| (a) Discharge planning. The facility must develop and
implement an effective discharge planning process.
(1) The facility's discharge planning process must:
(A) ensure that the discharge needs of each resident
are identified and result in the development of a discharge plan for
each resident;
(B) include regular re-evaluation of a resident to
identify changes that require modification of the discharge plan and
update the discharge plan to reflect these changes;
(C) involve the interdisciplinary team in the ongoing
process of developing the discharge plan;
(D) consider caregiver or support person availability
and the resident's or caregiver's or support person's capacity and
capability to perform required care, as part of the identification
of discharge needs;
(E) involve the resident and resident representative
in the development of the discharge plan and inform the resident and
resident representative of the final plan;
(F) address the resident's goals of care and treatment
preferences; and
(G) document that a resident has been asked about their
interest in receiving information regarding returning to the community.
(i) If the resident indicates an interest in returning
to the community, the facility must document any referrals to local
contact agencies or other appropriate entities made for this purpose.
(ii) Facilities must update a resident's comprehensive
care plan and discharge plan as appropriate, in response to information
received from referrals to local contact agencies or other appropriate
entities.
(iii) If discharge to the community is determined to
not be feasible, the facility must document who made the determination
and why.
(2) The evaluation of the resident's discharge needs
and discharge plan must be completed on a timely basis and documented
in the resident's clinical record.
(3) The results of the evaluation of the resident's
discharge needs and discharge plan must be discussed with the resident
or the resident representative.
(b) When a facility anticipates a resident's discharge,
the facility must develop a discharge summary that includes:
(1) a recapitulation of the overall course of the resident's
stay that includes diagnoses, course of illness, treatment, or therapy
and pertinent lab, radiology, and consultation results, a final summary
of the resident's status;
(2) reconciliation or all pre-discharge medications
with the resident's post-discharge medications both prescribed and
over-the-counter;
(3) a statement notifying a resident granted permanent
medical necessity (PMN) under the Medicaid program that:
(A) PMN status continues after discharge, unless the
resident is discharged to home;
(B) PMN status expires 30 consecutive days after the
resident is discharged to home; and
(C) a new medical necessity determination is required
if the resident applies to be admitted to a nursing facility under
the Medicaid program more than 30 consecutive days after the resident
moves home from a nursing facility; and
(4) a post-discharge care plan, developed with the
participation of the resident and a resident representative that:
(A) will assist the resident to adjust to the new living
environment; and
(B) indicates where the resident plans to reside and
arrangements that have been made for follow-up care and any post discharge
medical and non-medical services.
(c) The facility discharge summary must be available
for release to authorized persons, facilities or agencies with the
consent of the resident or resident representative.
|
| Source Note: The provisions of this §554.803 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective August 31, 2015, 40 TexReg 5461; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871 |
