D.C. Mun. Regs. tit. 29, r. 29-6511

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 29-6511 - BEHAVIORALLY COMPLEX CARE

6511.1

In addition to the patient specific per diem rate described in § 6501.2, DHCF shall pay an additional per diem amount for any day that a resident qualifies as behaviorally complex pursuant to the definition set forth in § 6511.2.

6511.2

A behaviorally complex resident is defined as one who demonstrates two (2) or more of the following categories of behaviors, with at least one (1) behavior occurring four (4) or more days per week:

(a) Demonstrates self injury, including head banging, self-biting, hitting oneself, or throwing oneself to floor with or without injury;

(b) Demonstrates physical aggression, including assaulting other residents, staff, or property with or without injury to other residents or staff;

(c) Demonstrates verbal aggression, including disruptive sounds, noises, screaming that disturbs roommate, staff or other residents;

(d) Demonstrates aggressive behaviors, including sexual behaviors, disrobing, throwing or smearing food, feces, stealing, hoarding, going through other residents' or staff belongings, or elopement attempts; or

(e) Consistently rejects medical care.

6511.3

Reimbursement for behaviorally complex residents shall be prior authorized by DHCF. Medical records including the MDS, nursing progress notes, and incident reports supporting experience of behavior, including documentation of disruptive behavior within the last thirty (30) days is required for prior authorization. The documentation shall support that a resident meets the definition set forth in § 6511.2.

6511.4

If the resident has transferred within the last thirty (30) days, the documentation shall include the records from the referring facility.

6511.5

DHCF may authorize reimbursement of the add-on rate not to exceed ninety (90) consecutive days. Any subsequent reimbursement after expiration shall require prior authorization.

D.C. Mun. Regs. tit. 29, r. 29-6511

Final Rulemaking published at 53 DCR 1370 (February 24, 2006); amended by Final Rulemaking published at 66 DCR 13664 (10/18/2019)