471 NAC 20-020. TRANSITION AND DISCHARGE PLANNING

020. TRANSITION AND DISCHARGE PLANNING. When a beneficiary is transferred from one level of care to another, transition and discharge planning must be performed and documented by the treating providers, beginning at the time of admission. 020.01 STANDARDS FOR TRANSITION AND DISCHARGE PLANNING. Providers must meet the following standards regarding transition and discharge planning: (A)Transition and discharge planning must begin on admission; (B)Discharge planning must be based on the treatment plan to achieve the beneficiary’s discharge from the current treatment status and transition into a different level of care; (C)Transition and discharge planning must address the beneficiary’s need for ongoing treatment to maintain treatment gains and to continue normal physical and mental development following discharge; (D)Discharge planning must include identification of and clear transition into developmentally appropriate services needed following discharge; (E)Treatment providers must make or facilitate referrals and applications to the next level of care or treatment provider; (F)The current provider must arrange for prompt transfer of appropriate records and information to ensure continuity of care during transition into the next level of care; and (G)A written transition and discharge summary must be provided as part of the medical record.