Current through Supplement No. 394, October, 2024
Each resident must have their discharge plan developed upon
admission and reviewed ongoing as part of the treatment plan.
1. Persons involved in discharge planning
should include:
a. Resident;
b. Resident's parent or guardian;
c. Custodian, if applicable;
d. Psychiatrist, if applicable;
e. Therapist, if applicable;
f. Clinical director;
g. Treatment coordinator employee;
h. Facility nurse;
i. Facility educator or community
teacher;
j. Direct care
employee;
k. Foster care providers,
if applicable;
l. Juvenile court,
if applicable; and
m. Other
individuals important to the resident and family.
2. The discharge plan must address the
following:
a. The date of admission;
b. The anticipated date of
discharge;
c. Details of the events
and circumstances leading to the decision to discharge;
d. The name and address of the individual or
agency to whom the resident must be discharged and the rationale for planning a
discharge to that individual or agency;
e. A summary of services provided during
placement;
f. A summary of goal
achievement;
g. A summary of the
resident's continuing needs, including health care, educational or vocational
training, psychiatric, medical, psychological, social, behavioral,
developmental, and chemical dependency treatment needs;
h. Appointments scheduled, including
individual therapy, psychiatric services, educational services, and other
services or supports as needed;
i.
Medication plan, including a seven-day supply of needed medication and a
prescription for medication to last through the first outpatient visit with a
prescribing provider;
j. A summary
of community-based service needs for the resident and resident's
family;
k. A summary of efforts
made by the facility to prepare the resident and the resident's family for
discharge; and
l. The facility's
plan for the six months of aftercare services for the resident and the
resident's family.
3. The
discharge committee shall review and approve each anticipated discharge thirty
days prior to the discharge and provide the completed discharge plan to the
custodian at least seven days prior to the anticipated discharge. A discharge
planning meeting involving the resident, custodian, parent or guardian,
facility treatment team, additional family members, community service
providers, and foster care provider, if applicable must take place at least
seven days before discharge to review and sign the discharge plan to ensure the
continuity of services consistent with the resident's treatment needs after
discharge.
4. If a discharge is not
anticipated at least thirty calendar days ahead of time, the discharge is
considered unplanned and the facility shall:
a. Hold a discharge planning meeting
involving the resident, custodian, parent or guardian, facility treatment team,
additional family members, and any other relevant parties. This meeting must
allow relevant parties time to review the discharge plan and aftercare
engagement strategies while discussing services needed to best meet the needs
of the resident.
b. Create and
provide in writing a finalized discharge and aftercare plan to the custodian
and parent or guardian at least seven days prior to the resident's
discharge.
c. Provide the discharge
plan and aftercare plan no greater than seven days postdischarge, if an
immediate discharge occurred.
General Authority: NDCC 50-11-03
Law Implemented: NDCC
50-11-02
