Page 85 - Business Development Orientation Binder

Applies to: VNSNY Certified Home Health Agency
Service: VNSNY Certified Home Health Agency
Procedure Section: Provider Service Administration
Number: CP.164
Page 1 of 5

TITLE: DISCHARGE, TERMINATION OR TRANSFER FROM SERVICE

PURPOSE:

To delineate process to ensure an appropriate, timely and safe discharge and transition
for the patient to the community or other health care provider to ensure continuity of
care.

KEY POINTS
A discharge plan shall be initiated prior to agency discharge to assure a timely, safe and
appropriate transition for the patient.

A patient may be discharged from services per agency discharge criteria noted in
Policy: Discharge, termination criteria.

PROCEDURE:

A. Clinician’s responsibilities when planning patient discharge

1. The clinician identifies discharge goal at admission and plots all anticipated visits
including planned discharge visit on the patient calendar
a) For planned discharges, a discharge visit (service code18) must be
scheduled to perform discharge OASIS assessment.
b) For “early” or unplanned discharges, clinician must write a discharge order
and CFM must review and approve it before type 18 visit (DC OASIS) is
plotted on the calendar and is assigned to a clinician. If it impossible to visit a
patient, type 66 (Discharge OASIS, No Visit) is completed by qualified skilled
clinician who saw the patient last based on the patient status during that last
skilled visit.
c) The discharge OASIS must be performed within 48 hours of the discharge
date or knowledge of need to discharge
d) All discharges must be approved by Clinical Field Manager (CFM).
e) Discharge OASIS data is reviewed, edited and locked by Clinical Review
Manager (CRM)

Responsibility: Quality Management Services-Homecare
Procedure date:
Revised: 6/2015, 12/2016, 12/2017, 12/2018
Approval: Senior Vice President Patient Care Service