Sec. 10.21.17.10. Discharge from Services

A. When an individual has attained the goals identified in the individual's service plan, the individual's program coordinator shall begin the process for discharge planning.

B. Discharge Policy. The program shall have and maintain written policies and procedures, which may be contained in one document, that include:

(1) The process for all types of discharge from the program, including:

(a) Collaborative discharge;

(b) The individual's discontinuation of services;

(c) The program's recommendation to discontinue services; and

(d) The ASO's determination to discontinue authorization for services; and

(2) The individual's right to appeal.

C. Discharge Plan.

(1) The individual's program coordinator and the individual, if appropriate, shall develop a discharge plan that:

(a) Is based on an assessment of the individual's current status, service needs, and mutually agreed upon goal attainment;

(b) Includes:

(i) A brief description of the recommendations for continued treatment, if any;

(ii) Referrals for continuing services; and

(iii) Information about how the individual can re-access services when needed; and

(c) With proper consent, is developed in collaboration with family or others designated by the individual, and other treatment, rehabilitation, and service providers.

(2) The individual's program coordinator shall provide the individual with a copy of the discharge plan as soon as possible, but in no event, not later than the date of discharge.

D. Discharge Summary. Within 10 working days after an individual is discharged from a program, a staff person responsible for coordinating services to the individual shall complete and sign a discharge summary that includes, at a minimum, the:

(1) Reason for admission;

(2) Reason for discharge;

(3) Services provided, including the frequency and duration of services;

(4) Progress that was made;

(5) Diagnosis at the time of discharge, if appropriate;

(6) Current medications, if any;

(7) Continuing service recommendations and summary of the transition process; and

(8) Extent of the individual's involvement in the discharge plan.

E. Program's Recommendation to Discontinue Services.

(1) If, in consultation with the program director, the program coordinator recommends discontinuing services for an individual for whom, because of the individual's actions, the program's services are not effective, or the individual's clinical needs exceed the program's ability to secure the safety and welfare of the individual or others, the program director shall provide written notice of the intention to discontinue services and recommend referral for alternative services.

(2) Except in the case of imminent danger, the program director shall provide the notice at least 30 calendar days before discontinuing services.

(3) The program director shall assure that the notice is sent to the individual and, with proper consent, to:

(a) Family or others designated by the individual; and

(b) If appropriate, the CSA and the Administration's ASO, for referral for alternative services.

(4) The notice shall include:

(a) The effective date of the action;

(b) The reason for the action; and

(c) A discharge plan.

(5) If an individual presents as a danger to self or to others, the program director shall make necessary arrangements to try to protect the individual, others, or both, and link the individual with the appropriate level of care.

F. ASO's Determination to Discontinue Authorization for Services. If the Administration's ASO determines that services are no longer medically necessary, the program coordinator shall follow the provision for discharge outlined in §C of this regulation.