| (a) At the time of an individual's admission to an
SMHF or facility with a CPB, the designated LMHA or LBHA, if any,
and the SMHF or facility with a CPB begins discharge planning for
the individual.
(b) The designated LMHA or LBHA continuity of care
worker or other designated staff; the designated LIDDA continuity
of care worker, if applicable; the individual; the individual's LAR,
if any; and any other person authorized by the individual coordinates
discharge planning with the SMHF or facility with a CPB.
(1) Except for the SMHF or facility with a CPB treatment
team and the individual, involvement in discharge planning may be
through teleconference or video-conference calls.
(2) The SMHF or the facility with a CPB must provide
a minimum of 24-hour notification before scheduled staffings and reviews
to persons involved in discharge planning.
(3) The LMHA, LBHA, or LIDDA, if applicable, and the
SMHF or facility with a CPB involved in discharge planning must coordinate
all discharge planning activities and ensure the development and completion
of the discharge plan before the individual's discharge.
(c) Discharge planning must consist of the following
activities:
(1) Considering all pertinent information about the
individual's clinical needs, the SMHF or facility with a CPB must
identify and recommend specific clinical services and supports needed
by the individual after discharge or while on ATP.
(2) The LMHA, LBHA, or LIDDA, if applicable, must identify
and recommend specific non-clinical services and supports needed by
the individual after discharge, including housing, food, and clothing
resources.
(3) If an individual needs a living arrangement, the
LMHA or LBHA continuity of care worker must identify a setting consistent
with the individual's clinical needs and preference that is available
and has accessible services and supports as agreed upon by the individual
or the individual's LAR.
(4) The LMHA, LBHA, or LIDDA, if applicable must identify
potential providers and resources for the services and supports recommended.
(5) The SMHF or facility with a CPB must counsel the
individual and the individual's LAR, if any, to prepare them for care
after discharge or while on ATP.
(6) The SMHF or facility with a CPB must provide the
individual and the individual's LAR, if any, with written notification
of the existence, purpose, telephone number, and address of the protection
and advocacy system established in Texas, pursuant to Texas Health
and Safety Code §576.008.
(7) The LMHA or LBHA must comply with the Preadmission
Screening and Resident Review processes as described in Chapter 303
of this title (relating to Preadmission Screening and Resident Review
(PASRR)) for an individual recommended to move to a nursing facility.
(d) Before an individual's discharge:
(1) The individual's treatment team must develop a
discharge plan to include the individual's stated wishes. The discharge
plan must consist of:
(A) a description of the individual's living arrangement
after discharge, or while on ATP, that reflects the individual's preferences,
choices, and available community resources;
(B) arrangements and referrals for the available and
accessible services and supports agreed upon by the individual or
LAR recommended in the individual's discharge plan;
(C) a written description of recommended clinical and
non-clinical services and supports the individual may receive after
discharge or while on ATP. The SMHF or facility with a CPB documents
arrangements and referrals for the services and supports recommended
upon discharge or ATP in the discharge plan;
(D) a description of problems identified at discharge
or ATP, including any issues that may disrupt the individual's stability
in the community;
(E) the individual's goals, strengths, interventions,
and objectives as stated in the individual's discharge plan in the
SMHF or facility with a CPB;
(F) comments or additional information;
(G) a final diagnosis based on the current edition
of the Diagnostic and Statistical Manual
of Mental Disorders (DSM) published by the American Psychiatric
Association;
(H) the names, contact information, and addresses of
providers to whom the individual will be referred for any services
or supports after discharge or while on ATP; and
(I) in accordance with Texas Health and Safety Code §574.081(c),
a description of:
(i) the types and amount of medication the individual
needs after discharge or while on ATP until the individual is evaluated
by a physician; and
(ii) the person or entity responsible for providing
and paying for the medication.
(2) The SMHF or facility with a CPB must request that
the individual or LAR, as appropriate, sign the discharge plan, and
document in the discharge plan whether the individual or LAR agree
or disagree with the plan.
(3) If the individual or LAR refuses to sign the discharge
plan described in paragraph (2) of this subsection, the SMHF or facility
with a CPB documents in the individual's record if the individual
or LAR agrees to the plan or not, reasons stated, and any other circumstances
of the refusal.
(4) If applicable, the individual's treating physician
must document in the individual's record reasons why the individual
does not require continuing care or a discharge plan in accordance
with Texas Health and Safety Code §574.081(g).
(5) If the LMHA or LBHA disagrees with the SMHF or
facility with a CPB treatment team's decision concerning discharge:
(A) the treating physician of the SMHF or facility
with a CPB consults with the LMHA or LBHA physician or designee to
resolve the disagreement within 24 hours;
(B) and if the disagreement continues unresolved:
(i) the medical director or designee of the SMHF or
facility with a CPB consults with the LMHA or LBHA medical director;
and
(ii) if the disagreement continues unresolved after
consulting with the LMHA or LBHA medical director:
(I) the medical director or designee of the SMHF or
facility with a CPB refers the issue to the State Hospital System
Chief Medical Officer; and
(II) the State Hospital System Chief Medical Officer
collaborates with the Medical Director of the Behavioral Health Section
to render a final decision within 24 hours of notification.
(e) Discharge notice to family or LAR.
