{"ref":"PA-HH-DC-01","title":"Discharge Planning, Transfer Summaries, and Transitions of Care","category":"Service delivery","summary":"Sets out how the Agency plans each patient’s discharge from the start of care, helps patients choose a post-acute provider using quality and resource use data, sends the information the next provider needs, prepares the discharge summary that 28 Pa. Code §601.36(a) requires, sends a copy of the record or an abstract with a patient transferred to another home health agency (§601.36(b)), and, if the Agency is Medicare-certified, sends discharge and transfer summaries within the time frames in 42 CFR §484.110(a)(6).","inShort":["Discharge planning starts at admission: the plan of treatment says how and when the patient will be ready to leave.","Help patients choose a nursing facility, rehab facility or another agency using CMS quality data; the choice is theirs.","Send the discharge summary to the patient’s primary care practitioner within 5 business days of discharge.","Send a transfer summary within 2 business days of a planned transfer, or of learning about an unplanned one.","A patient moving to another home health agency goes with a copy of the record or an abstract."],"primaryCitation":"42 CFR §484.58","citations":["28 Pa. Code §601.31(b)","28 Pa. Code §601.34","28 Pa. Code §601.36(a)","28 Pa. Code §601.36(b)","28 Pa. Code §601.36(c)","28 Pa. Code §601.22(c)","55 Pa. Code §1101.51(a)"],"federalCitations":["42 CFR §484.58","42 CFR §484.110(a)(5)","42 CFR §484.110(a)(6)","42 CFR §484.55(d)(3)","42 CFR §484.60(c)(3)(ii)","42 CFR §484.60(d)(5)"],"surveyorAsks":["When does discharge planning start for a patient here?","This patient went to a skilled nursing facility. How did you help her choose one?"],"forms":[{"ref":"PA-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)","5. Discharge Planning From Admission","6. Helping the Patient Choose a Post-Acute Provider","7. Discharge Assessment and Summary","8. Transfers to a Hospital or Other Facility","9. Transfers to Another Home Health Agency","10. Consent and Confidentiality","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":"pa-hha","state":"Pennsylvania","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}}