|(a) Involvement of staff, patient, and LAR in planning
(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
(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
(A) to ensure that placement of the patient in a nursing
facility is necessary;
(B) to identify alternate placement options when applicable;
(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
(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
(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.