(1) In accordance with Texas Health and Safety Code §576.007,
before discharging an individual who is an adult, the SMHF or facility
with a CPB makes a reasonable effort to notify the individual's family
or any other person providing support as authorized by the individual
or LAR, if any, of the discharge if the adult grants permission for
the notification.
(2) Before discharging an individual at least 16 years
of age or younger than 18 years of age, the SMHF or facility with
a CPB makes a reasonable effort to notify the individual's family
as authorized by the individual or LAR, if any, of the discharge if
the individual grants permission for the notification.
(3) Before discharging an individual younger than 16
years of age, the SMHF or facility with a CPB notifies the individual's
LAR of the discharge.
(f) Release of minors. Upon discharge, the SMHF or
facility with a CPB may release a minor younger than 16 years of age
only to the minor's LAR or the LAR's designee.
(1) If the LAR or the LAR's designee is unwilling to
retrieve the minor from the SMHF or facility with a CPB and the LAR
is not a state agency:
(A) the SMHF or facility with a CPB:
(i) notifies the Department of Family and Protective
Services (DFPS), so DFPS can take custody of the minor from the SMHF
or facility with a CPB;
(ii) refers the matter to the local CRCG to schedule
a meeting with representatives from the required agencies described
in subsection (f)(2)(A) of this section, the LAR, and minor to explore
resources and make recommendations; and
(iii) documents the CRCG referral in the discharge
plan; and
(B) the medical directors or their designees of the
SMHF or facility with a CPB; designated LMHA, LBHA, or LIDDA; and
DFPS meet to develop and solidify the discharge recommendations.
(2) If the LAR is a state agency unwilling to assume
physical custody of the minor from the SMHF or facility with a CPB,
the SMHF or the facility with a CPB:
(A) refers the matter to the local CRCG to schedule
a meeting with representatives from the member agencies, in accordance
with 40 TAC Chapter 702, Subchapter E (relating to Memorandum of Understanding
with Other State Agencies) the LAR, and minor to explore resources
and make recommendations; and
(B) documents the CRCG referral in the discharge plan.
(g) Notice to the designated LMHA, LBHA, or LIDDA.
At least 24 hours before an individual's planned discharge or ATP,
and no later than 24 hours after an unexpected discharge, an SMHF
or facility with a CPB notifies the designated LMHA, LBHA, or LIDDA
of the anticipated or unexpected discharge and conveys the following
information about the individual:
(1) identifying information, including address;
(2) legal status (e.g., regarding guardianship, charges
pending, or custody if the individual is a minor);
(3) the day and time the individual will be discharged
or on an ATP;
(4) the individual's destination after discharge or
ATP;
(5) pertinent medical information;
(6) current medications;
(7) behavioral data, including information regarding
COPSD; and
(8) other pertinent treatment information, including
the discharge plan.
(h) Discharge packet.
(1) At a minimum, a discharge packet must include:
(A) the discharge plan;
(B) referral instructions, including:
(i) SMHF or facility with a CPB contact person;
(ii) name of the designated LMHA, LBHA, or LIDDA continuity
of care worker;
(iii) names of community resources and providers to
whom the individual is referred, including contacts, appointment dates
and times, addresses, and phone numbers;
(iv) a description of to whom or where the individual
is released upon discharge, including the individual's intended residence
(address and phone number);
(v) instructions for the individual, LAR, and primary
care giver as applicable;
(vi) medication regimen and prescriptions, as applicable;
and
(vii) dated signature of the individual or LAR and
a member of the SMHF or facility with a CPB treatment team;
(C) copies of all available, pertinent, current summaries,
and assessments; and
(D) the treating physician's orders.
(2) At discharge or ATP, the SMHF or facility with
a CPB provides a copy of the discharge packet to the individual. Individuals
may request additional records. If the requested records are reasonably
likely to endanger the individual's life or physical safety, these
records can be withheld. Documentation of the determination to withhold
records is required in the individual's medical record.
(3) Within 24 hours after discharge or ATP, the SMHF
or facility with a CPB sends a copy of the discharge packet to:
(A) the designated LMHA, LBHA, or LIDDA; and
(B) the providers to whom the individual is referred,
including:
(i) an LMHA or LBHA network provider, if the LMHA or
LBHA is responsible for ensuring the individual's services after discharge
or while on an ATP;
(ii) an alternate provider, if the individual requested
referral to an alternate provider; and
(iii) a county jail, if the individual will be taken
to the county jail upon discharge.
(i) Unexpected Discharge.
(1) The SMHF or facility with a CPB and the designated
LMHA, LBHA, or LIDDA must make reasonable efforts to provide discharge
planning for an individual discharged unexpectedly.
(2) If there is an unexpected discharge, the facility
social worker or a staff with an equivalent credential to a social
worker must document the reason for not completing discharge planning
activities in the individual's record.
(j) Transportation. An SMHF or facility with a CPB
must:
(1) initiate and secure transportation in collaboration
with an LMHA or LBHA to a planned location after an individual's discharge;
and
(2) inform a designated LMHA, LBHA, or LIDDA of an
individual's transportation needs after discharge or an ATP.
(k) Discharge summary.
(1) Within ten days after an individual's discharge,
the individual's physician of the SMHF or facility with a CPB completes
a written discharge summary for the individual.
(2) Within 21 days after an individual's discharge
from a LMHA or LBHA the LMHA or LBHA must complete a written discharge
summary for the individual.
Cont'd... |
