Nursing homes and other healthcare facilities must develop and implement an effective discharge planning process that focuses on the resident’s discharge goals, preparation for post-discharge care, and factors leading to preventable readmissions. The process must involve the interdisciplinary team, resident, and resident representative and include regular re-evaluation of the resident’s needs, caregiver/support person availability, and referrals to local contact agencies, as appropriate. Facilities must also document the resident’s interest in receiving information regarding returning to the community, and provide assistance in selecting a post-acute care provider. This requirement intends to ensure that nursing homes and other healthcare facilities have a discharge planning process that meets the needs of each resident, and involves the resident and their representative in developing a plan that addresses their goals and preferences.

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