(a) Discharge planning. The facility must develop and implement an effective discharge planning process.
  (1) The facility's discharge planning process must:
    (A) ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident;
    (B) include regular re-evaluation of a resident to identify changes that require modification of the discharge plan and update the discharge plan to reflect these changes;
    (C) involve the interdisciplinary team in the ongoing process of developing the discharge plan;
    (D) consider caregiver or support person availability and the resident's or caregiver's or support person's capacity and capability to perform required care, as part of the identification of discharge needs;
    (E) involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan;
    (F) address the resident's goals of care and treatment preferences; and
    (G) document that a resident has been asked about their interest in receiving information regarding returning to the community.
      (i) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose.
      (ii) Facilities must update a resident's comprehensive care plan and discharge plan as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities.
      (iii) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why.
  (2) The evaluation of the resident's discharge needs and discharge plan must be completed on a timely basis and documented in the resident's clinical record.
  (3) The results of the evaluation of the resident's discharge needs and discharge plan must be discussed with the resident or the resident representative.
(b) When a facility anticipates a resident's discharge, the facility must develop a discharge summary that includes:
  (1) a recapitulation of the overall course of the resident's stay that includes diagnoses, course of illness, treatment, or therapy and pertinent lab, radiology, and consultation results, a final summary of the resident's status;
  (2) reconciliation or all pre-discharge medications with the resident's post-discharge medications both prescribed and over-the-counter;
  (3) a statement notifying a resident granted permanent medical necessity (PMN) under the Medicaid program that:
    (A) PMN status continues after discharge, unless the resident is discharged to home;
    (B) PMN status expires 30 consecutive days after the resident is discharged to home; and
    (C) a new medical necessity determination is required if the resident applies to be admitted to a nursing facility under the Medicaid program more than 30 consecutive days after the resident moves home from a nursing facility; and
  (4) a post-discharge care plan, developed with the participation of the resident and a resident representative that:
    (A) will assist the resident to adjust to the new living environment; and
    (B) indicates where the resident plans to reside and arrangements that have been made for follow-up care and any post discharge medical and non-medical services.
(c) The facility discharge summary must be available for release to authorized persons, facilities or agencies with the consent of the resident or resident representative.

Source Note: The provisions of this §554.803 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective August 31, 2015, 40 TexReg 5461; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871