Section 29-2352. SERVICES AND SUPPORTS: STANDARDS FOR CORE REQUIREMENTS -- DISCHARGE SUMMARY

 

2352.1 A substance abuse treatment facility or program shall develop criteria and implement written policies and procedures regarding:

 

(a) Termination or removal from the program;

 

(b) Discharge planning;

 

(c) Discharge or completion of the program; and

 

(d) Re-entry following termination or discharge.

 

2352.2 Prior to a patient’s discharge from a substance abuse treatment facility or program, an aftercare plan shall be developed.

 

2352.3 The patient’s record shall contain a discharge summary that summarizes information regarding the patient’s condition from the time of first contact through treatment termination. The discharge summary shall minimally include and address the following:

 

(a) Admission date and referral source;

 

(b) Initial assessment, including present problems;

 

(c) Initial diagnosis;

 

(d) Significant findings;

 

(e) Course and progress of treatment towards the goals in the rehabilitation plan;

 

(f) Outcomes at the time of discharge, in relation to identified problems;

 

(g) Final assessment, including prognosis;

 

(h) Final diagnosis;

 

(i) Recommendations and referrals made as stated in the continuing care or aftercare plan;

 

(j) Discharge date and reason; and,

 

(k) Follow-up plans.

 

2352.4 If a patient voluntarily terminates involvement with a substance abuse treatment facility or program against the advice of staff, the discharge summary shall include a statement that explains the circumstances under which the patient was terminated.

 

2352.5 If a patient is involuntarily terminated for non-compliance as specified in the facility’s or program’s policies and procedures, the discharge summary shall include a statement that explains the circumstances under which the patient was terminated and the conditions that must be met by the patient for re admission.

 

2352.6 The discharge summary shall be completed and entered into the patient’s record no later than fifteen (15) days after the patient’s discharge from a substance abuse treatment facility or program and shall be signed by the primary care counselor, the clinical case manager, and the supervisor. The discharge date shall be considered the date on which services were last provided.

 

 

source

Final Rulemaking published at 47 DCR 9341 (November 24, 2000), adopting Emergency and Proposed Rulemaking published at 47 DCR 7708, 7778 (September 22, 2000).