Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 568 - STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS › Subchapter E - DISCHARGE › Section 568.81 - Discharge Planning

Current through Reg. 49, No. 28; July 12, 2024
(a) Involvement of
				  staff, patient, and legally authorized representative (LAR), when applicable,
				  in planning activities.
(1) Following the
				  admission of a patient to a hospital, the hospital shall conduct discharge
				  planning with the patient and LAR, as well as the LMHA or LBHA if the patient
				  is in a psychiatric inpatient bed funded under a contract with HHSC or operated
				  by or funded under a contract with a LMHA or LBHA.
(2) Discharge planning shall involve the
				  interdisciplinary treatment team (IDT), which includes the patient and LAR, as
				  well as the LMHA or LBHA if the patient is in a psychiatric inpatient bed
				  funded under a contract with HHSC or operated by or funded under a contract
				  with a LMHA or LBHA.
(3) Discharge
				  planning shall include, at a minimum, the following activities:
(A) the patient's IDT recommending services
				  and supports needed by the patient after discharge, including the placement
				  after discharge;
(B) qualified
				  staff members arranging for the services and supports recommended by the
				  patient's IDT;
(C) qualified staff
				  members counseling the patient, the patient's LAR, when applicable, and as
				  appropriate, the patient's caregivers, to prepare them for post-discharge care;
				  and
(D) Preadmission Screening and
				  Resident Review (PASRR) as required by paragraph (5) of this
				  subsection.
(4) The
				  discharge plan shall consist of:
(A) a
				  description of the individual's living arrangement after discharge 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 may receive
				  after discharge. The hospital documents arrangements and referrals for the
				  services and supports recommended upon discharge in the discharge
				  plan;
(D) a description of problems
				  identified at discharge, including any issues that may disrupt the individual's
				  stability in the community;
(E) the
				  individual's goals, strengths, interventions, and objectives as stated in the
				  individual's discharge plan in the hospital;
(F) comments or additional
				  information;
(G) a final diagnosis
				  based on the current edition of the Diagnostic and Statistical Manual of Mental
				  Disorders (DSM) published by the American Psychiatric Association;
(H) the names, contact information, and
				  addresses of providers to whom the individual will be referred for any services
				  or supports after discharge; and
(I) in accordance with Texas Health and
				  Safety Code §
												574.081,
				  a description of:
(i) the types and amount of
				  medication the individual needs after discharge until the individual is
				  evaluated by a physician; and
(ii)
				  the person or entity responsible for providing and paying for the
				  medication.
(5) Screening and evaluation before patient
				  discharge from hospital. In accordance with 42 CFR Part 483, Subpart C
				  (relating to Requirements for Long Term Care Facilities) and the rules set
				  forth in Chapter 303 of this title (relating to Preadmission Screening and
				  Resident Review (PASRR)), all patients who are being considered for discharge
				  from the hospital to a nursing facility shall be screened, and if appropriate,
				  evaluated, before discharge by the hospital and admission to the nursing
				  facility to determine whether the patient may have a mental illness,
				  intellectual disability, or developmental disability. If the screening
				  indicates that the patient has a mental illness, intellectual disability, or
				  developmental disability, the hospital shall contact and arrange for the local
				  mental health authority designated pursuant to Texas Health and Safety Code
				  §
											533.035,
				  to conduct before hospital discharge an evaluation of the patient in accordance
				  with the applicable provisions of the PASRR rules. The purpose of PASRR is:
(A) to ensure that placement of the patient
				  in a nursing facility, is necessary;
(B) to identify alternate placement options,
				  when applicable; and
(C) to
				  identify specialized services that may benefit the person with a diagnosis of
				  mental illness, intellectual disability, or developmental disability.