| (a) A limited services rural hospital (LSRH) shall
have an effective, ongoing, discharge planning process that facilitates
the provision of follow-up care and focuses on the patient's goals
and treatment preferences and includes the patient and their caregivers
or support persons as active partners in the discharge planning for
post-discharge care.
(b) The discharge planning process and the discharge
plan shall be consistent with the patient's goals for care and their
treatment preferences, ensure an effective transition of the patient
from the LSRH to post-discharge care, and reduce the factors leading
to preventable LSRH admissions or readmissions.
(c) An LSRH's discharge planning process shall identify,
at an early stage of the provision of services, those patients who
are likely to suffer adverse health consequences on discharge in the
absence of adequate discharge planning and must provide a discharge
planning evaluation for those patients so identified as well as for
other patients upon the request of the patient, patient's legally
authorized representative, or patient's physician.
(d) Any discharge planning evaluation must be made
on a timely basis to ensure appropriate arrangements for post-LSRH
care will be made before discharge and to avoid unnecessary delays
in discharge.
(e) A discharge planning evaluation must include:
(1) an evaluation of a patient's likely need for appropriate
services following those furnished by the LSRH, including:
(A) hospice care services;
(B) post-LSRH extended care services;
(C) home health services;
(D) non-health care services; and
(E) community-based care providers;
(2) a determination of the availability of the appropriate
services; and
(3) a determination of the patient's access to those
services.
(f) The discharge planning evaluation must be included
in the patient's medical record for use in establishing an appropriate
discharge plan and the results of the evaluation must be discussed
with the patient (or the patient's legally authorized representative).
(g) On the request of a patient's physician, the LSRH
must arrange for the development and initial implementation of a discharge
plan for the patient.
(h) Any discharge planning evaluation or discharge
plan required under this section must be developed by, or under the
supervision of, a registered nurse, social worker, or other appropriately
qualified personnel.
(i) The LSRH's discharge planning process must require
regular re-evaluation of the patient's condition to identify changes
that require modification of the discharge plan. The discharge plan
must be updated, as needed, to reflect these changes.
(j) The LSRH must assess its discharge planning process
on a regular basis. The assessment must include ongoing periodic review
of a representative sample of discharge plans.
(k) The LSRH must assist patients, their families,
or the patient's legally authorized representative in selecting a
post-acute care provider by using and sharing data that includes,
but is not limited to, home health agency, skilled nursing facility
(SNF), inpatient rehabilitation facility, or long-term care hospital
data on quality measures and data on resource use measures. The LSRH
must ensure that the post-acute care data on quality measures and
data on resource use measures is relevant and applicable to the patient's
goals of care and treatment preferences.
(l) The LSRH must discharge the patient, and also transfer
or refer the patient where applicable, along with all necessary medical
information pertaining to the patient's current course of illness
and treatment, post-discharge goals of care, and treatment preferences,
at the time of discharge, to the appropriate post-acute care service
providers and suppliers, facilities, agencies, and other outpatient
service providers and practitioners responsible for the patient's
follow-up or ancillary care.
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