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RULE §511.62Discharge Planning

(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.

Source Note: The provisions of this §511.62 adopted to be effective October 5, 2023, 48 TexReg 5668

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