Section Q. Goal Setting and Discharge Planning

March 31, 2024


Section Q focuses on hearing the residents’ goals for discharge, identifying barriers to discharge and when an active discharge plan can be completed as well as when assistance is required from an outside local contact agency. CMS has expanded the agencies that can act as local contact agencies. Interviewing the resident or designated individuals places the resident or their family at the center of decision-making.

The items in this section are intended to record the participation and expectations of the resident, family members, or significant other(s) in the assessment, and to understand the resident’s overall goals. Discharge planning follow-up is already a regulatory requirement (CFR 483.21(c)(1)). Section Q of the MDS uses a person-centered approach to ensure that all individuals have the opportunity to learn about home and community-based services and to receive long-term care in the least restrictive setting possible. This may not be a nursing home. This is also a civil right for all residents.

Learning Objectives:
1. State 2 agencies that are now considered to be “local contact agencies.”
2. Explain what an “active discharge plan” includes.
3. Report when a referral to a local contact agency is not required.



Carol Maher is a Board Certified Gerontological Registered Nurse with over 30 years of long term care experience and has worked in long term care in many roles. She worked as the MDS Coordinator in a 300 bed SNF in Pennsylvania for 8 years before moving to CA to become the MDS Coordinator/Director for a 1200 bed SNF in San Francisco. She has also worked as the MDS Coordinator in a SNF that typically had 60-75 residents on Medicare in addition to 160 long-term care residents. Most recently she was the Senior VP of Utilization Services and Director of Reimbursement for large multi-facility organizations.

Carol has worked as one of the Gold Standard nurses for MDS 3.0, serving on the RAP workgroup to prepare the way for the CAAs for MDS 3.0, and participating on a number of Technical Expert Panels related to MDS, Quality Measures and care planning. A sought-after speaker, she has given presentations at AANAC, AHCA and Leading Age national conferences as well as many state organization presentations. She is also a frequent author of articles related to the RAI process and PPS. Carol served as a member of the AANAC Board of Directors for 9 years. She is presently serving as the chair of the AANAC Expert Advisory Panel and as an AANAC Master Teacher of the RAC-CT and RAC-CTA certification courses. Ms. Maher is the Director of Education for Hansen Hunter, providing MDS and Medicare classes across the country, presenting monthly educational webinars and completing compliance audits. She is the author of Long-Term Care MDS Coordinator’s Field Guide (HCPRO 2016).

Credit Hours

  • 1.5 hours for Licensed Nurses
  • 1.5 NAB hours for Nursing Home Adminstrators

This pre-recorded webinar expires on February 28, 2026.


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  • This nursing continuing professional development activity was approved by Montana Nurses Association, an accredited approver with distinction by the American Nurses Credentialing Center’s Commission on Accreditation.
  • Enduring material: To meet the requirements for these contact hours, you must watch the entire recorded presentation as well as answer and submit the post-test evaluation that is provided as a link along with the link to your webinar which you will receive via email after completing your purchase.