A. The provider shall have written policies and procedures regarding the discharge or termination of individuals from the service. These policies and procedures shall include medical and clinical criteria for discharge.

B. Discharge instructions shall be provided in writing to the individual, the individual's authorized representative, and the successor provider, as applicable. Discharge instructions shall include, at a minimum, medications and dosages; names, telephone numbers, and addresses of any providers to whom the individual is referred; current medical issues or conditions; and the identity of the treating health care providers.

C. The provider shall make appropriate arrangements or referrals to all service providers identified in the discharge plan prior to the individual's scheduled discharge date.

D. A provider of an inpatient or residential substance abuse (substance use disorder) treatment program shall prepare and record a valid discharge plan prior to discharge or withdrawal of any individual who has received substance use disorder treatment from the service. The discharge plan shall (i) identify, and describe the coordination by the provider with, public and private agencies or persons able to deliver any needed services; and (ii) provide care coordination with the individual’s payor to assist the individual in executing the discharge plan. Failure to prepare and record valid discharge plans in accordance with this section may result in issuance of a licensing report, reduction in license status, or sanctions enumerated in § 37.2-419 of the Code of Virginia, as deemed appropriate by the department.

D. E. The content of the discharge plan and the determination to discharge the individual shall be consistent with the ISP and the criteria for discharge.

E. F. The provider shall document in the individual's service record that the individual, the individual's authorized representative, and the individual's family members, as appropriate, have been involved in the discharge planning process.

F. G. A written discharge summary shall be completed within 30 days of discharge and shall include, at a minimum, the following:

1. Reason for the individual's admission to and discharge from the service;

2. Description of the individual's or the individual's authorized representative's participation in discharge planning;

3. The individual's current level of functioning or functioning limitations, if applicable;

4. Recommended procedures, activities, or referrals to assist the individual in maintaining or improving functioning and increased independence;

5. The status, location, and arrangements that have been made for future services;

6. Progress made by the individual in achieving goals and objectives identified in the ISP and summary of critical events during service provision;

7. Discharge date;

8. Discharge medications prescribed by the provider, if applicable;

9. Date the discharge summary was actually written or documented; and

10. Signature of the person who prepared the summary.

G. H. This section does not apply to crisis services as crisis services shall comply with Part VIII of this chapter.