Texas Administrative Code
Title 26 - HEALTH AND HUMAN SERVICES
Part 1 - HEALTH AND HUMAN SERVICES COMMISSION
Chapter 554 - NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION
Subchapter I - RESIDENT ASSESSMENT
Section 554.803 - Discharge Summary (Discharge Plan of Care)
Universal Citation: 26 TX Admin Code ยง 554.803
Current through Reg. 49, No. 38; September 20, 2024
(a) Discharge planning. The facility must develop and implement an effective discharge planning process.
(1) The facility's discharge planning process
must:
(A) ensure that the discharge needs of
each resident are identified and result in the development of a discharge plan
for each resident;
(B) include
regular re-evaluation of a resident to identify changes that require
modification of the discharge plan and update the discharge plan to reflect
these changes;
(C) involve the
interdisciplinary team in the ongoing process of developing the discharge
plan;
(D) consider caregiver or
support person availability and the resident's or caregiver's or support
person's capacity and capability to perform required care, as part of the
identification of discharge needs;
(E) involve the resident and resident
representative in the development of the discharge plan and inform the resident
and resident representative of the final plan;
(F) address the resident's goals of care and
treatment preferences; and
(G)
document that a resident has been asked about their interest in receiving
information regarding returning to the community.
(i) If the resident indicates an interest in
returning to the community, the facility must document any referrals to local
contact agencies or other appropriate entities made for this purpose.
(ii) Facilities must update a resident's
comprehensive care plan and discharge plan as appropriate, in response to
information received from referrals to local contact agencies or other
appropriate entities.
(iii) If
discharge to the community is determined to not be feasible, the facility must
document who made the determination and why.
(2) The evaluation of the resident's
discharge needs and discharge plan must be completed on a timely basis and
documented in the resident's clinical record.
(3) The results of the evaluation of the
resident's discharge needs and discharge plan must be discussed with the
resident or the resident representative.
(b) When a facility anticipates a resident's discharge, the facility must develop a discharge summary that includes:
(1) a recapitulation of the overall course of
the resident's stay that includes diagnoses, course of illness, treatment, or
therapy and pertinent lab, radiology, and consultation results, a final summary
of the resident's status;
(2)
reconciliation or all pre-discharge medications with the resident's
post-discharge medications both prescribed and over-the-counter;
(3) a statement notifying a resident granted
permanent medical necessity (PMN) under the Medicaid program that:
(A) PMN status continues after discharge,
unless the resident is discharged to home;
(B) PMN status expires 30 consecutive days
after the resident is discharged to home; and
(C) a new medical necessity determination is
required if the resident applies to be admitted to a nursing facility under the
Medicaid program more than 30 consecutive days after the resident moves home
from a nursing facility; and
(4) a post-discharge care plan , developed
with the participation of the resident and a resident representative that:
(A) will assist the resident to adjust to the
new living environment; and
(B)
indicates where the resident plans to reside and arrangements that have been
made for follow-up care and any post discharge medical and non-medical
services.
(c) The facility discharge summary must be available for release to authorized persons, facilities or agencies with the consent of the resident or resident representative .
Disclaimer: These regulations may not be the most recent version. Texas 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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