Ch. 11, § 10. Discharge Planning

(a) The facility shall maintain a centralized, coordinated program to ensure that each resident has a planned program of continuing care which meets the post discharge needs. (i) The administrator shall delegate responsibility for discharge planning, in writing, to one (1) or more members of the facility's staff, with consultation, if necessary, or arrange for this service to be provided by a health, social or welfare agency. (ii) The facility shall have in operation an organized discharge planning program. (A) This program shall include the resident, physician(s), nurses, social services personnel, dietitian, and therapists to identify problems and goals thus preparing the resident for the next level of care and arranging for placement in the appropriate care environment. (iii) The facility shall maintain written discharge planning procedures which describe: (A) How the discharge coordinator will function, and his/her authority and relationship with the facility's staff. (B) The time period in which each resident's need for discharge planning is determined (preferably within seven (7) days after the day of admission). (C) The maximum time period after which a reevaluation of each resident's discharge plan is made. (D) Local resources available to the facility, the resident, and the attending physician to assist in developing and implementing individual discharge plans. (E) Provisions for periodic review and reevaluation of the facility's discharge planning program.