Conn. Agencies Regs. § 17b-262-783

Current through December 27, 2024

Section 17b-262-783 - Need for service

In order for a client to be approved for admission to a chronic disease hospital, the client shall meet the criteria for admission as either a chronic disease client or a rehabilitation client. All care shall be medically necessary and medically appropriate.

(a) The criteria for admission as a chronic disease client are as follows:

(1) Each chronic disease client shall require services that can be provided safely and effectively at a chronic disease hospital level, shall be ordered by a physician and documented in the client's medical record, and shall include at least a daily physician visit and assessment or the 24-hour availability of medical services and equipment available only in a hospital setting; and

(2) The client's medical condition and treatment needs are such that no effective, safe, less costly alternative placement is available to the client.

(b) The criteria for admission as a rehabilitation client are as follows:

(1) Each rehabilitation client shall require an intensive rehabilitation program at the level of a chronic disease hospital level of care that includes a multi-disciplinary approach to improve the client's ability to function to his or her maximum potential. Factors shall be present in the client's condition that indicate the potential for functional improvement or freedom from pain. A client who requires therapy solely to maintain function shall not be considered an appropriate rehabilitation candidate;

(2) Each client's medical condition and treatment needs are such that no effective, safe, less costly alternative placement is available to the client;

(3) A preadmission assessment shall be developed, prior to admission by specialized skilled nurses, physical therapists, occupational therapists or other rehabilitation specialists, such as speech therapists, prosthetists or orthotists;

(4) The treatment plan of care shall be directed by a physician who is board certified or eligible for board certification in an appropriate specialty; and

(5) The treatment plan of care shall be designed to achieve specific goals within a specified timeframe.

(c) Team conferences shall be conducted for each client. The first team conference shall occur not later than seven calendar days after the client's admission.

(d) For rehabilitation clients, subsequent conferences shall occur at least once every fourteen calendar days. All team members, or a designee within the same specialty, shall be in attendance. The purpose of the conference shall be to conduct an assessment of the client's progress, make adjustments to the established goals as indicated or terminate the program when the expected goal has been reached or determined to be no longer attainable.

(e) For chronic disease clients, subsequent conferences shall occur at least once every 90 days. The depth of the periodic review shall be appropriate to the client's clinical status and prognosis.

(f) The department may use nationally recognized guidelines applicable to chronic disease hospitals or inpatient rehabilitation hospitals in determining if the admission is medically necessary and medically appropriate.

(g) The department shall authorize payment for any individual who meets the criteria set forth in subsections (a) or (b) of this section when he or she:

(1) is a client seeking admission to a chronic disease hospital;

(2) is an individual who applies for Medicaid while in the chronic disease hospital; or

(3) is a client seeking an extension of treatment at a chronic disease hospital.

(h) The department shall pay a provider only when the department has authorized the client's admission to that chronic disease hospital and all other requirements for payment are met.

Conn. Agencies Regs. § 17b-262-783

Adopted effective October 6, 2009