Current through Register Vol. 42, No. 11, August 30, 2024
(1) The
hospital shall have in effect a discharge planning process that applies to all
patients. The hospital's policies and procedures shall be specified in
writing.
(2) Identification of
patients in need of discharge planning. The hospital shall identify at an early
stage of hospitalization all patients who are likely to suffer adverse health
consequences upon discharge if there is no adequate discharge
planning.
(3) Discharge planning
evaluation.
(a) The hospital shall provide a
discharge planning evaluation to the patients identified in paragraph (2) of
this rule, and to other patients upon the patient's request, the request of a
person acting on the patient's behalf, or the request of the
physician.
(b) A registered nurse,
social worker, or other appropriately qualified personnel shall develop, or
supervise the development of, the evaluation.
(c) The discharge planning evaluation shall
include an evaluation of the likelihood of a patient needing post-hospital
services and of the availability of the services.
(d) The discharge planning evaluation shall
include an evaluation of the likelihood of a patient's capacity for self-care
or of the possibility of the patient being cared for in the environment from
which he or she entered the hospital.
(e) Hospital personnel shall complete the
evaluation on a timely basis so that appropriate arrangements for post-hospital
care are made before discharge, and to avoid unnecessary delays in
discharge.
(f) The hospital shall
include the discharge planning evaluation in the patient's medical record for
use in establishing an appropriate discharge plan and shall discuss the results
of the evaluation with the patient or individual acting on his or her
behalf.
(4) Discharge
plan.
(a) A registered nurse, social worker,
or other appropriately qualified personnel shall develop, or supervise the
development of, a discharge plan if the discharge planning evaluation indicates
a need for a discharge plan.
(b) In
the absence of a finding by the hospital that a patient needs a discharge plan,
the patient's physician may request a discharge plan. In such a case, the
hospital shall develop a discharge plan for the patient.
(c) The hospital shall arrange for the
initial implementation of the patient's discharge plan.
(d) The hospital shall reassess the patient's
discharge plan if there are factors that may affect continuing care needs or
the appropriateness of the discharge plan.
(e) As needed, the patient and family members
or interested persons shall be counseled to prepare them for post-hospital
care.
(5) Transfer or
referral. The hospital shall transfer or refer patients, along with necessary
medical information, to appropriate licensed facilities, agencies, or
outpatient services, as needed, for follow up or ancillary care. In no event
shall the hospital knowingly transfer or refer a patient to an unlicensed
health care facility in violation of §
22-21-33(b),
Code of Ala. 1975.
(6) Reassessment. The hospital shall reassess
its discharge planning process on an on-going basis. The reassessment shall
include a review of discharge plans to ensure that they are responsive to
discharge needs.
Author: W.T. Geary, Jr., M.D., Carter
Sims
Statutory Authority:
Code of Ala.
1975, §§
22-21-20, et seq.
