Discharge Plan

(A) Each patient determined to need assistance with arrangements for post-hospital care shall have a comprehensive, individualized discharge plan, which is in writing and is consistent with medical discharge orders and identified patient needs. A discharge plan for patients treated in the emergency department of an acute hospital shall mean a plan that addresses the specific problem for which the patient is seen in the emergency department. Except for the requirements of 105 CMR 130.343(B) and (D) through (F), the requirements of 105 CMR 130.342 do not apply to Medicare patients who are transferred from the emergency department of one acute hospital to another acute hospital and to a Medicare patient residing in a nursing home who, after treatment in an emergency department, is returned back to that nursing home provided appropriate transfer/referral forms are properlycompleted to include information to assure continuity of care. The plan shall include at least the following information: (1) identification of the post hospital services needed by the patient including home health and homemaker service, and of the post-hospital social needs of the patient, as determined in accordance with procedures set forth in 105 CMR 130.342; (2) the services arranged for the patient; (3) the names, addresses and telephone numbers of service providers; (4) the service schedule as requested by the hospital; (5) medications prescribed and instructions for their use or verification that such information was provided separately; and (6) scheduled follow-up medical appointments or verification that such information was provided separately. (B) The discharge plan shall be developed with the participation of appropriate health professionals, the patient and as appropriate the patient’s family/patient representative. In instances of Medicare patients treated in emergencydepartments of acute hospitals, participation in the plan means that the patient receives an oral explanation of the treatment that was provided and written follow-up care instructions regarding care and other services necessary after discharge. Such instructions and information about necessary services shall be signed by the patient. If the patient is unable to sign, a notation shall be included in the patient’s record that indicates the reason the patient is unable to sign. (C) The patient shall receive the discharge plan in accordance with the following: (1) As soon as the plan is completed and to the extent possible, at least before the end of the working day on the day before discharge, the patient and/or as appropriate the patient’s family shall receive an oral and written discharge plan in understandable language that includes the post-hospital services that are required and the arrangements made for the provision of these services. (2) In addition, for all Medicare patients, the hospital shall comply with all Medicare discharge requirements as set out in 42 CFR 482.43. (D) The patient’s medical record shall document that the plan was communicated orally to the patient and/or as appropriate the family/patient representative. (E) For non-English speaking patients, the hospital shall provide translation assistance to assist the patient and/or as appropriate the family/patient representative in understanding the discharge plan. (F) If a patient, and/or the patient’s family/patient representative, as appropriate, notifies any professional staff member involved in the patient’s care that the patient and/or the patient’s family/patient representative does not agree with the discharge plan, the discharge planning coordinator and patient’s physician shall arrange and conduct a meeting with the patient and/or family in an effort to develop a plan that is acceptable. For the purposes of 105 CMR 130.343, the nurse, social worker or other responsible emergencydepartment health care professional may be considered the discharge coordinator and the emergency room physician may be considered the patient’s physician. (G) The discharge planning unit shall notify the patient’s physician, nurse practitioner or physician’s assistant of any difficulties that are impeding the patient’s discharge, such as unavailability of necessary services and/or the patient/family representative’s objection to the discharge plan. (H) No patient shall be discharged or transferred without an order by a physician, nurse practitioner or physician’s assistant, except where such patient leaves against medical advice.