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Discharge Planning, Transfer and Discharge Summaries, and Written Termination Notice

Sets how the Agency plans for discharge from admission, the reasons it may transfer or discharge a patient, and the Florida rule that when it ends services for a patient who still needs care (as the practitioner determines), it develops a plan and makes a referral to another agency or provider before termination and notifies the patient in writing of the date of and reason for termination and the plan for continued services. It covers the discharge visit, Medicare termination notices, transfer to a facility or another agency (including sending a copy of the record on request), the Florida termination summary, and, if the Agency is Medicare-certified, the transfer summary within 2 business days and the discharge summary within 5 business days.

Preview: full text with a package
About this policy
Policy number
FL-HH-DC-01
Version
1.0
Main rule
Rule 59A-8.020(4), F.A.C.
Library
Florida home health · 57 policies
Category
Service delivery
Sections
21

In short

  • Discharge planning starts at admission: tell the patient what goals we are working toward.
  • If a patient still needs care when we stop, we arrange another provider first and give written notice of the date, the reason, and the plan.
  • When nursing is ordered, our employee or contractor makes the discharge visit.
  • Send the needed information when a patient goes to the hospital or another agency, and a copy of the record if the new agency asks.
  • Complete the termination summary for every patient whose services end.

What's inside

21 sections. The full text comes with the One-time Policy Pack.

Full text with a package
  • Terms of Reference
  • 1. Purpose
  • 2. Scope
  • 3. Definitions
  • 4. Policy Statement (Rule 59A-8.020(4), F.A.C.)
  • 5. Discharge Planning Begins at Admission
  • 6. Reasons for Transfer or Discharge
  • 7. Ending Services for a Patient Who Still Needs Care
  • 8. Medicare Notices Before Services End (Medicare-Certified Agency)
  • 9. The Discharge Visit
  • 10. Transfer to a Facility or Another Home Health Agency
  • 11. Termination, Discharge, and Transfer Summaries
  • 12. Death of a Patient
  • 13. Communicating the Discharge
  • 14. Responsibilities
  • 15. Records and Compliance Monitoring
  • 16. Staff Training
  • 17. References
  • 18. Related Policies and Forms
  • 19. Approval
  • 20. Revision History

An inspector may ask

  • This patient was discharged but still needed care. Show me the referral, the plan for continued services, and the written notice you gave.
  • Show me the termination summary: dates of first and last visit, reason, goals, condition, and disposition.

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