{"ref":"NC-HH-DC-01","title":"Discharge Planning, Transfer, and Discharge and Transfer Summaries","category":"Service delivery","summary":"Requires discharge planning from the start of care, help in choosing a post-acute provider using quality and resource-use data, a discharge assessment, and a discharge summary that gives an overall summary of services and the date and reason for discharge, sent to the follow-up practitioner within 5 business days; a transfer summary sent within 2 business days of a planned transfer or of learning of an unplanned one; and documentation of the date and reason whenever one service ends while others continue.","inShort":["Plan for discharge from the first visit and teach the patient and family what they need to manage at home.","Help patients choose a nursing facility or another agency using quality data, and respect their choice.","Send the discharge summary to the patient’s follow-up doctor within 5 business days.","Send a transfer summary within 2 business days of a planned transfer or of learning of a hospital admission.","When one service ends but others continue, write down the date and reason."],"primaryCitation":"42 CFR §484.58","citations":["10A NCAC 13J .1001(a)(2)","10A NCAC 13J .1004(c)","10A NCAC 13J .1103(c)","10A NCAC 13J .1105(c)","10A NCAC 13J .1402(a)(2)","NC Medicaid Clinical Coverage Policy 3A"],"federalCitations":["42 CFR §484.58","42 CFR §484.110(a)(6)","42 CFR §484.60(c)(3)","42 CFR §484.55(d)(3)"],"surveyorAsks":["This patient was discharged last month. Show me the discharge summary and when you sent it to the primary care practitioner.","This patient went to the hospital unexpectedly. When did you learn of it, and when did you send the transfer summary?"],"forms":[{"ref":"NC-HH-DC-01-A","title":"Transfer and Discharge Summary"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §484.58; 42 CFR §484.110(a)(6); 10A NCAC 13J .1402(a)(2)(D))","5. Discharge Planning From the Start of Care","6. Helping the Patient Choose a Post-Acute Provider","7. The Discharge Assessment and Visit","8. Discharge Summary","8.1 Content","8.2 Sending it","9. Transfer Summary","10. When One Service Ends and Others Continue","11. Death of a Patient","12. Reasons for Discharge in the Annual Evaluation","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":"nc-hha","state":"North Carolina","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}}