La. Admin. Code tit. 50 § II-10155

Current through Register Vol. 50, No. 11, November 20, 2024

Section II-10155 - Standards for Levels of Care

A. Classifications of care are established to ensure placement of residents in Long Term Care Facilities with available and appropriate resources to meet their social psychological, psychological, and biophysical needs.

B. Classifications of care are established with consideration of the resident as a person with innate dignity and worth as a human being.

C. Classifications of care are defined and established so that a resident's total needs, the complexity of the services rendered, and the time required to render these services be assessed in determining placement.

D. Classifications of care are established to prevent placement of residents in facilities where they would present a danger to themselves or other residents.

E. Classifications of care are established to maintain health care so residents achieve a reasonable recovery, maintain a current level of wellness, or experience minimal health status deterioration.

F. Facility Submission of Data. Evaluative data for medical certification for IC I, IC II, and SNF levels of care shall be submitted to the appropriate Bureau of Health Services Financing-Health Standards, Admission Review Unit. This includes data for the following situations:

1. initial applications and reapplication;

2. applications for residents already in long term care facilities;

3. transfers of residents from one level to another;

4. transfer of residents between facilities; and

5. applications for residents who are residents in a mental health facility.

a. All applicants for admission to a nursing facility must be screened for indications of mental illness or mental retardation prior to admission to the nursing facility. This is done by submitting the information requested on Forms 90-L and PASARR-1.

G. Nursing Hours Required

1. The facility will staff for any residents on pass and/or bed hold for hospitalization.

2. Private pay residents must be staffed at the highest level of care unless the level of care is determined by the attending physician.

3. The facility shall provide a minimum nurse staffing pattern and ratio for each level of care as follows.

a. Skilled service shall provide a minimum nurse staffing pattern over a 24 hour period at a ratio of 2.6 hours per skilled resident.

b. Intermediate care services shall provide a minimum licensed nurse staffing pattern over a 24 hour period of 2.35 hours per resident medically certified at the intermediate level.

c. NRTP/Rehabilitation 5.5; NRTP/Complex 4.5.

d. TDC 4.5.

e. Skilled ID 4.0.

4. Intermediate Care I. Intermediate Care I is defined as follows:

a. This is a medium level of care provided to Medicaid recipients residing in nursing facilities. The conditions requiring this level of care are characterized by a need for monitoring of moderate intensity. Care shall be provided by qualified facility staff or by ancillary health care providers under the supervision of a registered nurse or licensed practical nurse in accordance with physician's orders. This care shall be available to residents on a 24 hour a day basis.

b. Intermediate Care I services is determined by the following:

i. The resident shall need services in order to attain and maintain a maximum level of wellness.

ii. Care usually considered IC II can become IC I if there are complicating circumstances.

iii. A resident may have multiple conditions, any one of which could require only IC II level of care, but the sum total of which would indicate the need for IC I level of care.

NOTE: Examples of IC I Services (not all inclusive):

Administration of oral medications and eye drops;

Special appliance: Urethral catheter care;

Colostomy care;

Surgical dressings;

Care of decubitus ulcers which are not extensive;

Dependence on staff for a majority of personal care needs;

Bed or chair bound;

Frequent periods of agitation requiring physical or chemical restraints;

Combined sensory defects (e.g. blindness, deafness, significant speech impairment);

Care of limbs in cast, splints, and other appliances;

Post surgical convalescence;

Incontinence of bladder and/or bowel;

Recent history of seizures;

Need for protective restraints;

Use of oxygen occasionally;

Frequent monitoring and recording of vital signs;

Need for physical therapy; and

Uncommunicative or aphasic and unable to express needs adequately.

5. Intermediate Care II. Intermediate Care II is defined as follows:

a. This is a level of care provided to Medicaid recipients residing in nursing facilities characterized by the need for monitoring of less intensity than Skilled Nursing or Intermediate Care I. This care shall be such that it can be given by facility staff (trained aides and orderlies) who are monitored by and under the supervision of licensed nurses in accordance with physician's orders. These residents require care by licensed personnel for 12 hours a day during daylight hours.

NOTE: Examples of IC II Services (not all inclusive):

Supervision or assistance with personal care needs;

Assistance in eating;

Administration of medication, eye drops, topical applications which can be given in a 12 hour period;

Injections given less frequently than daily or for which a rigid time schedule is not important;

Prophylactic skin care or treatment of minor skin problems in ambulatory residents;

Protection from hazards;

Mild confusion or withdrawal;

Medications for stable conditions or those requiring monitoring only once a day; and

Stable blood pressure requiring daily monitoring.

