26 Tex. Admin. Code § 306.201 - Discharge Planning
(a) At the time of
an individual's admission to a state hospital or CPB, the designated LMHA or
LBHA, if applicable, and the state hospital or CPB must begin discharge
planning for the individual. The state hospital or CPB must send an electronic
admission initial notification within three business days to the appropriate
LMHA, LBHA, and LIDDA to initiate discharge planning.
(b) The designated LMHA or LBHA CoC liaison
or other designated staff; the designated LIDDA continuity of care worker, if
applicable; the individual; the LAR, if applicable; and any other person
authorized by the individual, such as guardian ad litem or attorney ad litem,
must participate in discharge planning with the state hospital or CPB. The
state hospital or CPB must initiate coordination of discharge planning.
(1) Except for the state hospital or CPB
treatment team and the individual, involvement in discharge planning may be
through teleconference or video-conference calls.
(2) The state hospital or CPB must invite the
LMHA, LBHA, or LIDDA, as applicable, to routine recovery or treatment plan
meetings as well as any additional meetings that arise specific to discharge
planning. The state hospital or CPB must notify meeting participants a minimum
of 24 hours before each scheduled meeting regarding recovery or treatment
planning and any additional meetings specific to discharge planning.
(3) The state hospital or CPB must ensure the
development and completion of the discharge plan as listed in subsection (c) of
this section and coordinate with the LMHA, LBHA, or LIDDA, if applicable,
before the individual's discharge.
(4) The LMHA or LBHA must facilitate the
transition of individuals who are determined by the state hospital or CPB to be
medically appropriate for discharge in accordance with Texas Health and Safety
Code §
534.0535 from
a facility to a community setting by connecting the individuals to resources
available in the individuals' county of residence or choice.
(c) Discharge planning must
consist of the following activities:
(1)
Considering all pertinent information about the individual's clinical needs,
the state hospital or CPB must identify and recommend specific clinical
services and supports needed by the individual after discharge or while on pass
or furlough.
(2) The state hospital
or CPB and the LMHA, LBHA, or LIDDA, if applicable, must jointly identify,
recommend, and help coordinate access to services for the individual and LAR,
if applicable, regarding specific non-clinical services and supports needed by
the individual after discharge, including the individual's need for housing,
supported employment, education resources, and food assistance, clothing
resources, and other supplemental supports or governmental benefits as
applicable.
(3) If an individual
needs a living arrangement, the LMHA or LBHA CoC liaison or LIDDA continuity of
care worker must:
(A) identify a living
arrangement consistent with the individual's clinical needs and preference that
is available and has accessible services and supports as agreed upon by the
individual or LAR; or
(B) ensure
the individual or LAR is referred to housing services and support the
individual through the process of obtaining and applying for housing services
during the discharge planning process if a living arrangement is
unavailable.
(4) The
LMHA or LBHA CoC liaison or LIDDA continuity of care worker in collaboration
with the individual and LAR, if applicable, must identify potential providers
and resources for the recommended services and supports and arrange for
provision of services upon discharge in accordance with Texas Health and Safety
Code §
534.0535.
(5) The state hospital or CPB must attempt to
educate the individual and LAR, if applicable, to prepare the individual for
care after discharge or while on pass or furlough.
(6) The state hospital or CPB must provide
the individual and LAR, if applicable, with written notification of the
existence, purpose, telephone number, and address of the protection and
advocacy system established in Texas, pursuant to Texas Health and Safety Code
§
576.008.
(7) The LMHA, LBHA, or LIDDA must comply with
the PASRR processes as described in Chapter 303 of this title (relating to
Preadmission Screening and Resident Review (PASRR)) for an individual referred
to a nursing facility.
(d) Before an individual's discharge or
approval for a pass or furlough:
(1) the
individual's treatment team must ensure the development of a plan to include
the individual's stated goals. The plan must consist of:
(A) a description of the individual's living
arrangement after discharge, or while on pass or furlough, that reflects the
individual's preferences, choices, and available community resources;
(B) arrangements and referrals for the
available and accessible services and supports agreed upon by the individual or
LAR recommended in the individual's discharge plan;
(C) a written description of recommended
clinical and non-clinical services and supports the individual receives after
discharge or while on pass or furlough;
(D) documentation of arrangements and
referrals for the services and supports recommended upon discharge or while on
pass or furlough.
