.12 Transfer or Discharge.

A. If the hospice care program does not provide inpatient hospice services directly, the hospice care program shall have a written transfer agreement with a hospice care program which provides those services.

B. The hospice care program shall provide adequate and appropriate information about the patient and family at the time of transfer or discharge.

C. When a patient and family transfers from one hospice care program to another or from home-based service to inpatient service, or vice versa, the current care provider shall provide a written summary of:

(1) The services being provided;

(2) The specific medical, psychosocial, spiritual, or other problems that require intervention or follow-up; and

(3) Any scheduled follow-up by a current interdisciplinary care team member.

D. The hospice care program shall document the specific reasons for transferring or discharging a patient from its program. These reasons may include:

(1) The patient moves from the service area;

(2) There is a change in terminal status;

(3) The patient and family are unwilling to comply with the interdisciplinary plan of care or consistently act in a way which compromises the standards of care;

(4) Issues of patient safety cannot be resolved;

(5) Issues of staff safety cannot be resolved; or

(6) Patient and family desire for discharge.

E. The hospice care program shall prepare a written discharge summary which shall be provided to the patient or the patient's family before the patient's discharge.

F. Before discharge, the hospice care program shall assess the patient's and family's continuing care needs and make referrals to appropriate services.