1. (A) A member must be discharged by the AFC provider upon the member’s request, or if the member ceases to benefit from AFC, including the following circumstances:

   1. (1) the member no longer meets the clinical eligibility criteria for AFC;
   2. (2) the member demonstrates behavioral or other problems that may endanger the member, the AFC caregiver, or AFC provider staff;
   3. (3) the member’s clinical needs are beyond the scope of AFC;
   4. (4) the member’s needs cannot be met by the AFC provider;
   5. (5) the member does not reside in an AFC-qualified setting;
   6. (6) the member selects another service that is duplicative of AFC; or
   7. (7) the member transitions to another AFC provider.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-19

Provider Manual Series (130 CMR 408.000)

Transmittal Letter Date

Adult Foster Care Manual

AFC-20 04/26/24

1. (B) For all discharges, the AFC provider must

   1. (1) develop a discharge and transition plan that must

      1. (a) include the date and reason for discharge;
      2. (b) identify any referrals by the AFC provider to other appropriate service providers for any health or social services required by the member;
      3. (c) ensure continuity of care by the member, including during transitions of care as specified in the AFC plan of care;
      4. (d) be dated and signed by the AFC registered nurse, the AFC care manager, and the member; and
      5. (e) require at least one follow-up telephone call within 30 business days after discharge to determine the member’s post-discharge status and condition;
   2. (2) provide assistance to the member in identifying and locating another provider;
   3. (3) arrange for the member to be discharged and transitioned to the provider identified in 130 CMR 408.432(B)(2);
   4. (4) coordinate the discharge and transition with the member, member's family or legal guardian, and staff of the program or agency to which the member is to be transferred; and
   5. (5) maintain current level of services until the member is admitted with a new provider.