Ala. Admin. Code r. 560-X-10-.10

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-10-.10 - Admission Criteria

(1) Guidelines for nursing facility admission criteria: The principal aspect of covered care relates to the care rendered. The controlling factor in determining whether a person is receiving covered care is the medical supervision that the resident requires. Nursing facility care provides physician and nursing services on a continuing basis. The nursing services are provided under the general supervision of a licensed registered nurse. An individual may be eligible for care under the following circumstances:

(a) The physician must state "I certify" need for admission and continuing stay.

(b) Nursing care is required on a daily basis.

(c) Nursing services are required that as a practical matter can only be provided in a nursing facility on an inpatient basis.

(d) Nursing service must be furnished by or under the supervision of a RN and under the general direction of a physician.

(2) Listed below, but not limited to, are specific services that a resident requires on a regular basis: (Resident must meet at least two criteria for initial admissions.)

(a) Administration of a potent and dangerous injectable medication and intravenous medications and solutions on a daily basis or administration of routine oral medications, eye drops, or ointment.

(b) Restorative nursing procedures (such as gait training and bowel and bladder training) in the case of residents who are determined to have restorative potential and can benefit from the training on a daily basis.

(c) Nasopharyngeal aspiration required for the maintenance of a clear airway.

(d) Maintenance of tracheotomy, gastrostomy, colostomy, ileostomy and other tubes indwelling in body cavities as an adjunct to active treatment for rehabilitation of disease for which the stoma was created.

(e) Administration of tube feedings by naso-gastric tube.

(f) Care of extensive pressure ulcers or other widespread skin disorders.

(g) Observation of unstable medical conditions required on a regular and continuing basis that can only be provided by or under the direction of a registered nurse.

(h) Use of oxygen on a regular or continuing basis.

(i) Application of dressing involving prescription medications and aseptic techniques and/or changing of dressing in noninfected, post operative, or chronic conditions.

(j) Comatose patient receiving routine medical treatment.

(k) Assistance with at least one of the activities of daily living below on an ongoing basis:

1. Transfer - The individual is incapable of transfer to and from bed, chair, or toilet unless physical assistance is provided by others on an ongoing basis (daily or multiple times per week).

2. Mobility - The individual requires physical assistance from another person for mobility on an ongoing basis (daily or multiple times per week). Mobility is defined as the ability to walk, using mobility aids such as a walker, crutch, or cane if required, or the ability to use a wheelchair if walking is not feasible. The need for a wheelchair, walker, crutch, cane, or other mobility aid shall not by itself be considered to meet this requirement.

3. Eating - The individual requires gastrostomy tube feedings or physical assistance from another person to place food/drink into the mouth. Food preparation, tray set-up, and assistance in cutting up foods shall not be considered to meet this requirement.

4. Toileting - The individual requires physical assistance from another person to use the toilet or to perform incontinence care, ostomy care, or indwelling catheter care on an ongoing basis (daily or multiple times per week).

5. Expressive and Receptive Communication - The individual is incapable of reliably communicating basic needs and wants (e.g., need for assistance with toileting; presence of pain) using verbal or written language; or the individual is incapable of understanding and following very simple instructions and commands (e.g., how to perform or complete basic activities of daily living such as dressing or bathing) without continual staff intervention.

6. Orientation - The individual is disoriented to person (e.g., fails to remember own name, or recognize immediate family members) or is disoriented to place (e.g., does not know residence is a Nursing Facility).

7. Medication Administration - The individual is not mentally or physically capable of self-administering prescribed medications despite the availability of limited assistance from another person. Limited assistance includes, but is not limited to, reminding when to take medications, encouragement to take, reading medication labels, opening bottles, handing to individual, and reassurance of the correct dose.

8. Behavior - The individual requires persistent staff intervention due to an established and persistent pattern of dementia-related behavioral problems (e.g., aggressive physical behavior, disrobing, or repetitive elopement attempts).

9. Skilled Nursing or Rehabilitative Services - The individual requires daily skilled nursing or rehabilitative services at a greater frequency, duration, or intensity than, for practical purposes, would be provided through a daily home health visit.

The above criteria should reflect the individual's capabilities on an ongoing basis and not isolated, exceptional, or infrequent limitations of function in a generally independent individual who is able to function with minimal supervision or assistance.

Admission to a certified nursing facility still requires that the patient meet two or more criteria listed on Form 161 (a-k). As a result, an individual who meets one or more ADL deficits under (k) must also meet an additional criterion from the list (a-j). All applications for admission to a nursing facility must include supporting documentation.

Four exceptions are noted:

* Criterion (a) and Criterion (k) (7) are the same as they both involve medication administration. Only one may be used. Therefore, if an individual meets criterion (a), criterion (k) (7) may not be used as the second qualifying criterion.

* Criterion (g) and Criterion (k) (9) are the same as they both involve direction by a registered nurse. Only one may be used. Therefore, if an individual meets criterion (g), Criterion (k) (9) may not be used as the second qualifying criterion.

* Criterion (k) (3) cannot be used as a second criterion if used in conjunction with criterion (d) if the ONLY stoma (opening) is Gastrostomy or PEG tube.

* Criterion (k) (4) cannot be counted as a second criterion if used in conjunction with criterion (d) if used for colostomy, ileostomy, or urostomy.

(3) The above criteria will be applied to all initial admissions to a nursing facility with the exception of Medicaid residents who have had no break in institutional care since discharge from a nursing home and residents who are re-admitted in less than 30 days after discharge into the community. These residents need to meet only one of the above criteria in paragraph two, above.

(4) Individuals admitted to a nursing facility as a private pay resident in spend down status with no break in institutional care for more than 3 0 days and becomes financially eligible for Medicaid, must meet only one of the criteria to transfer from private pay to a Medicaid admission.

Ala. Admin. Code r. 560-X-10-.10

Rule effective October 1, 1982. Amended: Effective February 8, 1984; December 6, 1984. Emergency rule: Effective October 1, 1990. Amended: Effective February 13, 1991. Amended: Filed July 7, 1993; Effective August 11, 1993. Amended: Filed August 11, 2003; effective September 15, 2003. Amended: Filed August 11, 2011; effective September 15, 2011. Amended: Filed November 9, 2012; effective December 14, 2012.

Rule 560-X-10-.09, Admission Criteria, was renumbered to Rule 560-X-10-.10 as per certification Filed August 11, 2003; effective September 15, 2003.

Author: Robin Arrington, Administrator, LTC Program Management Unit

Statutory Authority: State Plan; Title XIX, Social Security Act; P.L. 92-603, P.L. 98-369; 42 C.F.R. §§ 435.1009, 456.1.