Current through Register 1531, September 27, 2024
(A) There shall be
written policies and procedures concerning the implementation of discharge
planning services, which reflect acceptable standards of practice and
compliance with applicable regulations.
(B) The coordinator of discharge planning or
discharge planning unit shall be responsible for the coordination of patients'
plans for continuing care in cooperation with the patient's physician, nurse
practitioner or physician's assistant and in cooperation with the patient,
and/or the family/representative as appropriate and other members of the
professional staff.
(C) The
coordinator of discharge planning or the discharge planning unit shall
establish effective systems for identifying patients in need of the hospital's
discharge planning service. The goal of these systems shall be the early, as
well as ongoing, identification of patients in need of discharge planning
assistance.
(1) These systems shall include
but not be limited to:
(a) requests for
discharge planning consultation from the professional staff, the patient, or
his or her family/patient representative;
(b) regular multidisciplinary meetings to
review an individual patient's need for continuing care; and
(c) implementation of a high risk screening
system to identify patients who may require discharge planning
services.
(2) The
coordinator of discharge planning or the discharge planning unit shall be
responsible for developing a written procedure describing the systems employed
by the hospital to identify patients in need of discharge planning
assistance.
(D)
Early Screening.
(1)
High risk case finding screening criteria shall be in writing and reflect the
hospital's experience with patients requiring post-hospital care. Criteria
shall be reviewed and revised as needed but at least annually.
(2) At a minimum high risk screening criteria
shall include the lack of a readily available informal personal support
network, e.g., family support.
(3) The hospital's high-risk screening and
assessment system shall include the following provisions:
(a) all patients shall be screened against
the hospital's high-risk criteria within 24 hours of admission; and
(b) an initial discharge planning assessment
of all patients determined to be high-risk shall take place as soon as
possible, but at least within two working days of the identification of such
patients.
(E)
Policies regarding Outpatient Discharge Planning
Services.
(1) The coordinator of
discharge planning or discharge planning unit shall develop policies and
procedures and written criteria for use in the hospital emergency service and
day surgical services indicating the circumstances under which discharge
planning services shall be provided for a person who is in need of
post-emergency or post-ambulatory surgical planning services but not in need of
in-patient hospital care.
(2)
Policies shall as appropriate reflect compliance with the requirements of
105 CMR 130.343(A) and (B), (D)
through (H) and
130.345(B)
relative to Medicare patients receiving services in emergency departments of
acute hospitals.
(F)
Discharge planning staff shall maintain in writing a description of
out-of-hospital resources, which shall be readily available to the attending
physician, nurse practitioner, physician's assistant, other members of the
professional staff, the patients and their families/patient representatives.
(1) Resource information available shall
cover the range of services in the hospital's primary service area that have
the capability of assisting the patient and/or the patient's
family/representative in meeting the patient's discharge needs. Where possible,
information shall include admission and discharge policies and payment
criteria.
(2) The hospital shall
employ reasonable efforts to identify and arrange for necessary postdischarge
services for patients from outside of the hospital's primary service
area.
(3) The hospital shall make
reasonable efforts to keep resource information current.
(G) In instances where the professional
services of the discharge planning coordinator or unit are not required,
professional staff of the appropriate professional departments shall plan for
and coordinate the patient's discharge in accordance with departmental policy
outlining their responsibility.
