13A.11.08.08

.08 Discharge Planning.

A. For clients receiving medical functional evaluations, comprehensive assessments, and employment skills training, the case manager and the client shall initiate a discharge plan upon the client's admission to the Center and document the discharge plan in the record. The case manager shall include in the discharge planning process:

(1) The client;

(2) Family members or others who can provide support and assistance to the client;

(3) Members of the interdisciplinary team who may be involved in the delivery of services to the client; and

(4) The referral source.

B. The case manager shall notify the client, the client's family, representative, the referral source, and rehabilitation team members of the proposed discharge date.

C. The case manager for clients receiving medical functional evaluations, comprehensive assessments, and employment skills training shall hold a discharge conference with the client on or shortly before the day of discharge to summarize services, discuss issues, and outline the steps needed to facilitate transition to the next phase of the client's rehabilitation program. The client shall be informed that a written report will be submitted to the referral source in a timely fashion after the conclusion of the service.