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Discharge Planning, Transfer, and Discharge Summaries

Requires the Agency to plan for discharge from the start of care, help patients who are moving to another home health agency or to a skilled nursing, inpatient rehabilitation, or long-term care hospital choose a provider using quality and resource use data, send a copy of the record or an abstract with a patient who transfers, send the attending physician a summary report at discharge, and, if the Agency is Medicare-certified, send discharge and transfer summaries within the federal time frames.

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About this policy
Policy number
GA-HH-DC-01
Version
1.0
Main rule
42 CFR §484.58
Library
Georgia home health · 56 policies
Category
Service delivery
Sections
17

In short

  • Planning for discharge starts at the first visit. Teach the patient and family what they will need to manage after we leave.
  • When a patient transfers to another agency or a facility, a copy of the record or a summary goes with them.
  • The patient’s doctor gets a discharge summary within 5 business days of discharge.
  • If a patient goes to a nursing facility or another agency, help them choose using quality information, and respect their choice.

What's inside

17 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 (42 CFR §484.58 and Ga. Comp. R. & Regs. 111-8-31-.09(d))
  • 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. Responsibilities
  • 11. Records and Compliance Monitoring
  • 12. Staff Training
  • 13. References
  • 14. Related Policies and Forms
  • 15. Approval
  • 16. Revision History

An inspector may ask

  • Show me where discharge planning started in this patient’s plan of treatment.
  • This patient went to a nursing facility. What did you send with the patient, and when?

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