(E) a description
of behavioral health symptoms identified at discharge or before a pass or
furlough, including any symptoms that may disrupt the individual's stability in
the community;
(F) the individual's
goals, strengths, interventions, and objectives as stated in the individual's
discharge plan in the state hospital or CPB;
(G) comments or additional
information;
(H) a final diagnosis
based on the version of the DSM currently recognized by HHSC;
(I) the names, contact information, and
addresses of providers to whom the individual will be referred for any services
or supports after discharge or while on pass or furlough; and
(J) a description of:
(i) the types and amount of medication the
individual needs after discharge or while on pass or furlough until the
individual is evaluated by a physician; or
(ii) for 90 days after discharge, the person
or entity responsible for providing and paying for the medication.
(2) The state hospital
or CPB must request that the individual or LAR sign the discharge plan and
document in the discharge plan whether the individual or LAR agree or disagree
with the plan.
(3) If the
individual or LAR refuses to sign the discharge plan described in paragraph (2)
of this subsection, the state hospital or CPB must document in the individual's
record whether the individual or LAR agrees to the plan or not, reasons stated,
and any other circumstances of the refusal.
(4) If applicable, the individual's treating
physician must document in the individual's record reasons why the individual
does not require continuing care or a discharge plan.
(5) If the LMHA or LBHA disagrees with the
state hospital or CPB treatment team's decision concerning discharge:
(A) the treating physician of the state
hospital or CPB must consult with the LMHA or LBHA physician or designee to
resolve the disagreement within 24 hours; and
(B) if the disagreement continues unresolved,
the medical director or designee of the state hospital or CPB must refer the
issue to the Texas State Hospitals Chief Medical Officer to render a final
determination.
(e) Discharge notice to family or LAR.
(1) In accordance with Texas Health and
Safety Code §
576.007,
before discharging an adult, the state hospital or CPB must make a reasonable
effort to notify the individual's family or any identified person providing
support to the individual. Discharge notification requires authorization by the
individual or LAR.
(2) Before
discharging an individual who is at least 16 years of age, but younger than 18
years of age, who voluntarily consented for the individual's own admission, the
state hospital or CPB must make a reasonable effort to notify the individual's
LAR, if applicable, of the discharge within 72 hours before the date of
discharge.
(3) Before discharging a
minor for whom a parent, managing conservator, or guardian provided consent for
admission, the state hospital or CPB must notify the minor's LAR of the
discharge.
(f) Release
of minors. Upon discharge, the state hospital or CPB may release a minor only
to the minor's LAR or the LAR's designee.
(1)
If the LAR or the LAR's designee is unwilling to retrieve the minor from the
state hospital or CPB and the LAR is not a state agency:
(A) the state hospital or CPB must:
(i) notify DFPS, so DFPS can take custody of
the minor from the state hospital or CPB;
(ii) refer the matter to the LMHA or LBHA to
schedule a meeting with representatives from the required agencies described in
subsection (f)(2)(A) of this section, the LAR, and minor to explore resources
and make recommendations;
(iii)
document the LMHA or LBHA referral in the discharge plan;
(iv) refer the matter to the local CRCG to
schedule a meeting with representation from the required agencies described in
subsection (f)(2)(A) of this section, the LAR, and the minor to explore
resources and make recommendations; and
(v) document the CRCG referral in the
discharge plan; and
(B)
the medical directors or the medical directors' designees of the state hospital
or CPB; designated LMHA, LBHA, or LIDDA; and DFPS must meet to develop and
finalize the discharge recommendations.
(2) If the LAR is a state agency unwilling to
assume physical custody of the minor from the state hospital or CPB, the state
hospital or CPB must:
(A) refer the matter to
the local CRCG office, or state CRCG office if applicable, to schedule a
meeting with representatives from the member agencies, in accordance with 40
TAC, Part 19, Chapter 702, Subchapter E (relating to Memorandum of
Understanding with Other State Agencies), the LAR, and minor to explore
resources and make recommendations; and
(B) document the CRCG referral in the
discharge plan.
