(a) Three Admissions Within 180 Days. An individual admitted to a state hospital or CPB three times within 180 days is considered at risk for future admission to inpatient services. To prevent potentially unnecessary admissions to an inpatient facility, the designated LMHA or LBHA must: (1) during discharge planning, review the individual's previous recovery or treatment plans to determine the effectiveness of the clinical services received; (2) include in the recovery or treatment plan: (A) non-clinical supports, such as those provided by a mental health peer specialist or recovery support peer specialist, identified to support the individual's ongoing recovery; and (B) recommendations for services and interventions from the individual's current or previous care plan that support the individual's strengths and goals and prevent unnecessary admission to a state hospital or CPB; (3) determine the availability and level of care, including type, amount, scope, and duration of clinical and non-clinical supports, such as those provided by a mental health peer specialist or recovery support peer specialist, that promote ongoing recovery and prevent unnecessary admission to a state hospital or CPB; and (4) consider appropriateness of the individual's continued stay in the state hospital or CPB. (b) Discharge Planning Specialists. Pursuant to Texas Health and Safety Code §534.053, each state hospital must designate at least one employee to deliver continuity of care services for individuals who are determined medically appropriate for discharge from the facility. The state hospital must concentrate the provision of continuity of care services for individuals who have been: (1) admitted to and discharged from a state hospital three or more times during a 30-day period; or (2) in the state hospital for longer than 365 consecutive days. (c) Nursing Facility Referral or Admission. (1) In accordance with 42 CFR Part 483, Subpart C, and as described in Chapter 554, Subchapter BB of this title (relating to Nursing Facility Responsibilities Related to Preadmission Screening and Resident Review (PASRR)), a nursing facility must coordinate with the referring entity to ensure the referring entity screens the individual for admission to the nursing facility before the nursing facility admits the individual. (2) As the referring entity, the state hospital or CPB must complete a PL1 Screening and forward the completed form in accordance with §303.301 of this title (relating to Referring Entity Responsibilities Related to the PASRR Process). (3) The LMHA, LBHA, or LIDDA must conduct a PE in accordance with Chapter 303 of this title (relating to Preadmission Screening and Resident Review (PASRR)). (4) If a nursing facility admits an individual while on pass or furlough, the designated LMHA or LBHA must conduct and document, including justification for its recommendations, the activities described in paragraphs (5) and (6) of this subsection. (5) The designated LMHA or LBHA must make at least one in-person contact with the individual at the nursing facility while on pass or furlough. The contact must consist of: (A) a review of the individual's record at the nursing facility; and (B) discussions with the individual, the LAR, if applicable, the nursing facility staff, and other staff who provide care to the individual regarding: (i) the individual's needs and the care the individual is receiving; (ii) the ability of the nursing facility to provide the appropriate care; (iii) the provision of mental health services, if needed by the individual; and (iv) the individual's adjustment to the nursing facility. (6) Before the end of the initial pass or furlough period described in §306.205(a) of this subchapter (relating to Pass or Furlough from a State Hospital or Facility with a Contracted Psychiatric Bed, the designated LMHA or LBHA must recommend to the state hospital or CPB one of the following: (A) discharging the individual if the LMHA or LBHA determines that: (i) the nursing facility is capable and willing to provide appropriate care to the individual after discharge; (ii) any mental health services needed by the individual are being provided to the individual while residing in the nursing facility; and (iii) the individual and LAR, if applicable, agrees to the nursing facility admission; (B) extending the individual's pass or furlough period in accordance with §306.205(a)(2) of this subchapter; (C) returning the individual to the state hospital or CPB in accordance with §306.205 of this subchapter (relating to Pass or Furlough from a State Hospital or a Facility with a Contracted Psychiatric Bed); or (D) initiating involuntary admission to the state hospital or CPB in accordance with §306.176 (relating to Admission Criteria for a State Hospital or a Facility with a Contracted Psychiatric Bed for Emergency Detention) and §306.177 (relating to Admission Criteria Under Order of Protective Custody or Court-ordered Inpatient Mental Health Services) of this subchapter. (d) Assisted Living. (1) A state hospital, a CPB, an LMHA, or an LBHA may only refer an individual to an assisted living facility that is licensed under Texas Health and Safety Code Chapter 247. (2) As required by Texas Health and Safety Code §247.063(b), if a state hospital, a CPB, an LMHA, or an LBHA gains knowledge of an assisted living facility not operated or licensed by the state, the state hospital, CPB, LMHA, or LBHA must report the name, address, and telephone number of the facility to HHSC Complaint and Incident Intake at 1-800-458-9858. (e) Minors. (1) To the extent permitted by medical privacy laws, the state hospital or CPB and designated LMHA or LBHA must make a reasonable effort to involve a minor's LAR or the LAR's designee in the treatment and discharge planning process. (2) A minor committed to or placed in a state hospital or CPB under Texas Family Code Chapter 55, Subchapter C or D, shall be discharged in accordance with the Texas Family Code Chapter 55, Subchapter C or D as applicable. (f) An individual suspected of having an ID. If a state hospital or CPB suspects an individual has an ID, the state hospital or CPB must notify the designated LMHA or LBHA CoC liaison and the designated LIDDA to: (1) assign a LIDDA continuity of care worker to the individual; and (2) conduct an assessment in accordance with Chapter 304 of this title (relating to Diagnostic Assessment). (g) Criminal Code. (1) Texas Code of Criminal Procedure Chapter 46B.