Transitional Planning
CARF expects discharge planning to begin at this point in service delivery.
What is at admission or the start of services?
CARF expects staff to follow MHA’s policy regarding these items brought into the agency that may threaten safety or violate rules.
What are contraband or prohibited items?
A safety plan should be developed collaboratively with this person.
Who is the individual served?
Besides the individual served, this group must be included in satisfaction measurements.
Who is families, guardians, or other stakeholders.
Even with a subpoena, this federal protection law still applies.
What is HIPAA?
Transitional planning must include coordination with these supports.
What are community providers, natural supports, or next level of care?
When illegal drugs are found, staff must do this immediately.
What is contact supervisor and ask the individual to remove item from premises.
A safety plan must include these early indicators of escalation.
What are warning signs or triggers?
This is used to increase access to services, increased supports, and enhance services.
MHA's follows this procedure to respond to legal requests.
What is contacting the Chief Executive Officer and/or Chief Operating Officer?
Surveyors may ask this to make sure your transition plan reflects the preferences of the person.
What is by making sure the plan is individualized and respects the person served?
Even when the agency doesn’t hold medications, CARF expects staff to do this to support safety.
What is provide education and guidance on proper administration?
Safety planning should identify these immediate supports.
What are coping strategies and emergency contacts?
Information is provided to staff through these three channels.
What is emails, team meetings, individual supervision.
CARF requires organizations to have a policy and process in place to respond to this type of unexpected event that results in serious harm or death.
What is a sentinel event?
A strong transitional plan includes this beyond just an appointment date.
What are strengths, needs, abilities, and preferences (SNAP)?
Surveyors may ask: “How do you ensure that clients safely self-administer medications?”
What is through education, monitoring adherence, providing reminders, observing for side effects, and documenting all interventions?
CARF expects safety plans to be this — not generic or copy-pasted.
What is individualized and regularly reviewed/updated?
Surveyors may ask: “What should staff do if approached by the media?”
What is contact Chief Executive Officer?
If a breach of electronic protected health information occurs, the organization must do this.
What is notify senior management then notify affected individuals, investigate the breach, and implement corrective actions per policy?
Surveyors may ask: “How do you verify that transitional plans are effective?”
What is through follow-up contacts, outcome tracking, and reviewing whether the individual successfully connected with recommended supports?
If a client chooses not to take a prescribed medication, staff must do this while respecting autonomy.
What is document informed refusal and educate on potential risks?
What is before a crisis or high-risk situation occurs?
This type of review uses data to determine if staff are following policies and providing services correctly.
What is chart review, documentation audit, or direct observation?
Surveyors may ask: “How do you respond when a client repeatedly makes risky choices?”
What is ongoing risk assessment, collaborative problem-solving, revisiting the safety plan, and documenting interventions and support offered?