(g) Notice to the designated LMHA, LBHA, or
LIDDA. At least 24 hours before an individual's planned discharge, pass, or
furlough, and no later than 24 hours after an unexpected discharge, a state
hospital or CPB must notify the designated LMHA, LBHA, or LIDDA of the
anticipated or unexpected discharge and convey the following information about
the individual:
(1) identifying information,
including address and contact information of the individual or LAR;
(2) legal status, for example, regarding
guardianship, charges pending, or custody if the individual is a
minor;
(3) the day and time the
individual will be discharged or participating in a pass or furlough;
(4) the individual's destination address
after discharge, or while on pass or furlough;
(5) medical information;
(6) current medications;
(7) clinical documentation, including
information regarding a COPSD, an ID, or a DD; and
(8) other pertinent treatment information,
including the discharge plan.
(h) Discharge packet.
(1) At a minimum, a discharge packet must
include:
(A) the discharge plan;
(B) referral instructions, including:
(i) state hospital or CPB contact
person;
(ii) name of the designated
LMHA or LBHA CoC liaison or LIDDA continuity of care worker;
(iii) names of community resources and
providers to whom the individual is referred, including contacts, appointment
dates and times, addresses, and phone numbers;
(iv) a description of to whom or where the
individual is released upon discharge, including the individual's intended
residence, address, and phone number;
(v) instructions for the individual or
LAR;
(vi) medication regimen and
prescriptions, as applicable; and
(vii) dated signature of the individual or
LAR and a member of the state hospital or CPB treatment team;
(C) copies of all available,
pertinent, current summaries, and assessments; and
(D) the treating physician's
orders.
(2) At
discharge, or while on pass or furlough, the state hospital or CPB provides a
copy of the discharge packet or pass or furlough plan to the individual and
LAR, if applicable. An individual or LAR may request additional
records.
(3) Within 24 hours after
discharge, or while on pass or furlough, the state hospital or CPB must send a
copy of the discharge packet or pass or furlough plan to:
(A) the designated LMHA, LBHA, or LIDDA;
and
(B) the providers to whom the
individual is referred, including:
(i) an LMHA
or LBHA network provider, if the LMHA or LBHA is responsible for ensuring the
individual's services after discharge or while on pass or furlough;
(ii) an alternate provider if the individual
requested referral to an alternate provider; and
(iii) a county jail if the individual will be
transported to the county jail upon discharge.
(i) Unexpected Discharge.
(1) The state hospital or CPB and the
designated LMHA, LBHA, or LIDDA must make reasonable efforts to provide
discharge planning for an individual discharged unexpectedly.
(2) If there is an unexpected discharge, the
state hospital or CPB social worker or a designee must document the reason for
not completing discharge planning activities in the individual's
record.
(j)
Transportation. A state hospital or CPB must:
(1) initiate and secure transportation in
collaboration with an LMHA, an LBHA, or a LIDDA pursuant to an individual's
discharge or pass or furlough plan; and
(2) inform a designated LMHA, LBHA, or LIDDA
of an individual's transportation needs after discharge or while on pass or
furlough.
(k) Discharge
summary.
(1) Within ten days after an
individual's discharge, the individual's physician of the state hospital or CPB
must complete a written discharge summary for the individual.
(2) Within 21 days after an individual's
discharge from an LMHA or LBHA, the LMHA or LBHA must complete a written
discharge summary for the individual.
(3) The written discharge summary must
include:
(A) a description of the individual's
treatment and the individual's response to that treatment;
(B) a description of the level of care for
services received;
(C) a
description of the individual's level of functioning at discharge;
(D) a description of the individual's living
arrangement after discharge;
(E) a
description of the community services and supports the individual will receive
after discharge;
(F) a final
diagnosis based on the version of the DSM currently recognized by HHSC;
and
(G) a description of the amount
of medication available to the individual, if applicable.
(4) The discharge summary must be sent to the
individual's:
(A) designated LMHA, LBHA, or
LIDDA, as applicable; and
(B)
providers to whom the individual was referred.
(5) Documentation of refusal. If the
individual or LAR refuses to participate in the discharge planning, the
circumstances of the refusal must be documented in the individual's record.
(l) An LMHA or LBHA
must provide continuity of care services designed to support joint discharge
planning efforts in accordance with Texas Health and Safety Code §
534.0535.
Notes
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No prior version found.