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

1. (1) the member no longer meets the clinical eligibility criteria for GAFC;
2. (2) the member demonstrates behavioral or other problems that may endanger the member or GAFC provider staff;
3. (3) the member’s clinical needs are beyond the scope of GAFC;
4. (4) the member’s needs cannot be met by the GAFC provider;
5. (5) the member selects another service which is duplicative of GAFC; or
6. (6) the member transitions to another GAFC provider.

(B) For all discharges, the GAFC provider must:

1. (1) develop a discharge and transition plan, which must:

   1. (a) include the date and reason for discharge;
   2. (b) identify any referrals by the GAFC 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 GAFC plan of care;
   4. (d) be dated and signed by the GAFC registered nurse, the GAFC 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 408.523(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 services until the member is admitted with a new provider.