2023 California Code › Health and Safety Code - HSC › DIVISION 2 - LICENSING PROVISIONS › CHAPTER 2.4 - Quality of Long-Term Health Facilities › Section 1418.81.

1418.81. (a)  In order to assure the provision of quality patient care and as part of the planning for that quality patient care, commencing at the time of admission, a skilled nursing facility, as defined in subdivision (c) of Section 1250, shall include in a resident’s care assessment the resident’s projected length of stay and the resident’s discharge potential. The assessment shall include whether the resident has expressed or indicated a preference to return to the community and whether the resident has social support, such as family, that may help to facilitate and sustain return to the community. The assessment shall be recorded with the relevant portions of the minimum data set, as described in Section 14110.15 of the Welfare and Institutions Code. The plan of care shall reflect, if applicable, the care ordered by the attending physician needed to assist the resident in achieving the resident’s preference of return to the community.
(b)  The skilled nursing facility shall evaluate the resident’s discharge potential at least quarterly or upon a significant change in the resident’s medical condition.
(c)  The interdisciplinary team shall oversee the care of the resident utilizing a team approach to assessment and care planning and shall include the resident’s attending physician, a registered professional nurse with responsibility for the resident, other appropriate staff in disciplines as determined by the resident’s needs, and, where practicable, a resident’s representative, in accordance with applicable federal and state requirements.
(d)  If return to the community is part of the care plan, the facility shall provide to the resident or responsible party and document in the care plan the information concerning services and resources in the community. That information may include information concerning:
(1)  In-home supportive services provided by a public authority or other legally recognized entity, if any.
(2)  Services provided by the Area Agency on Aging, if any.
(3)  Resources available through an independent living center.
(4)  Other resources or services in the community available to support return to the community.
(e)  If the resident is otherwise eligible, a skilled nursing facility shall make, to the extent services are available in the community, a reasonable attempt to assist a resident who has a preference for return to the community and who has been determined to be able to do so by the attending physician, to obtain assistance within existing programs, including appropriate case management services, in order to facilitate return to the community. The targeted case management services provided by entities other than the skilled nursing facility shall be intended to facilitate and sustain return to the community.
(f)  Costs to skilled nursing facilities to comply with this section shall be allowable for Medi-Cal reimbursement purposes pursuant to Section 1324.25, but shall not be considered a new state mandate under Section 14126.023 of the Welfare and Institutions Code.
(Added by Stats. 2004, Ch. 875, Sec. 2. Effective September 29, 2004.)