Discharge Planning, Transfer, and Discharge Summaries
Sets the Agency’s written criteria and procedures for transfer, discharge, and referral; requires discharge planning from admission, documented in the record; sets how transfers to other providers, unplanned hospital admissions, and DC Medicaid provider changes are handled; and requires a discharge summary stating the reason and effective date, sent (if the Agency is Medicare-certified, and as the Agency’s standard for all patients) within 5 business days of discharge, or a transfer summary within 2 business days.
About this policy
- Policy number
- DC-HH-DC-01
- Version
- 1.0
- Main rule
- 22-B DCMR §3909.1
- Library
- Washington, DC home health · 58 policies
- Category
- Service delivery
- Sections
- 20
In short
- Discharge planning starts at admission. Teach the patient and family what they need to manage after we leave.
- Get the physician’s agreement before a planned discharge, and help the patient choose the next provider.
- Send the discharge summary within 5 business days of discharge, and a transfer summary within 2 business days of a transfer.
- If a patient goes into the hospital, tell the case manager the same day.
- DC Medicaid personal care: keep serving a beneficiary who is changing providers until the new provider has started.
What's inside
20 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (22-B DCMR §3909.1, §3909.3)
- 5. Discharge Planning from Admission
- 6. Criteria for Transfer, Discharge, and Referral
- 7. Planning a Discharge or Transfer
- 8. Unplanned Transfers to a Hospital or Other Facility
- 9. Discharge and Transfer Summaries
- 10. DC Medicaid Beneficiaries Who Change Providers
- 11. Death of a Patient
- 12. Closing the Record
- 13. Responsibilities
- 14. Records and Compliance Monitoring
- 15. Staff Training
- 16. References
- 17. Related Policies and Forms
- 18. Approval
- 19. Revision History
An inspector may ask
- Show me this patient’s discharge planning. When did it start, and who took part?
- Show me the discharge summary. Does it give the reason for ending services and the effective date?
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