| (a) Involvement of staff, patient, and legally authorized
representative (LAR), when applicable, in planning activities.
(1) Following the admission of a patient to a hospital,
the hospital shall conduct discharge planning with the patient and
LAR, as well as the LMHA or LBHA if the patient is in a psychiatric
inpatient bed funded under a contract with HHSC or operated by or
funded under a contract with a LMHA or LBHA.
(2) Discharge planning shall involve the interdisciplinary
treatment team (IDT), which includes the patient and LAR, as well
as the LMHA or LBHA if the patient is in a psychiatric inpatient bed
funded under a contract with HHSC or operated by or funded under a
contract with a LMHA or LBHA.
(3) Discharge planning shall include, at a minimum,
the following activities:
(A) the patient's IDT recommending services and supports
needed by the patient after discharge, including the placement after
discharge;
(B) qualified staff members arranging for the services
and supports recommended by the patient's IDT;
(C) qualified staff members counseling the patient,
the patient's LAR, when applicable, and as appropriate, the patient's
caregivers, to prepare them for post-discharge care; and
(D) Preadmission Screening and Resident Review (PASRR)
as required by paragraph (5) of this subsection.
(4) The discharge plan shall consist of:
(A) a description of the individual's living arrangement
after discharge 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. The hospital documents arrangements and referrals for the
services and supports recommended upon discharge in the discharge
plan;
(D) a description of problems identified at discharge,
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
hospital;
(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; and
(I) in accordance with Texas Health and Safety Code §574.081,
a description of:
(i) the types and amount of medication the individual
needs after discharge until the individual is evaluated by a physician;
and
(ii) the person or entity responsible for providing
and paying for the medication.
(5) Screening and evaluation before patient discharge
from hospital. In accordance with 42 CFR Part 483, Subpart C (relating
to Requirements for Long Term Care Facilities) and the rules set forth
in Chapter 303 of this title (relating to Preadmission Screening and
Resident Review (PASRR)), all patients who are being considered for
discharge from the hospital to a nursing facility shall be screened,
and if appropriate, evaluated, before discharge by the hospital and
admission to the nursing facility to determine whether the patient
may have a mental illness, intellectual disability, or developmental
disability. If the screening indicates that the patient has a mental
illness, intellectual disability, or developmental disability, the
hospital shall contact and arrange for the local mental health authority
designated pursuant to Texas Health and Safety Code §533.035,
to conduct before hospital discharge an evaluation of the patient
in accordance with the applicable provisions of the PASRR rules. The
purpose of PASRR is:
(A) to ensure that placement of the patient in a nursing
facility, is necessary;
(B) to identify alternate placement options, when applicable;
and
(C) to identify specialized services that may benefit
the person with a diagnosis of mental illness, intellectual disability,
or developmental disability.
(b) Discharge summary. The patient's treating physician
shall prepare a written discharge summary that includes:
(1) a description of the patient's treatment at the
hospital and the response to that treatment;
(2) a description of the patient's condition at discharge;
(3) a description of the patient's placement after
discharge;
(4) a description of the services and supports the
patient will receive after discharge;
(5) a final diagnosis based on the DSM;
(6) a description of the amount of medication the patient
will need until the patient is evaluated by a physician; and
(7) in accordance with Texas Health and Safety Code §574.081(c)
and (h), for involuntary patients admitted under an order described
in §568.24(a)(2) of this chapter (related to Admission of an
Individual under an Order of Protective Custody, for Court-ordered
Inpatient Mental Health Services, or Under Order for Commitment or
Order for Placement), the name of the individual or entity responsible
for providing and paying for the medication referenced in paragraph
(6) of this subsection, which is not required to be the hospital.
(c) Documentation of refusal. If it is not feasible
for any of the activities listed in subsection (a)(3) of this section
to be performed because the patient, the patient's LAR, when applicable,
or the patient's caregivers refuse to participate in the discharge
planning, the circumstances of the refusal shall be documented in
the patient's medical record.
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