A facility shall have an effective discharge planning process that includes the discharging resident and the resident's caregiver or support person as an active partner for post-discharge care. The discharge planning process and discharge plan must:

1. (1) Be consistent with the resident's goals and treatment preferences;
2. (2) Ensure an effective transition of the resident from the facility to discharge care; and

3. (3) Reduce the factors leading to preventable readmission to the facility.

   The facility shall have policies and procedures to support the discharge planning process that outline the person responsible for discharge planning, members of the discharge planning team, a list of all area agencies and resources, and a description of the process.

   The facility shall initiate planning with applicable agencies to meet the resident's identified needs, and the resident must be offered assistance to obtain needed services prior to discharge.

Source: 22 SDR 70, effective November 19, 1995; 26 SDR 96, effective January 23, 2000; 38 SDR 115, effective January 9, 2012; transferred from § 44:04:04:17 , 42 SDR 51, effective October 13, 2015 ; 51 SDR 53, effective November 11, 2024 .

General Authority: SDCL 34-12-13 .

Law Implemented: SDCL 34-12-13 .

Prior versions effective: 2015-10-13.