Discharge Plan of Care/Summary/Instructions Sample Clauses

Discharge Plan of Care/Summary/Instructions. The Interdisciplinary Care Team develops the Discharge Plan of Care with the participation of the Resident and, with the Resident's consent, the Resident Representative. The Discharge Plan of Care must be designed to assist the Resident in adjusting to his or her new living environment. The Team meets with the Resident/Resident Representative at the scheduled meeting, reviews the Discharge Plan of Care with the Resident and provides the Resident with a copy. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the Resident's follow up care and any post- discharge medical and non-medical services. Prior to discharge, the Resident or Resident Representative will receive specific discharge instructions provided by the Interdisciplinary Care Team. Appropriate community resources, telephone numbers and contact persons will also be provided. The discharge summary will include, but not be limited to, the following: