Page 42 - Policies and Procedures

f. Referrals made;
g. Date, signature, and credentials of the staff member preparing the summary.
h. The level of care which the resident will be discharged to (i.e., psychiatric

services, counseling services or other therapeutic programs, etc.).
i. A listing of all medications that the resident is to continue taking after discharge.
j. All professionals who will follow-up with the resident, including medical follow-

up to monitor medications.
k. Discharge Summaries are communicated to the resident and family, as

appropriate.
l. The therapist will fax the Discharge Summary to the receiving and referring

clinician/agencies within 24 hours.
m. Utilization Management faxes Discharge Summaries to requesting managed care

companies if requested.
n. The resident progress in meeting treatment goals, including treatment goals that

were and were not achieved, are included in the summary.

3. HOPESS will ensure that:

a. A request for participation in developing a resident’s Discharge Summary is
made to the resident or the resident’s representative

b. At the time of discharge a resident receives a referral for treatment for ancillary
services that the resident may need after discharge.

D. Against Facility Advice Discharge

1. When a resident, or his or her guardian, requests for a resident to be discharged AFA,
the therapist will be notified.

2. The resident or guardian will be informed that as soon as possible, the clinical team
will assist the resident/guardian in creating a written aftercare plan and present it to
the resident for the resident/guardian's signature.

3. Efforts will be made to assist the resident and/or legal guardian in identifying his/her
reasons for wanting to leave, the possible consequences for doing so, and the benefits to
be gained by completing the program. If this is refused, the therapist or staff member
will notify the Executive Director.

4. A safety analysis will be conducted. This analysis will include review of the resident’s
history from assessments and treatment documentation. Consultation with friends and/or
family with the resident’s permission in order to determine safety factors before discharge
and to determine resources needed.

5. The AFA Discharge will be documented by the therapist and include reason for
discharge request and efforts to encourage resident to continue needed care.

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HOPESS – Policy and Procedure Manual