105 CMR, § 130.340

Current through Register 1533, October 25, 2024

Section 130.340 - Discharge Planning Service Required

(A) Each acute-care hospital shall organize a multi-disciplinary discharge planning service to aid the attending physician and the patient and/or as appropriate the patient's family/patient representative in planning for the continuing care needs of the patient upon discharge from the hospital. The discharge planning service shall be responsible for coordinating the transfer of the patient from the hospital setting to an appropriate independent living arrangement or to another institution.

For the purposes of 105 CMR 130.000, a patient representative may be a court-appointed guardian; a person with written authorization to act on the patient's behalf; or if neither of the above is available, a person who has been known to the patient and determined by the discharge planning service to be acting responsibly on the patient's behalf.

(B) Each patient receiving discharge planning services in a hospital licensed under 105 CMR 130.000 shall have the following rights as set forth in 105 CMR 130.000:

(1) To participate in the discharge planning process to the maximum extent possible, with the assistance of family members or other representatives where the patient does not object to such assistance.

(2) To review any information which the hospital has about out-of-hospital resources including community based services capable of meeting the patient's discharge needs.

(3) To receive a written discharge plan, in non-technical language, along with sufficient oral explanations to assist the patient in understanding the plan.

(4) To acknowledge participation in and receipt of the discharge plan by signing it and, where the patient is unable or refuses to sign the plan, to have the reasons for such inability or refusal noted in the patient's medical records.

(5) To meet with the discharge planning coordinator and physician to attempt to resolve questions or disagreements about the discharge plan.