10A NCAC 13B .5406      DISCHARGE CRITERIA FOR INPATIENT REHABILITATION FACILITIES OR UNITS

(a)  Discharge planning shall be an integral part of the patient's treatment plan and shall begin upon admission to the facility.  After established goals have been reached, or a determination has been made that care in a less intensive setting would be appropriate, or that further progress is unlikely, the patient shall be discharged to an appropriate setting.  Other reasons for discharge may include an inability or unwillingness of patient or family to cooperate with the planned therapeutic program or medical complications that preclude a further intensive rehabilitative effort.  The facility shall involve the patient, family, staff members and referral sources in discharge planning.

(b)  The case manager shall facilitate the discharge or transfer process in coordination with the facility social worker.

(c)  If a patient is being referred to another facility for further care, appropriate documentation of the patient's current status shall be forwarded with the patient.  A formal discharge summary shall be forwarded within 48 hours following discharge and shall include the reasons for referral, the diagnosis, functional limitations, services provided, the results of services, referral action recommendations and activities and procedures used by the patient to maintain and improve functioning.

 

History Note:        Authority G.S. 131E-79;

Eff. March 1, 1996.