{"ref":"DC-HH-DC-01","title":"Discharge Planning, Transfer, and Discharge Summaries","category":"Service delivery","summary":"Sets the Agency’s written criteria and procedures for transfer, discharge, and referral; requires discharge planning from admission, documented in the record; sets how transfers to other providers, unplanned hospital admissions, and DC Medicaid provider changes are handled; and requires a discharge summary stating the reason and effective date, sent (if the Agency is Medicare-certified, and as the Agency’s standard for all patients) within 5 business days of discharge, or a transfer summary within 2 business days.","inShort":["Discharge planning starts at admission. Teach the patient and family what they need to manage after we leave.","Get the physician’s agreement before a planned discharge, and help the patient choose the next provider.","Send the discharge summary within 5 business days of discharge, and a transfer summary within 2 business days of a transfer.","If a patient goes into the hospital, tell the case manager the same day.","DC Medicaid personal care: keep serving a beneficiary who is changing providers until the new provider has started."],"primaryCitation":"22-B DCMR §3909.1","citations":["22-B DCMR §3909.1","22-B DCMR §3909.3","22-B DCMR §3911.2","22-B DCMR §3914.3","22-B DCMR §3917.2","22-B DCMR §3925.3","22-B DCMR §3910.4","29 DCMR §5006.9","29 DCMR §5006.13","29 DCMR §5007.7","29 DCMR §5007.9","29 DCMR §5013.1","29 DCMR §5013.6","29 DCMR §4205.2","29 DCMR §4205.9"],"federalCitations":["42 CFR §484.58","42 CFR §484.58(a)","42 CFR §484.58(b)","42 CFR §484.110(a)(5)","42 CFR §484.110(a)(6)","42 CFR §484.55(d)(3)","42 CFR §484.60(c)(3)","42 CFR §484.50(d)"],"surveyorAsks":["Show me this patient’s discharge planning. When did it start, and who took part?","Show me the discharge summary. Does it give the reason for ending services and the effective date?"],"forms":[{"ref":"DC-HH-DC-01-A","title":"Discharge or Transfer Summary"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (22-B DCMR §3909.1, §3909.3)","5. Discharge Planning from Admission","6. Criteria for Transfer, Discharge, and Referral","7. Planning a Discharge or Transfer","8. Unplanned Transfers to a Hospital or Other Facility","9. Discharge and Transfer Summaries","10. DC Medicaid Beneficiaries Who Change Providers","11. Death of a Patient","12. Closing the Record","13. Responsibilities","14. Records and Compliance Monitoring","15. Staff Training","16. References","17. Related Policies and Forms","18. Approval","19. Revision History"],"version":"1.0","sample":false,"pack":"dc-hha","state":"Washington, DC","service":"Home health","guides":[{"path":"/guides/home-health-agency-policies/","h1":"What policies and procedures are required for home health agencies?"},{"path":"/guides/home-health-conditions-of-participation/","h1":"Home health Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}