharge to take place.
DEFINITION
ACTIVE DISCHARGE
PLANNING
An active discharge plan
means a plan that is being
currently implemented. In
other words, the resident’s
care plan has current goals
to make specific
arrangements for discharge,
staff are taking active steps
to accomplish discharge, and
there is a target discharge
date for the near future.
If there is not an active
discharge plan, residents
should be asked if they want
to talk to someone about
community living (Q0500B)
and then referred to the LCA
accordingly. Furthermore,
referrals to the LCA are
recommended as part of
many residents’ discharge
plans. Such referrals are a
helpful source of information
for residents and facilities in
informing the discharge
planning process.
Q0400: Discharge Plan (cont.)
Coding Instructions
for Q0400A, Is active discharge planning already
occurring for the resident to return to the community?
•
Code 0, No: if there is not active discharge planning already occurring for the resident
to return to the community.
•
Code 1, Yes: if there is active discharge planning already occurring for the resident to
return to the community.
MDS item matrixAssessment Applicability
See where this item applies across Nursing Home, Swing Bed, discharge, required-use, OBRA, and program or policy columns.
13 relationships5 groups+
Assessment Applicability
See where this item applies across Nursing Home, Swing Bed, discharge, required-use, OBRA, and program or policy columns.
Nursing Home Subsets
Swing Bed Subsets
OBRA Stand Alone Assessments
OBRA Admission A=01, B=99, F=99, G=^, H=0
MDS Item Matrix v1.20.1 v4
OBRA Quarterly A=02, B=99, F=99, G=^, H=0
MDS Item Matrix v1.20.1 v4
OBRA Annual / Sig Chg A=03, B=99, F=99, G=^, H=0 A= 04, B=99, F=99, G=^, H=0
MDS Item Matrix v1.20.1 v4
OBRA Discharge A=99, B=99, F=10, 11, G=1, 2, H=0
MDS Item Matrix v1.20.1 v4
Program and Policy Use
D/C Items (Only when A0310F = 10 or 11)
Official CMS source
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