| (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.
(3) Written discharge summary includes:
(A) a description of the individual's treatment and
their response to that treatment;
(B) a description of the level of care for services
received;
(C) a description of the individual's level of functioning
at discharge;
(D) a description of the individual's living arrangement
after discharge;
(E) a description of the community services and supports
the individual will receive after discharge;
(F) a final diagnosis based on the current edition
of the DSM; and
(G) a description of the amount of medication available
to the individual, if applicable.
(4) The discharge summary must be sent to the individual's:
(A) designated LMHA, LBHA, or LIDDA, as applicable;
and
(B) providers to whom the individual was referred.
(5) Documentation of refusal. If the individual, the
individual's LAR, or the individual's caregivers refuse to participate
in the discharge planning, the circumstances of the refusal must be
documented in the individual's record.
(l) Care after discharge. An individual discharged
from an SMHF or facility with a CPB is eligible for:
(1) community transitional services for 90 days if
referred to an LMHA or LBHA; or
(2) ongoing services.
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