6. Skilled Nursing Facility Within a NF (Distinct Part SNF Unit). Skilled nursing facilities must provide 24 hour nursing services. Except where waived, the services of a registered nurse is required at least eight consecutive hours a day, seven days a week. The facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Nursing services are not included under "shared services." The distinct part SNF must demonstrate the capacity to provide the services, facilities, and supervision required by SNF requirements of participation.

H. Skilled Nursing Care

1. This is the classification of care provided to Medicaid recipients residing in nursing facilities. The conditions requiring this classification of care are characterized by a need for intensive, frequent, and comprehensive monitoring by professional staff.

2. This care shall be such that it can only be given by a registered nurse or licensed practical nurse or under the supervision and observation of such persons in accordance with physician's orders.

3. This care shall be available to residents only on a 24 hour a day basis.

4. An individual shall be determined to meet the requirements for the SNF classification of care in a nursing facility when the following criteria based on current needs are met. These criteria are meant to be objective, self-explanatory, and universally applicable.

a. The individual requires nursing, psychosocial, or rehabilitation services, i.e., services that must be performed by or under the supervision of the professional health personnel; e.g., registered nurse, licensed practical nurse, physical therapist, occupational therapist, speech pathologist or audiologist, or a combination thereof.

b. The individual requires such services on a regular basis (seven days per week). Rehabilitation services must be at least five days per week.

I. Services Requiring Supervision of Professional Personnel. The following services are those which are considered to require the supervision of professional personnel (including but not limited to):

1. intravenous, intramuscular, or subcutaneous injections;

2. levine tube and gastrostomy feedings;

3. insertion, sterile irrigation and replacement of catheters as adjunct to active treatment of a urinary tract disease;

4. application of dressings involving prescription medications and sterile techniques;

5. nasopharyngeal or tracheostomy aspiration;

6. treatment of decubitus ulcers, of a severity Grade three or worse, or multiple lesions of a lesser severity;

7. heat treatments (moist) specifically ordered by a physician as part of active treatment done by physical therapist;

8. initial phases of a regimen involving administration of medical gases such as bronchodilator therapy;

9. rehabilitation nursing procedures, including the related teaching and adaptive aspects of nursing, i.e. bowel and bladder training;

10. care of a colostomy during the immediate postoperative period in the presence of associated complications;

11. observation, assessment, and judgement of professional personnel in presence of an unstable or complex medical condition and to assure safety of the resident and/or other residents in cases of active suicidal or assaultive behavior; and

12. therapy (at least five times per week):

a. physical therapy;

b. speech therapy; and

c. occupational therapy (in conjunction with another therapy.

i. Documentation must support that skilled services were actually needed and that these services were actually provided on a daily basis.

J. Skilled Id Nursing Care For AIDS. These residents have a clinical diagnosis of Human Immunodeficiency Virus (HIV) infection and related conditions which require 24 hour a day skilled nursing care.

1. Facility Responsibilities. The facility shall:

a. aggressively meet the medical needs of a predominantly young population who have a terminal illness;

b. provide comprehensive skilled nursing care and related services for residents who require constant nursing intervention and monitoring. The staff shall have specialized training and skills in the care of persons with HIV;

c. develop policy to govern the comprehensive skilled nursing care and related medical or other services provided. This includes a physician, registered nurse, and any other staff responsible for the execution of such policies;

d. have an established plan to insure that the health care of every resident is under the supervision of a licensed physician interested and experienced in the primary care of persons with HIV;

e. make provision to have a licensed physician available to make frequent visits and to furnish necessary medical care in cases of an emergency;

f. make provisions to have 24 hour access to services in an acute care hospital;

g. maintain clinical records on all residents and maintain the confidentiality of such records to the highest extent possible;

h. provide 24 hour nursing service sufficient to meet the complex nursing needs with registered nurse coverage 24 hours per day, seven days per week as the plan of care indicates;

i. provide appropriate methods and procedures for dispensing and administering medications and biologicals which shall also include a protocol for experimental pharmaceutical use;

j. provide policy, procedure, and ongoing education for enhanced universal precautions, be responsible for keeping policy update on current trends for universal precautions related to infectious diseases as outlined by the Center for Disease Control (CDC), and develop specific policies (Practices and Precautions) for preventing transmission of infection in the work-place including employee health issues;

k. provide social services sufficient to meet the mental, psychosocial, behavioral, and emotional needs of the resident. These services shall be provided by a social worker with at least a master level degree from an accredited school of social work and who is licensed as applicable by the state of Louisiana, who shall provide a minimum of two hours per week of services per resident;

