Discharge Planning, Transfer Summaries, and Transitions of Care
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).
About this policy
- Policy number
- PA-HH-DC-01
- Version
- 1.0
- Main rule
- 42 CFR §484.58
- Library
- Pennsylvania home health · 56 policies
- Category
- Service delivery
- Sections
- 18
In short
- 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.
What's inside
18 sections. The full text comes with the One-time Policy Pack.
- 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
An inspector may ask
- When does discharge planning start for a patient here?
- This patient went to a skilled nursing facility. How did you help her choose one?
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