Page 41 - Policies

3. Discharge planning must be completed before the discharge occurs and it must be
documented in the resident’s record within 48 hours after the discharge plan is
completed.

4. A copy of the discharge plan must be provided to the resident or the resident’s guardian
before the discharge occurs.

5. All residents should receive a referral for treatment or ancillary services that the resident
may need after discharge.

6. The Discharge Summary consists of the following:
a. Prepare the resident and family/supports for the transition to the next level of

care.

b. Address the resident and family/support needs and the need for continued

treatment.

c. Delineate how progress made in the current level of care will continue after

discharge.

d. Identify problems to be addressed in the next level of care.

e. Identify the responsibility for ensuring that the prescribed follow-up is
accomplished.

f. Include timely and direct communication with and transfer of information to
other programs, agencies, or individuals that will be providing continuing
care.

g. One of the best predictors of sustained response to treatment is compliance
with treatment after discharge. The discharge plan will take into account
the continuation or completion of those treatments which were generated
in the current level of care and the initiation of those treatments which are
needed but were deferred to another level of care.

C. Discharge Summary

1. A discharge summary is a documented brief review of services provided to a resident,
current resident status, and reasons for the resident’s discharge

2. A discharge summary will be completed on all residents and will be placed in the resident
record within 48 hours after discharge. This summary must be completed by a behavioral
health professional or a behavioral health technician. The summary must include:
a. The resident’s presenting issue and other issues identified in the resident’s
assessment, evaluation, final diagnosis and treatment and entered into the service
plan, including issues which were not resolved;
b. A summary of treatment provided and the resident’s progress in meeting
treatment goals. Include all goals that may have not been achieved;
c. Length of time services received;
d. Recommendations for continuing treatment;
e. Date and reason for discharge/termination of services;

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HOPESS – Policy and Procedure Manual