Discharge Procedures

(A) A member must be discharged by the AFC provider upon the member’s request, or if the member ceases to benefit from AFC, including the following circumstances: (1) the member no longer meets the clinical eligibility criteria for AFC; (2) the member demonstrates behavioral or other problems that may endanger the member, the AFC caregiver, or AFC provider staff; (3) the member’s clinical needs are beyond the scope of AFC; (4) the member’s needs cannot be met by the AFC provider; (5) the member does not reside in an AFC-qualified setting; (6) the member selects another service that is duplicative of AFC; or (7) the member transitions to another AFC provider. (B) For all discharges, the AFC provider must (1) develop a discharge and transition plan that must (a) include the date and reason for discharge; (b) identify any referrals by the AFC provider to other appropriate service providers for any health or social services required by the member; (c) ensure continuity of care by the member, including during transitions of care as specified in the AFC plan of care; (d) be dated and signed by the AFC registered nurse, the AFC care manager, and the member; and (e) require at least one follow-up telephone call within 30 business days after discharge to determine the member’s post-discharge status and condition; (2) provide assistance to the member in identifying and locating another provider; (3) arrange for the member to be discharged and transitioned to the provider identified in 130 CMR 408.432(B)(2); (4) coordinate the discharge and transition with the member, member's family or legal guardian, and staff of the program or agency to which the member is to be transferred; and (5) maintain current level of services until the member is admitted with a new provider.