(a) At the time of an individual's admission to a state hospital or CPB, the designated LMHA or LBHA, if applicable, and the state hospital or CPB must begin discharge planning for the individual. The state hospital or CPB must send an electronic admission initial notification within three business days to the appropriate LMHA, LBHA, and LIDDA to initiate discharge planning. (b) The designated LMHA or LBHA CoC liaison or other designated staff; the designated LIDDA continuity of care worker, if applicable; the individual; the LAR, if applicable; and any other person authorized by the individual, such as guardian ad litem or attorney ad litem, must participate in discharge planning with the state hospital or CPB. The state hospital or CPB must initiate coordination of discharge planning.(1) Except for the state hospital or CPB treatment team and the individual, involvement in discharge planning may be through teleconference or video-conference calls.(2) The state hospital or CPB must invite the LMHA, LBHA, or LIDDA, as applicable, to routine recovery or treatment plan meetings as well as any additional meetings that arise specific to discharge planning. The state hospital or CPB must notify meeting participants a minimum of 24 hours before each scheduled meeting regarding recovery or treatment planning and any additional meetings specific to discharge planning. (3) The state hospital or CPB must ensure the development and completion of the discharge plan as listed in subsection (c) of this section and coordinate with the LMHA, LBHA, or LIDDA, if applicable, before the individual's discharge.(4) The LMHA or LBHA must facilitate the transition of individuals who are determined by the state hospital or CPB to be medically appropriate for discharge in accordance with Texas Health and Safety Code §534.0535 from a facility to a community setting by connecting the individuals to resources available in the individuals' county of residence or choice. (c) Discharge planning must consist of the following activities: (1) Considering all pertinent information about the individual's clinical needs, the state hospital or CPB must identify and recommend specific clinical services and supports needed by the individual after discharge or while on pass or furlough. (2) The state hospital or CPB and the LMHA, LBHA, or LIDDA, if applicable, must jointly identify, recommend, and help coordinate access to services for the individual and LAR, if applicable, regarding specific non-clinical services and supports needed by the individual after discharge, including the individual's need for housing, supported employment, education resources, and food assistance, clothing resources, and other supplemental supports or governmental benefits as applicable. (3) If an individual needs a living arrangement, the LMHA or LBHA CoC liaison or LIDDA continuity of care worker must:(A) identify a living arrangement consistent with the individual's clinical needs and preference that is available and has accessible services and supports as agreed upon by the individual or LAR; or(B) ensure the individual or LAR is referred to housing services and support the individual through the process of obtaining and applying for housing services during the discharge planning process if a living arrangement is unavailable. (4) The LMHA or LBHA CoC liaison or LIDDA continuity of care worker in collaboration with the individual and LAR, if applicable, must identify potential providers and resources for the recommended services and supports and arrange for provision of services upon discharge in accordance with Texas Health and Safety Code §534.0535. (5) The state hospital or CPB must attempt to educate the individual and LAR, if applicable, to prepare the individual for care after discharge or while on pass or furlough. (6) The state hospital or CPB must provide the individual and LAR, if applicable, with written notification of the existence, purpose, telephone number, and address of the protection and advocacy system established in Texas, pursuant to Texas Health and Safety Code §576.008. (7) The LMHA, LBHA, or LIDDA must comply with the PASRR processes as described in Chapter 303 of this title (relating to Preadmission Screening and Resident Review (PASRR)) for an individual referred to a nursing facility. (d) Before an individual's discharge or approval for a pass or furlough: (1) the individual's treatment team must ensure the development of a plan to include the individual's stated goals. The plan must consist of: (A) a description of the individual's living arrangement after discharge, or while on pass or furlough, that reflects the individual's preferences, choices, and available community resources; (B) arrangements and referrals for the available and accessible services and supports agreed upon by the individual or LAR recommended in the individual's discharge plan; (C) a written description of recommended