Current through Reg. 49, No. 38; September 20, 2024
(a) A QMHP-CS or
LPHA must begin discharge planning for an individual at the time of the
individual's admission.
(1) Discharge
planning must involve the individual, the IDT, the individual's LAR or adult
caregiver, as applicable, and any other person authorized by the individual and
the individual's adult caregiver or LAR if applicable, unless clinically
contraindicated.
(2) Discharge
planning must be provided in accordance with §
510.41(m)(3)
of this title (relating to Facility Functions and Services) and include:
(A) the IDT recommendations for services and
supports, including placement needs, that should be provided after
discharge;
(B) the IDT arrangements
for the recommended services and supports;
(C) a PASRR screening, as required by
paragraph (3) of this subsection; and
(D) the IDT post-discharge care information
provided in a language and format easily understandable to the individual, and
the individual's LAR or adult caregiver, if applicable.
(3) An individual considered for discharge
from the CSU to a Medicaid-certified nursing facility must have a PASRR Level I
screening completed, in accordance with the Code of Federal Regulations, Title
42, Part 483, Subpart B (relating to Requirements for Long-Term Care
Facilities) before discharge; and
(4) if the screening indicates that the
individual has a mental illness, ID, or DD, the CSU staff member coordinating
the individual's transfer must contact and arrange for the designated LMHA,
LBHA, or LIDDA to conduct a PASRR Level II evaluation of the individual before
CSU discharge, in accordance with Chapter 303 of this title (relating to
Preadmission Screening and Resident Review (PASRR)).
(b) The individual's treating physician must
prepare a written discharge summary that includes:
(1) a description of the individual's
treatment at the CSU and the response to that treatment;
(2) a description of the individual's
condition at discharge;
(3) a
description of the individual's placement after discharge;
(4) a description of the services and
supports the individual will receive after discharge;
(5) a final diagnosis based on the current
edition of the Diagnostic and Statistical Manual of Mental
Disorders;
(6) a
description, including dosage instructions, of the prescribed medications the
individual will need until the individual is evaluated by a physician, or
provider with prescriptive authority; and
(7) the name of the person or entity
responsible for providing and paying for the medication referenced in paragraph
(6) of this subsection, which is not required to be the CSU.
(c) The CSU staff member
coordinating the individual's discharge must provide a copy of the discharge
summary as authorized by state and federal law, to LMHA, LBHA, LIDDA, or other
community providers and consult with them to ensure continuity of care for the
individual upon discharge from the CSU.
(d) The CSU staff member coordinating the
individual's discharge must contact and coordinate with the individual's
existing service providers and in accordance with the Health Insurance
Portability and Accountability Act or other law prior to the individual's
discharge.
(e) If the individual,
or the individual's LAR, adult caregiver, or others authorized by the
individual, refuse to participate in the discharge planning, the CSU staff
member coordinating the individual's discharge must document the circumstances
of the refusal in the individual's medical record.
(f) If extremely hazardous weather conditions
exist or a disaster occurs, the physician may request the presiding judge or
magistrate of a court that has jurisdiction over proceedings brought in
accordance with Texas Health and Safety Code Chapter 574 to extend the period
during which the individual may be detained in accordance with Texas Health and
Safety Code §
572.004(e).
