Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 435.000 - Chronic Disease And Rehabilitation Inpatient Hospital Services
Section 435.417 - Discharge-planning Standards

Universal Citation: 130 MA Code of Regs 130.435

Current through Register 1531, September 27, 2024

(A) Effective Date. The discharge-planning standards defined in 130 CMR 435.417 apply to members admitted on or after January 1, 1984.

(B) Exemptions from Discharge-planning Standards. A chronic disease or rehabilitation hospital will be exempted from the discharge-planning standards defined in 130 CMR 435.417 if the hospital has filed an application with the Determination of Need Program of the Massachusetts Department of Public Health to relicense the entire facility or a distinct unit within the facility as a nursing facility.

(C) Staff.

(1) The hospital must assign in writing the responsibility for all discharge planning to one appropriate department (such as social services or continuing care). That department in turn must designate specific staff members whose primary duties are discharge planning.

(2) The discharge-planning staff must include either a registered nurse or a social worker who is licensed, or who is eligible for licensure and has submitted an application for licensure to the appropriate Massachusetts board of registration or licensing agency in its state, and is under the supervision of, or in consultation with, a licensed graduate-level nurse or social worker.

(3) Unless permitted a lower ratio by the Division, the hospital must employ one discharge planner or full-time equivalent for every 60 licensed beds. Visiting Nurse Association (VNA) or home health staff who are not employed by the hospital, but who regularly perform discharge-planning activities there, may be included in this ratio.

(4) The hospital must demonstrate to the Division that it provides formal in-service training programs and regular case conferences for all discharge-planning staff and all other personnel who affect the discharge-planning process.

(D) Operations and Procedures.

(1) The discharge-planning staff must maintain a chronological list of all members on administrative-day status, which must be updated on a daily basis. The list must contain the date administrative-day status commenced and a recommendation for institutional or noninstitutional care based on nursing facility medical eligibility criteria upon discharge. The discharge-planning department must use this chronological list to ensure that members who have spent the longest time on administrative-day status receive priority in placement attempts.

(2) The discharge-planning department must maintain up-to-date lists of the following:
(a) all licensed nursing facilities within a 25-mile minimum radius of the hospital. This list must show the number of beds, whether the facility is Medicare certified, and any other notable characteristics (for example, availability of bilingual staff). The list must also contain the name of the individual at that institution responsible for admissions; and

(b) all community-based organizations and resources within a 25-mile minimum radius of the hospital that provide services and support to members discharged to the community. Such resources include housing for the elderly, home health agencies, homemaker services, transportation services, friendly visitor programs, and meal programs.

(3) As a routine practice, admissions data, including but not limited to age and diagnosis, must be screened by discharge-planning staff within 24 hours of admission in accordance with written criteria that identify pertinent patient characteristics and any high-risk diagnoses. Discharge-planning activities must then commence within 72 working hours of admission for every member expected to require posthospital care or services.

(4) The hospital must have a written policy that allows discharge-planning staff access to all members and their medical records. If such access is medically contraindicated, the member's physician must sign a statement specifying the reason for the contraindication and the hospital must maintain the statement in the member's medical or discharge-planning record.

(5) The discharge-planning staff and the primary-care team must coordinate and document in writing a plan for each member who requires posthospital care that specifies the services or care expected to be required by the member, the frequency, intensity, and duration of such services, and the resources available to provide the care or services, including available family and community support. The plan must be updated if the member's condition changes significantly. If an institutional placement is recommended upon the member's discharge, the plan must state why available community resources are inadequate to meet the member's needs.

(6) Each visit to a member by discharge-planning staff must be noted in the member's discharge-planning record. The notation must include the date of the meeting, any discharge options discussed, any particular problems noted, any agreements reached with the member, and the future activities of the discharge-planning staff that address the problems raised or that continue preparation of the member for discharge.

(7) Whenever possible, the discharge-planning staff or primary-care team must contact the member's family to encourage its involvement in planning the member's discharge. Family members must be informed of the discharge options and community resources available to the member and provided with lists of nursing facilities and community resources in the area. When possible, these meetings or telephone consultations with the family must be held once every two weeks until the member is discharged. The dates of these meetings and other family contacts, items discussed, problems identified, and agreements reached must be entered on the member's discharge-planning record.

(8) The hospital must have written procedures for arranging posthospital services for members. At a minimum, these procedures must include frequent, systematic contacts (usually three times weekly) by telephone or in person to all nursing facilities and community-service providers within a 25-mile minimum radius of the hospital.
(a) The purpose of these contacts is to:
1. determine what services at that location are or will soon become available and to ensure that the provider has current information, including medical and psychosocial status, on any member now or soon needing placement; and

2. arrange for placement or services or both for members awaiting discharge.

(b) These member-specific contacts must be documented as to their number, frequency, and outcome, and must be made by a registered nurse or by a social worker who is licensed, or who is eligible for licensure and has submitted an application for licensure to the appropriate Massachusetts board of registration or licensing agency in its state. The only exception in which such a call may be made by another person is when that person regularly works in the discharge-planning department, has received training in patient placement from a discharge planner, and consults all the relevant discharge documentation for the member when making the call. If, during the call, a question is asked that cannot be answered from the written data, it must be referred to a discharge planner.

(E) Nursing Facility Medical Eligibility Criteria. The member's physician and a registered nurse must determine the care required by a member upon discharge in accordance with the Division's nursing facility medical eligibility criteria. Both the member's medical and discharge-planning records must include the specific factors that indicate the recommended care and the names of the persons who determined it.

(F) Reporting Discrimination against Members. The hospital must have a formal written policy for the discharge-planning staff to use when reporting to the Division all suspected cases of discrimination against members by MassHealth providers.

(G) Disclosure Requirements. All written procedures and policies, lists, review criteria, discharge plans, and records used by the discharge-planning department in performing its duties must be made available for inspection by the Division.

Disclaimer: These regulations may not be the most recent version. Massachusetts may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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