A facility must have an effective discharge planning process that includes the patient and the patient’s caregiver or support person as active partners for post-discharge care. The discharge planning process and discharge plan must:

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

3. (3) Reduce the factors leading to preventable hospital readmissions.

   A 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.

   Within twenty-four hours after admission, a hospital must determine each patient's potential need for continuing care following discharge. The facility must initiate planning with applicable agencies to meet the patient's identified needs. To avoid any delays, the patient must be offered assistance to obtain needed services prior to discharge. The patient’s discharge plan must be reevaluated and modified as needed according to the patient’s condition.

   A facility must assess its discharge planning process on a regular basis. The assessment must include ongoing periodic review of a representative sample of discharge plans.

Source: 42 SDR 51, effective October 13, 2015 ; 50 SDR 62, effective November 27, 2023 .

General Authority: SDCL 34-12-13 (5)(14).

Law Implemented: SDCL 34-12-13 .

Prior versions effective: 2015-10-13.