26 Tex. Admin. Code § 511.62 - Discharge Planning
(a) A limited
services rural hospital (LSRH) shall have an effective, ongoing, discharge
planning process that facilitates the provision of follow-up care and focuses
on the patient's goals and treatment preferences and includes the patient and
their caregivers or support persons as active partners in the discharge
planning for post-discharge care.
(b) The discharge planning process and the
discharge plan shall be consistent with the patient's goals for care and their
treatment preferences, ensure an effective transition of the patient from the
LSRH to post-discharge care, and reduce the factors leading to preventable LSRH
admissions or readmissions.
(c) An
LSRH's discharge planning process shall identify, at an early stage of the
provision of services, those patients who are likely to suffer adverse health
consequences on discharge in the absence of adequate discharge planning and
must provide a discharge planning evaluation for those patients so identified
as well as for other patients upon the request of the patient, patient's
legally authorized representative, or patient's physician.
(d) Any discharge planning evaluation must be
made on a timely basis to ensure appropriate arrangements for post-LSRH care
will be made before discharge and to avoid unnecessary delays in
discharge.
(e) A discharge planning
evaluation must include:
(1) an evaluation of
a patient's likely need for appropriate services following those furnished by
the LSRH, including:
(A) hospice care
services;
(B) post-LSRH extended
care services;
(C) home health
services;
(D) non-health care
services; and
(E) community-based
care providers;
(2) a
determination of the availability of the appropriate services; and
(3) a determination of the patient's access
to those services.
(f)
The discharge planning evaluation must be included in the patient's medical
record for use in establishing an appropriate discharge plan and the results of
the evaluation must be discussed with the patient (or the patient's legally
authorized representative).
(g) On
the request of a patient's physician, the LSRH must arrange for the development
and initial implementation of a discharge plan for the patient.
(h) Any discharge planning evaluation or
discharge plan required under this section must be developed by, or under the
supervision of, a registered nurse, social worker, or other appropriately
qualified personnel.
(i) The LSRH's
discharge planning process must require regular re-evaluation of the patient's
condition to identify changes that require modification of the discharge plan.
The discharge plan must be updated, as needed, to reflect these
changes.
(j) The LSRH must assess
its discharge planning process on a regular basis. The assessment must include
ongoing periodic review of a representative sample of discharge
plans.
(k) The LSRH must assist
patients, their families, or the patient's legally authorized representative in
selecting a post-acute care provider by using and sharing data that includes,
but is not limited to, home health agency, skilled nursing facility (SNF),
inpatient rehabilitation facility, or long-term care hospital data on quality
measures and data on resource use measures. The LSRH must ensure that the
post-acute care data on quality measures and data on resource use measures is
relevant and applicable to the patient's goals of care and treatment
preferences.
(l) The LSRH must
discharge the patient, and also transfer or refer the patient where applicable,
along with all necessary medical information pertaining to the patient's
current course of illness and treatment, post-discharge goals of care, and
treatment preferences, at the time of discharge, to the appropriate post-acute
care service providers and suppliers, facilities, agencies, and other
outpatient service providers and practitioners responsible for the patient's
follow-up or ancillary care.
(m) An
LSRH shall comply with Texas Health and Safety Code §
256.003.
(1) Except as provided by paragraph (2) of
this subsection, an LSRH may discharge or release a patient to a group home,
boarding home facility, or similar group-centered facility only if the person
operating the group-centered facility holds a license or permit issued in
accordance with applicable state law.
(2) An LSRH may discharge or release a
patient to a group home, boarding home facility, or similar group-centered
facility operated by a person who does not hold a license or permit issued in
accordance with applicable state law only if:
(A) there is no group-centered facility
operated in the county where the patient is discharged that is operated by a
person holding the applicable license or permit; or
(B) the patient voluntarily chooses to reside
in the group-centered facility operated by an unlicensed or unpermitted
person.
Notes
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No prior version found.