Discharge planning

Section 125 Section 125.50  Discharge planning a)         During the earliest treatment/habilitation planning activities within a State-operated facility, active consideration must be given to the current and anticipated needs of the recipient.  While formal as well as informal planning is conducted with the recipient, the individualized services plan is recorded, as it evolves, in the recipient's record consistent with professional judgment and the provisions set forth in the Code, and Departmental and facility policy.  Establishing and maintaining the recipient's record is first and foremost a necessary practice which contributes to planning for and providing the most appropriate services.  In addition, recordkeeping establishes the necessary documentation which provides an audit trail which is used for a variety of accountability purposes such as securing facility certification and accreditation, responding to judicial inquiries and the assurance of general public accountability. b)         As the facility related treatment and habilitation goals contained in the individualized services plan come closer to realization, greater attention must be paid to numerous DLA related considerations.  Prior to making the decision to discharge and refer a recipient, the recipient's readiness for that move must be assessed as well as the recipient's desire and agreement to participate.  In this assessment, consideration must be given, not only to the desires of the recipient and the recommendations of State-operated facility treatment/habilitation staff, but also the desires and recommendations of the recipient's guardian, family, follow-up monitoring staff, community agency staff previously involved with the recipient or likely to provide services after discharge, and staff of other involved State agencies (such as Department of Public Aid, Department of Children and Family Services, State Board of Education and the Department of Corrections). Agency note:  Recipients who are drug abusers shall be referred to the state Office of Planning and Program Development, Dangerous Drugs Commission. The Commission shall participate in DLA planning and shall be responsible for assuring the treatment/habilitation services, placement and/or follow-up are provided to meet the individual recipient's aftercare needs. c)         The following general areas must be addressed for all recipients regardless of the aftercare setting to which the recipients may be discharged: 1)         The need of the recipient for various services as detailed in the individualized services plan. 2)         The readiness and desires of the recipient or the recipient's guardian. 3)         The recipient's area of origin and/or location of social supports. 4)         The effectiveness of any previous individualized services plans or other services the recipient may have received in the community prior to the last admission to the State-operated facility. 5)         A general assessment of the recipient's intellectual and emotional state including the recipient's behavior. 6)         Medication needs of the recipient. 7)         Special procedures which must be followed related to the legal status of the recipient due to the relationship of the recipient to the criminal justice system.  This includes recipients who are legally classified as: A)        Not guilty by reason of insanity (NGRI); B)        Guilty but mentally ill; C)        Unfit to stand trial, to plead or be sentenced; D)        Hold order from the court. AGENCY NOTE:  These recipients can only be released pursuant to the provisions of the Unified Code of Corrections [730 ILCS 5].  Further clarification on this subject is found in the publication entitled "Responsibilities of DMHDD for Persons Admitted as Unfit to Stand Trial, To Plead or Be Sentenced in Accordance With Public Act 81-1217", December, 1981. 8)         The availability of financial resources for recipients discharged from State-operated facilities including: A)        Consideration of the recipient's ability to be self-supporting; B)        Consideration of other sources of personal or family income; C)        Assisting the recipient who does not return to independent or semi-independent living in accessing necessary financial support, e.g., Supplemental Security Income (SSI), Department of Public Aid, and/or other applicable funding; D)        Reasonable assistance in accessing financial support for recipients returning to independent or semi-independent living. 9)         After considering the factors listed above, a decision may be made to discharge and refer the recipient to available and appropriate aftercare services. 10)         Before the actual discharge is completed the applicable items listed below on the discharge planning check list need to be completed: A)        Secure the recipient's informed consent on form DMHDD-146, "Authorization for Release of Information", in order to communicate and share records with individuals and organizations regarding the recipient. B)        Identify the location, when possible, of the aftercare living situation.  For a recipient being placed in long-term care, the licensed facility shall be identified. C)        Facilitate appropriate contact and linkage with family and/or other individuals who can provide extended social support to the recipient (see Section 125.50(b)). D)        Assist the recipient in accessing necessary financial resources. Special emphasis must be given to this activity when the recipient is not returning to independent or semi-independent living.  In these cases, applicable funding approval, such as the SSI approval letter or Department of Public Aid point count, shall be forwarded to the receiving facility. E)        Refer the recipient to available support services including social, psychological, vocational and transportation, and assist in the actual linkage contact between the aftercare service provider(s) and the recipient. F)         Notify the recipient, guardian, attorney or person who executed the application for admission of the intent to discharge.  Special attention as outlined in Section 125.50(c)(7) must be given to the discharge notification process for recipients who are associated with the criminal justice system. G)        Notice of discharge has been given and any and all written objections relating to it have been heard and an administrative decision has been rendered. H)        Complete part one of form DMHDD-20, "Discharge Summary", by the date of discharge and part two of DMHDD-20, within 48 hours following discharge. For recipients placed in a licensed long-term care facility, the DMHDD-20 must be transmitted at the time of placement. I)         Forward as necessary, any relevant medical or dental reports to the appropriate aftercare agency/facility. J)         Assure the provision of an adequate supply of medication sufficient to last until the first scheduled aftercare visit as contained in the recipient's DLA plan. K)        Forward a copy of the guardianship papers to the aftercare service provider(s) if the recipient is legally incompetent. L)        Assist the recipient in securing personal clothing, property and funds. M)       Complete parts one and two of form DMHDD-189, "Recipient Transfer Summary", for all recipients being placed in a long-term care facility and transmit both parts of the form to the facility at the time of placement. N)        Notify designated mandated follow-up staff of the placement of the recipient in a licensed long-term care facility. O)        Transmit to the ICF/DD facility a copy of a psychological assessment completed within the past 36 months for recipients who are being placed there. P)         Provide placement notification, when such agencies are the funding agencies, to the Department of Public Aid and the Social Security Administration, stating the recipient's name, address of the facility and date of placement.