clinical and non-clinical services and supports the individual receives after discharge or while on pass or furlough;(D) documentation of arrangements and referrals for the services and supports recommended upon discharge or while on pass or furlough. (E) a description of behavioral health symptoms identified at discharge or before a pass or furlough, including any symptoms that may disrupt the individual's stability in the community; (F) the individual's goals, strengths, interventions, and objectives as stated in the individual's discharge plan in the state hospital or CPB; (G) comments or additional information; (H) a final diagnosis based on the version of the DSM currently recognized by HHSC;(I) the names, contact information, and addresses of providers to whom the individual will be referred for any services or supports after discharge or while on pass or furlough; and (J) a description of: (i) the types and amount of medication the individual needs after discharge or while on pass or furlough until the individual is evaluated by a physician; or (ii) for 90 days after discharge, the person or entity responsible for providing and paying for the medication. (2) The state hospital or CPB must request that the individual or LAR sign the discharge plan and document in the discharge plan whether the individual or LAR agree or disagree with the plan. (3) If the individual or LAR refuses to sign the discharge plan described in paragraph (2) of this subsection, the state hospital or CPB must document in the individual's record whether the individual or LAR agrees to the plan or not, reasons stated, and any other circumstances of the refusal. (4) If applicable, the individual's treating physician must document in the individual's record reasons why the individual does not require continuing care or a discharge plan. (5) If the LMHA or LBHA disagrees with the state hospital or CPB treatment team's decision concerning discharge: (A) the treating physician of the state hospital or CPB must consult with the LMHA or LBHA physician or designee to resolve the disagreement within 24 hours; and(B) if the disagreement continues unresolved, the medical director or designee of the state hospital or CPB must refer the issue to the Texas State Hospitals Chief Medical Officer to render a final determination. (e) Discharge notice to family or LAR. (1) In accordance with Texas Health and Safety Code §576.007, before discharging an adult, the state hospital or CPB must make a reasonable effort to notify the individual's family or any identified person providing support to the individual. Discharge notification requires authorization by the individual or LAR.(2) Before discharging an individual who is at least 16 years of age, but younger than 18 years of age, who voluntarily consented for the individual's own admission, the state hospital or CPB must make a reasonable effort to notify the individual's LAR, if applicable, of the discharge within 72 hours before the date of discharge. (3) Before discharging a minor for whom a parent, managing conservator, or guardian provided consent for admission, the state hospital or CPB must notify the minor's LAR of the discharge. (f) Release of minors. Upon discharge, the state hospital or CPB may release a minor only to the minor's LAR or the LAR's designee. (1) If the LAR or the LAR's designee is unwilling to retrieve the minor from the state hospital or CPB and the LAR is not a state agency: (A) the state hospital or CPB must: (i) notify DFPS, so DFPS can take custody of the minor from the state hospital or CPB; (ii) refer the matter to the LMHA or LBHA to schedule a meeting with representatives from the required agencies described in subsection (f)(2)(A) of this section, the LAR, and minor to explore resources and make recommendations; (iii) document the LMHA or LBHA referral in the discharge plan; (iv) refer the matter to the local CRCG to schedule a meeting with representation from the required agencies described in subsection (f)(2)(A) of this section, the LAR, and the minor to explore resources and make recommendations; and(v) document the CRCG referral in the discharge plan; and(B) the medical directors or the medical directors' designees of the state hospital or CPB; designated LMHA, LBHA, or LIDDA; and DFPS must meet to develop and finalize the discharge recommendations. (2) If the LAR is a state agency unwilling to assume physical custody of the minor from the state hospital or CPB, the state hospital or CPB must: (A) refer the matter to the local CRCG office, or state CRCG office if applicable, to schedule a meeting with representatives from the member agencies, in accordance with 40 TAC, Part 19, Chapter 702, Subchapter E (relating to Memorandum of Understanding with Other State Agencies), the LAR, and minor to explore resources and make recommendations; and (B) document the CRCG referral in the discharge plan. (g) Notice to the