Policy Manual sample

MDT Home Health Care Agency, Inc. DISCHARGE OF PATIENTS Discharge of Patients policy includes but is not limited to the following: Reasons for patient discharge may include the patient expires, the patient’s condition improves and therefore the patient no longer needs the care provided, the physician discontinues the order for care, inadequate patient’s behavior or the patient declines (the Agency no longer meet the patient’s needs) the care and requests discontinuation of services. When services are to be terminated, the person shall be notified of the date of termination and reason for termination which shall be documented in the clinical record, at least 48 hrs before or the second to last day of service if care is not being provided daily , unless there is imminent danger for the patient (like unexpected emergency care that require transfer to an in-patient facility, unexpected exacerbation of health condition), and then the discharge should be processed as soon as possible. A plan shall be developed or referral made for any continuing care indicated. Planning for the Patient’s discharge from the home care service is an integral part of the Treatment Plan. The professional employee, in coordination with the patient’s physician will closely monitor the patients progress toward the achievement of the therapeutic goals. When services are to be terminated, the patient shall be notified of the date of termination and a letter of discharge will be sent to the patient and his/her physician. The discharge instructions will accompany the letter for the patient to follow. A copy of the discharge summary is maintained in the patient record and a copy is forwarded to the primary physician. The discharge summary includes, but is not limited to: • Date of discharge • Patient identifying information • Patient’s physician and phone number • Diagnosis • Reason for discharge • A brief description of care provided • Patient's medical and health status at the time of discharge • Any instructions given to the patient or responsible party The clinical record should maintain documentation that the physician was notified of the discharge in compliance with coordination of care, (Summary must be faxed/emailed to the patient’s physician), discharge instructions to patients, in Medicare beneficiaries must be included the Medicare Non Coverage information and if applicable the Advanced Beneficiary Notice. If applicable, the OASIS Discharge assessment must be completed by a qualified staff, the summary completed in the form can be faxed to the patient’s physician instead of any other summary form, and is not necessary request doctor signature. Home Health Agency Policies A-193