Current through Register Vol. 51, No. 19, September 20, 2024
A. When
an individual has attained the goals identified in the individual's service
plan, the individual's program coordinator shall begin the process for
discharge planning.
B. Discharge
Policy. The program shall have and maintain written policies and procedures,
which may be contained in one document, that include:
(1) The process for all types of discharge
from the program, including:
(a)
Collaborative discharge;
(b) The
individual's discontinuation of services;
(c) The program's recommendation to
discontinue services; and
(d) The
ASO's determination to discontinue authorization for services; and
(2) The individual's right to
appeal.
C. Discharge
Plan.
(1) The individual's program
coordinator and the individual, if appropriate, shall develop a discharge plan
that:
(a) Is based on an assessment of the
individual's current status, service needs, and mutually agreed upon goal
attainment;
(b) Includes:
(i) A brief description of the
recommendations for continued treatment, if any;
(ii) Referrals for continuing services;
and
(iii) Information about how the
individual can re-access services when needed; and
(c) With proper consent, is developed in
collaboration with family or others designated by the individual, and other
treatment, rehabilitation, and service providers.
(2) The individual's program coordinator
shall provide the individual with a copy of the discharge plan as soon as
possible, but in no event, not later than the date of discharge.
D. Discharge Summary. Within 10
working days after an individual is discharged from a program, a staff person
responsible for coordinating services to the individual shall complete and sign
a discharge summary that includes, at a minimum, the:
(1) Reason for admission;
(2) Reason for discharge;
(3) Services provided, including the
frequency and duration of services;
(4) Progress that was made;
(5) Diagnosis at the time of discharge, if
appropriate;
(6) Current
medications, if any;
(7) Continuing
service recommendations and summary of the transition process; and
(8) Extent of the individual's involvement in
the discharge plan.
E.
Program's Recommendation to Discontinue Services.
(1) If, in consultation with the program
director, the program coordinator recommends discontinuing services for an
individual for whom, because of the individual's actions, the program's
services are not effective, or the individual's clinical needs exceed the
program's ability to secure the safety and welfare of the individual or others,
the program director shall provide written notice of the intention to
discontinue services and recommend referral for alternative services.
(2) Except in the case of imminent danger,
the program director shall provide the notice at least 30 calendar days before
discontinuing services.
(3) The
program director shall assure that the notice is sent to the individual and,
with proper consent, to:
(a) Family or others
designated by the individual; and
(b) If appropriate, the CSA and the
Administration's ASO, for referral for alternative services.
(4) The notice shall include:
(a) The effective date of the
action;
(b) The reason for the
action; and
(c) A discharge
plan.
(5) If an
individual presents as a danger to self or to others, the program director
shall make necessary arrangements to try to protect the individual, others, or
both, and link the individual with the appropriate level of care.
F. ASO's Determination to
Discontinue Authorization for Services. If the Administration's ASO determines
that services are no longer medically necessary, the program coordinator shall
follow the provision for discharge outlined in §C of this
regulation.