designated LMHA, LBHA, or LIDDA. At least 24 hours before an individual's planned discharge, pass, or furlough, and no later than 24 hours after an unexpected discharge, a state hospital or CPB must notify the designated LMHA, LBHA, or LIDDA of the anticipated or unexpected discharge and convey the following information about the individual: (1) identifying information, including address and contact information of the individual or LAR; (2) legal status, for example, regarding guardianship, charges pending, or custody if the individual is a minor; (3) the day and time the individual will be discharged or participating in a pass or furlough; (4) the individual's destination address after discharge, or while on pass or furlough; (5) medical information; (6) current medications; (7) clinical documentation, including information regarding a COPSD, an ID, or a DD; and (8) other pertinent treatment information, including the discharge plan. (h) Discharge packet. (1) At a minimum, a discharge packet must include: (A) the discharge plan; (B) referral instructions, including: (i) state hospital or CPB contact person; (ii) name of the designated LMHA or LBHA CoC liaison or LIDDA continuity of care worker; (iii) names of community resources and providers to whom the individual is referred, including contacts, appointment dates and times, addresses, and phone numbers; (iv) a description of to whom or where the individual is released upon discharge, including the individual's intended residence, address, and phone number; (v) instructions for the individual or LAR; (vi) medication regimen and prescriptions, as applicable; and (vii) dated signature of the individual or LAR and a member of the state hospital or CPB treatment team; (C) copies of all available, pertinent, current summaries, and assessments; and (D) the treating physician's orders. (2) At discharge, or while on pass or furlough, the state hospital or CPB provides a copy of the discharge packet or pass or furlough plan to the individual and LAR, if applicable. An individual or LAR may request additional records.(3) Within 24 hours after discharge, or while on pass or furlough, the state hospital or CPB must send a copy of the discharge packet or pass or furlough plan to: (A) the designated LMHA, LBHA, or LIDDA; and (B) the providers to whom the individual is referred, including: (i) an LMHA or LBHA network provider, if the LMHA or LBHA is responsible for ensuring the individual's services after discharge or while on pass or furlough; (ii) an alternate provider if the individual requested referral to an alternate provider; and (iii) a county jail if the individual will be transported to the county jail upon discharge. (i) Unexpected Discharge. (1) The state hospital or CPB and the designated LMHA, LBHA, or LIDDA must make reasonable efforts to provide discharge planning for an individual discharged unexpectedly. (2) If there is an unexpected discharge, the state hospital or CPB social worker or a designee must document the reason for not completing discharge planning activities in the individual's record. (j) Transportation. A state hospital or CPB must: (1) initiate and secure transportation in collaboration with an LMHA, an LBHA, or a LIDDA pursuant to an individual's discharge or pass or furlough plan; and (2) inform a designated LMHA, LBHA, or LIDDA of an individual's transportation needs after discharge or while on pass or furlough. (k) Discharge summary. (1) Within ten days after an individual's discharge, the individual's physician of the state hospital or CPB must complete a written discharge summary for the individual. (2) Within 21 days after an individual's discharge from an LMHA or LBHA, the LMHA or LBHA must complete a written discharge summary for the individual. (3) The written discharge summary must include: (A) a description of the individual's treatment and the individual's response to that treatment; (B) a description of the level of care for services received; (C) a description of the individual's level of functioning at discharge; (D) a description of the individual's living arrangement after discharge; (E) a description of the community services and supports the individual will receive after discharge; (F) a final diagnosis based on the version of the DSM currently recognized by HHSC; and (G) a description of the amount of medication available to the individual, if applicable. (4) The discharge summary must be sent to the individual's: (A) designated LMHA, LBHA, or LIDDA, as applicable; and (B) providers to whom the individual was referred. (5) Documentation of refusal. If the individual or LAR refuses to participate in the discharge planning, the circumstances of the refusal must be documented in the individual's record.(l) An LMHA or LBHA must provide continuity of care services designed to support joint discharge planning efforts in accordance with Texas Health and Safety Code §534.0535.