Ala. Admin. Code r. 420-5-7-.25

Current through Register Vol. 43, No. 1, October 31, 2024

Section 420-5-7-.25 - Discharge Planning

(1) The hospital shall have in effect a discharge planning process that applies to all patients. The hospital's policies and procedures shall be specified in writing.

(2) Identification of patients in need of discharge planning. The hospital shall identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning.

(3) Discharge planning evaluation.

(a) The hospital shall provide a discharge planning evaluation to the patients identified in paragraph (2) of this rule, and to other patients upon the patient's request, the request of a person acting on the patient's behalf, or the request of the physician.

(b) A registered nurse, social worker, or other appropriately qualified personnel shall develop, or supervise the development of, the evaluation.

(c) The discharge planning evaluation shall include an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services.

(d) The discharge planning evaluation shall include an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he or she entered the hospital.

(e) Hospital personnel shall complete the evaluation on a timely basis so that appropriate arrangements for post-hospital care are made before discharge, and to avoid unnecessary delays in discharge.

(f) The hospital shall include the discharge planning evaluation in the patient's medical record for use in establishing an appropriate discharge plan and shall discuss the results of the evaluation with the patient or individual acting on his or her behalf.

(4) Discharge plan.

(a) A registered nurse, social worker, or other appropriately qualified personnel shall develop, or supervise the development of, a discharge plan if the discharge planning evaluation indicates a need for a discharge plan.

(b) In the absence of a finding by the hospital that a patient needs a discharge plan, the patient's physician may request a discharge plan. In such a case, the hospital shall develop a discharge plan for the patient.

(c) The hospital shall arrange for the initial implementation of the patient's discharge plan.

(d) The hospital shall reassess the patient's discharge plan if there are factors that may affect continuing care needs or the appropriateness of the discharge plan.

(e) As needed, the patient and family members or interested persons shall be counseled to prepare them for post-hospital care.

(5) Transfer or referral. The hospital shall transfer or refer patients, along with necessary medical information, to appropriate licensed facilities, agencies, or outpatient services, as needed, for follow up or ancillary care. In no event shall the hospital knowingly transfer or refer a patient to an unlicensed health care facility in violation of § 22-21-33(b), Code of Ala. 1975.

(6) Reassessment. The hospital shall reassess its discharge planning process on an on-going basis. The reassessment shall include a review of discharge plans to ensure that they are responsive to discharge needs.

Ala. Admin. Code r. 420-5-7-.25

New Rule: Filed November 18, 1994; effective December 23, 1994. Repealed and New Rule: Filed August 24, 2012; effective September 28, 2012.

Author: W.T. Geary, Jr., M.D., Carter Sims

Statutory Authority:Code of Ala. 1975, §§ 22-21-20, et seq.