{"ref":"MO-HH-DC-01","title":"Discharge Planning, Transfer, and Transition Summaries","category":"Service delivery","summary":"Sets out the Agency's discharge planning process from admission onward: helping patients transferred to another home health agency or discharged to a SNF, IRF or LTCH choose a post-acute care provider using quality and resource use data, the steps for a planned discharge, sending all necessary medical information to the receiving provider, the discharge summary within 5 business days of discharge, transfer summaries within 2 business days of a planned or (once known) unplanned transfer, answering requests for more information, and discharge at death.","inShort":["Plan for discharge from the first visit, and keep the after-discharge practitioner's contact in the record.","Help patients choose a nursing facility or another agency using quality data, and respect their choice.","Send the discharge summary within 5 business days of discharge.","Send a transfer summary within 2 business days of a planned transfer, or of learning of a hospital admission.","Tell the case manager the same day if you learn a patient went to the hospital."],"primaryCitation":"42 CFR §484.58 (adopted by 19 CSR 30-26.010(1)(A))","citations":["19 CSR 30-26.010(1)(A)","RSMo §190.603.4"],"federalCitations":["42 CFR §484.58","42 CFR §484.110(a)(5)","42 CFR §484.110(a)(6)","42 CFR §484.60(a)(2)(xiii)","42 CFR §484.60(c)(3)(ii)","42 CFR §484.55(d)(3)","42 CFR §484.50(d)"],"surveyorAsks":["Show me the discharge summary for this patient. When was the patient discharged, and when was the summary sent, and to whom?","This patient went to the hospital. When did you learn of it, and when was the transfer summary sent?"],"forms":[{"ref":"MO-HH-DC-01-A","title":"Discharge or Transfer Summary"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §484.58; 42 CFR §484.110(a)(5), (6); 19 CSR 30-26.010(1)(A))","5. Discharge Planning Starts at Admission","6. Choosing a Post-Acute Care Provider","7. Planned Discharge","8. The Discharge Summary","9. Transfer to a Health Care Facility","10. Transfer to Another Home Health Agency or to Hospice","11. Discharge at Death","12. Responsibilities","13. Records and Compliance Monitoring","14. Staff Training","15. References","16. Related Policies and Forms","17. Approval","18. Revision History"],"version":"1.0","sample":false,"pack":"mo-hha","state":"Missouri","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}}