{"ref":"OH-HH-DC-01","title":"Discharge Planning, Transfer Summaries, and Transitions of Care","category":"Service delivery","summary":"Runs an effective discharge planning process from the start of care: the patient’s goals and preferences guide planning; patients transferring to another home health agency or discharged to a skilled nursing facility, inpatient rehabilitation facility or long-term care hospital are helped to choose a provider using quality and resource use data; necessary medical information goes to the receiving provider; and the discharge summary is sent within 5 business days of discharge and the transfer summary within 2 business days of a planned transfer or of learning of an unplanned one.","inShort":["Plan for discharge from the first visit, around the patient’s goals.","When a patient goes to another home health agency or a nursing or rehabilitation facility, help them choose using quality data, and let them decide.","Send the receiving provider the information it needs, including medications and DNR status.","Send the discharge summary within 5 business days of discharge, and the transfer summary within 2 business days of a transfer or of learning about it."],"primaryCitation":"42 CFR §484.58","citations":["OAC 5160-44-31(B)(20)"],"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 §484.60(c)(3)(ii)","42 CFR §484.55(d)(3)"],"surveyorAsks":["Show me how you planned for this patient’s discharge from the start of care.","This patient went to a skilled nursing facility. How did you help them choose, and what data did you share?"],"forms":[{"ref":"OH-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)","5. Planning for Discharge From the Start of Care","6. Helping the Patient Choose a Post-Acute Provider","7. Information Sent With a Patient Who Transfers","8. Discharge and Transfer Summaries","9. Assessments at Transfer and Discharge","10. Communication at Discharge","11. Responsibilities","12. Records and Compliance Monitoring","13. Staff Training","14. References","15. Related Policies and Forms","16. Approval","17. Revision History"],"version":"1.0","sample":false,"pack":"oh-hha","state":"Ohio","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}}