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RULE §411.628Discharge Planning

(a) Involvement of staff, patient, and LAR in planning activities.

  (1) Following the admission of a patient to a CSU, the CSU shall conduct discharge planning for the patient.

  (2) Discharge planning shall involve qualified staff, the patient, the patient's LAR, and any other individual authorized by the patient or LAR, unless clinically contraindicated.

  (3) Discharge planning shall include, at a minimum, the following activities:

    (A) qualified staff members recommending services and supports needed by the patient after discharge, including the placement after discharge;

    (B) qualified staff members arranging for the recommended services and supports;

    (C) Preadmission Screening and Resident Review (PASRR) as required by paragraph (4) of this subsection; and

    (D) qualified staff members counseling the patient, the patient's LAR, and as appropriate, the patient's caregivers, to prepare them for post-discharge care.

  (4) Screening and evaluation before patient discharge from the CSU. In accordance with 42 Code of Federal Regulations (CFR), Part 483, Subpart C (relating to Requirements for Long Term Care Facilities) and the rules of the Department of Aging and Disability Services (DADS) set forth in 40 TAC Chapter 17, (relating to Preadmission Screening and Resident Review (PASRR)), all patients who are being considered for discharge from the CSU to a nursing facility shall be screened, and if appropriate, evaluated, prior to discharge by the CSU and admission to the nursing facility to determine whether the patient may have a mental illness, intellectual disability or developmental disability. If the screening indicates that the patient has a mental illness, intellectual disability or developmental disability, the CSU shall contact and arrange for the local mental health authority designated pursuant to Texas Health and Safety Code, §533.035, to conduct prior to CSU discharge an evaluation of the patient in accordance with the applicable provisions of the PASRR rules. The purpose of PASRR is:

    (A) to ensure that placement of the patient in a nursing facility is necessary;

    (B) to identify alternate placement options when applicable; and

    (C) to identify specialized services that may benefit the person with a diagnosis of mental illness, intellectual disability, or developmental disability.

(b) Discharge summary. The patient's treating physician shall prepare a written discharge summary that includes:

  (1) a description of the patient's treatment at the CSU and the response to that treatment;

  (2) a description of the patient's condition at discharge;

  (3) a description of the patient's placement after discharge;

  (4) a description of the services and supports the patient will receive after discharge;

  (5) a final diagnosis based on all five axes of the DSM;

  (6) a description of the amount of medication the patient will need until the patient is evaluated by a physician; and

  (7) the name of the individual 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) Contact with the local mental health authority. In conducting the discharge planning activities described in subsections (a)(3)(A) and (B) of this section, a CSU shall consult with personnel at the local mental health authority who are responsible for ensuring continuity of care for individuals upon discharge from the CSU.

(d) Documentation of refusal. If it is not feasible for any of the activities listed in subsection (a)(3) of this section to be performed because the patient, the patient's LAR, or the patient's caregivers refuse to participate in the discharge planning, the circumstances of the refusal shall be documented in the patient's medical record.

Source Note: The provisions of this §411.628 adopted to be effective January 1, 2004, 28 TexReg 11323; amended to be effective May 24, 2013, 38 TexReg 3028

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