(A) An individual committed to a state hospital or CPB under Texas Code of Criminal Procedure Article 46B.102 may only be discharged by order of the committing court under Texas Code of Criminal Procedure, Article 46B.107.(B) An individual committed to a state hospital or CPB under Texas Code of Criminal Procedure Article 46B.073 must be discharged and transferred, in accordance with Texas Code of Criminal Procedure Article 46B.081 through Article 46B.083. (C) For an individual committed under Texas Code of Criminal Procedure Chapter 46B, who is discharged and returned to the committing court, the state hospital or CPB, within 24 hours after discharge, must notify the following of the discharge: (i) the individual's designated LMHA or LBHA; and (ii) the TCOOMMI. (2) Texas Code of Criminal Procedure Chapter 46C: Insanity defense. An individual committed to a state hospital or CPB under Texas Code of Criminal Procedure Chapter 46C may only be discharged by order of the committing court in accordance with Texas Code of Criminal Procedure Article 46C.253 or Article 46C.268. (h) Offenders with special needs following discharge from a state hospital or CPB. The LMHA or LBHA must comply with the requirements as defined by the LMHA's and LBHA's TCOOMMI contract for offenders with special needs. (1) An LMHA or LBHA that receives a referral for an offender with special needs in the MH priority population from a county or city jail at least 24 hours before the individual's release must complete one of the following actions: (A) if the offender with special needs is currently receiving LMHA or LBHA services, the LMHA or LBHA must: (i) notify the offender with special needs of the referral from a county or city jail; (ii) arrange an in-person contact between the offender with special needs and a QMHP-CS to occur within 15 days after the individual's release; and (iii) ensure that the QMHP-CS, at the in-person contact, reassesses the individual and arranges for appropriate services, including transportation needs at the time of release; (B) if the individual is not currently receiving LMHA or LBHA services from the LMHA or LBHA that is notified of the referral, the LMHA or LBHA must:(i) ensure that at the in-person contact required in subparagraph (A) of this paragraph, the QMHP-CS conducts a pre-admission assessment in accordance with §301.353(a) of this title (relating to Provider Responsibilities for Treatment Planning and Service Authorization); and (ii) comply with §306.161(b) of this subchapter (relating to Screening and Assessment), as applicable; or (C) if the LMHA or LBHA is unable to conduct an in-person contact with the individual required in paragraph (1)(A) of this subsection, the LMHA or LMHA must document the reasons for not doing so in the individual's record. (2) If an LMHA or LBHA is notified of the anticipated release from prison or a state jail of an offender with special needs in the MH priority population who is currently taking psychoactive medications for a mental illness and who will be released with a 30-day supply of the psychoactive medications, the LMHA or LBHA must arrange an in-person contact required in paragraph (1)(A) of this subsection between the individual and QMHP-CS within 15 days after the individual's release. (A) If the offender with special needs is released from state prison or state jail after hours or the LMHA or LBHA is otherwise unable to schedule the in-person contact required in paragraph (2) of this subsection before the individual's release, the LMHA or LBHA must make a good faith effort to locate and contact the individual. If the designated LMHA or LBHA is unable to have an in-person contact with the individual within 15 days after being released, the LMHA or LBHA must document the reasons for not doing so in the individual's record. (B) At the in-person contact required in paragraph (2) of this subsection: (i) the QMHP-CS with appropriate supervision and training must perform an assessment in accordance with §301.353(a) of this title and comply with §306.161(b) and (c) of this subchapter, as applicable; and (ii) if the LMHA or LBHA determines that the offender with special needs should receive services immediately, the LMHA or LBHA must arrange for the individual to meet with a physician or designee authorized by state law to prescribe medication before the individual requires a refill of the prescription. (C) If the LMHA or LBHA is unable to conduct an in-person contact with the offender with special needs required in paragraph (2) of this subsection, the LMHA or LBHA must document the reasons for being unable to do so in the individual's record. (3) If the offender with special needs is on parole or probation, the state hospital or CPB must notify a representative of TCOOMMI before the discharge of the individual known to be on parole or probation.