1. (a) Admission procedures shall include:

   1. (1) Completion of a health assessment and medical evaluation in accordance with the licensee’s policy which shall be documented for each patient accepted for care and treatment;
   2. (2) Provision of information concerning patient rights in a language the patient can understand, which might require a translator;
   3. (3) Provision of information in a clear concise manner to enable the patient to make appropriate treatment decisions;
   4. (4) Collection of specific patient medical and social history information as required by the licensee’s policy including information concerning advanced directives or alternative decision makers; and
   5. (5) Development of a treatment plan.

2. (b) Discharge documentation shall include:

   1. (1) The date and time of discharge;
   2. (2) The status of the patient at the time of discharge; and
   3. (3) Any discharge planning or referrals that have been conducted for the patient.

Source. #5846, eff 6-22-94, EXPIRED: 6-22-00 New. #9580, eff 10-24-09; ss by #12407, INTERIM, eff 10-24-17, EXPIRED: 4-22-18 New. #13166, eff 1-28-21; ss by #14081, eff 9-25-24, EXPIRES: 9-25-34 (formerly He-P 802.19)