12VAC35-105-693: Discharge

A. The provider shall have written policies and procedures regarding the discharge or termination of individuals from the service. These policies and procedures shall include medical and clinical criteria for discharge.

B. Discharge instructions shall be provided in writing to the individual, the individual's authorized representative, and the successor provider, as applicable. At a minimum, discharge instructions shall include medications and dosages, if applicable; names, telephone numbers, and addresses of any successor providers to whom the individual is referred; current medical issues or conditions; and the identity of the individual's treating health care practitioners.

C. The provider shall make appropriate arrangements or referrals to all services or successor providers identified in the discharge plan prior to the individual's scheduled discharge date.

D. The content of the discharge plan and the determination to discharge the individual shall be consistent with the ISP and the criteria for discharge.

E. The provider shall complete a written discharge summary within 30 days of discharge that includes, at a minimum, the following:

1. Reason for the individual's admission to and discharge from the service;

2. Description of participation by the individual or the individual's authorized representative in discharge planning;

3. The individual's current level of functioning or functioning limitations, if applicable;

4. Recommended procedures, activities, or referrals to assist the individual in maintaining or improving functioning and increased independence;

5. The status, location, and arrangements that were made for future services;

6. Progress made by the individual in achieving goals and objectives identified in the ISP and a summary of critical events during service provision;

7. Date of discharge and when the discharge summary was actually written or documented; and

8. Signature of the provider's employee or contractor responsible for preparing the discharge summary.

F. This section does not apply to crisis services as crisis services shall comply with Part VIII of this chapter.