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DiraChart MDS item reference
Q0400ASection Qv1.20.1Manual page Q-8
Active discharge plan for return to community
This item is referenced against CMS MDS source materials. Verify coding against the current CMS RAI Manual, item set instructions, and facility documentation before submission.
Quick coding
Answer Codes
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Response format: Coded response
1
Yes
Manual page Q-8Item-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.
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