Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 425.000 - Psychiatric Inpatient Hospital Services › Section 425.418 - Discharge Planning

Current through Register 1525, July 5, 2024
(A) The psychiatric
			 inpatient hospital must assign, in writing, the responsibility for all member
			 discharge planning to one department (such as social services or continuing
			 care).
(B) Admission data,
			 including but not limited to age and diagnosis, must be screened by
			 discharge-planning staff within 24 hours of admission in accordance with
			 written criteria that identify pertinent patient characteristics and any
			 high-risk diagnoses. Discharge-planning activities must then commence within
			 three working days of admission for every member expected to require
			 post-hospital care or services. Admission data must be noted in the member's
			 record by the discharge-planning department. The written criteria used to
			 screen members must be available to the MassHealth agency.
(C) The hospital's discharge-planning staff
			 and interdisciplinary review team must coordinate and document, in writing, a
			 plan for each member who requires post-hospital care. Such plan must be
			 prepared by the hospital's interdisciplinary review team, in conjunction with
			 any primary care provider, DMH, DCF, DYS, or DDS case managers, and must ensure
			 continuity of care with the member's family, school, and community upon
			 discharge. The plan must also specify the services and care required by the
			 member and the frequency, intensity, and duration of such services, including
			 available family and community support. The plan must be updated if the
			 member's condition changes significantly. The hospital must ensure that a
			 clinician certified in accordance with
			 130
			 CMR 425.412 completes a CANS during the
			 discharge planning process for members younger than 21 years old.
(D) The hospital must have a written policy
			 that allows discharge-planning staff access to all members and their medical
			 records. If such access is clinically contraindicated, the member's
			 psychiatrist must sign a statement specifying the reason for the
			 contraindication and the hospital must maintain the statement in the member's
			 medical and discharge-planning records.
(E) Unless clinically contraindicated, the
			 hospital's discharge-planning staff or interdisciplinary review team must
			 contact the member's family to involve them in planning the member's discharge.
			 To this end, family members must be informed of the discharge options and
			 community resources available to the member and provided with lists of
			 community resources in the area.
(F) Each visit to a member or meeting with
			 the family by a member of the discharge-planning staff must be noted in the
			 member's discharge-planning record. The notation must include the date of the
			 meeting, all discharge options discussed, any problems raised and plans for
			 addressing them, all agreements reached with the member, and additional steps
			 required for the discharge-planning staff to prepare the member for
			 discharge.