l. provide dietary services to meet the complex and comprehensive nutritional needs of the resident. These services shall be provided by registered dietician who shall provide at least one hour per week per resident, but in no case less than four hours per month;

m. provide a dynamic activity program congruent with the needs and ages of the resident which includes an exercise program when indicated to promote and maintain the residents tolerance level to daily activity levels;

n. provide and/or arrange transportation services to meet the medical needs of the resident;

o. provide for the resident the opportunity to participate in the coordination and facilitation in the service delivery and personal treatment plan;

p. provide care plan meetings and updates as often as necessary as necessary by the residents changing condition;

q. provide for appropriate consultation and services to meet the needs of the resident including but not limited to: oncology, infectious diseases, hematology, neurology, dermatology, gastro-enterology, thoracic, gynecology, pediatrics, mental health and/or any other specialized services as indicated;

r. develop respiratory therapy protocols. The respiratory therapist shall work with other medical staff to assure compliance. These services shall be provided as often as necessary by a respiratory therapist either contractually or full-time employment for no less than eight hours per month;

s. provide physical therapy and other rehabilitative services as necessary to meet the special needs of the resident with sensory perception deficit (touch, hearing, sight, etc.);

t. provide and/or arrange through community resources for legal and/or pastoral services an needed by the resident;

u. provide a component of care related to personality changes and communication problems brought on as the illness progresses;

v. provide for access to volunteers and community resources;

w. provide for access to "significant others" to participate in the emotional support and personal care services;

x. Provide a minimum daily average of 4.0 actual nursing hours per resident.

2. Determination of Skilled Nursing Services for Aids. An individual shall be determined to meet the requirements for SN-ID HIV classification of care in a Long Term Care facility when the following criteria, based on current needs are met. These criteria are meant to be objective, self-explanatory, and universally applicable.

3. Payment or reimbursement is not made just because of a diagnosis of AIDS or being HIV+. The payment is intended to be reimbursement for the additional expenses of administering IV therapy and the additional RN hours required to provide this type of therapy in the nursing facility.

a. Enhanced level of universal precautions based on resident needs (blood and body fluid precautions)

b. Continuous ongoing education regarding disease process, infection control, medication, side effects, etc.

4. These services are in conjunction with the following:

a. intermittent or continuous IV therapy, respiratory therapy, nutritional therapy, or other intervention;

b. administration of highly toxic pharmaceutical and experimental drugs which include monitoring of side effects;

c. continuous changes in treatment plan for symptom control;

d. daily medical/nursing assessment for residents changing condition;

e. continuous monitoring for:

i. tolerance level;

ii. skin integrity;

iii. bleeding;

iv. persistent diarrhea;

v. pain intensity;

vi. mental status;

vii. nutritional status; and

viii. tuberculosis (monthly sputum for AFB).

5. The following related conditions may also require SNF ID LOC for HIV:

a. opportunist infections;

i. pneumocystis carnii pneumonia (PCP);

ii. mycobacterium avium-intracellular complex (MAC);

iii. cytomegalovirus;

iv. cyptocpccus neoformans;

v. strongylcides stercoralis

b. non-opportunistic infections:

i. mycobacterium tuberculosis;

ii. pyogenic bacteria (staphylococcus, Strepto-coccus, etc.); and

iii. histoplasmosis;

c. Malignancies-Kaposi's Sarcoma;

d. opportunistic gastrointestinal infections:

i. Cyptosporidium;

ii. Isospora Belli; and

iii. Malabsorption Syndrome with progressive malnutrition;

e. neurological complications:

i. progressive multi-focal leukoencephalopathy;

ii. brain abscesses;

iii. acute encephalitis;

iv. vascular accident;

v. toxoplasmosis; and

vi. retinopathy.

K. Infectious Disease For Methicillin-Resistant Staphylococcus Aureus (MRSA)- Determination of Skilled Nursing Services for MRSA

1. The following resident criteria for reimbursement of services under the Infectious Disease (MRSA) rate must be met to establish the need for care at this designation. These criteria are meant to be objective, self-explanatory, and applicable to those residents seeking care at this designation. The resident shall:

a. have a positive MRSA culture (symptomic). Symptoms may be manifested locally or systemically and include but not limited to: Erthema, edema, cellulitis, abcessed furuncles, carbuncles, septicemia, osteomyelitis, purulent drainage, elevated white count, elevated temperature, wound infections or urinary infections;

b. require IV antibiotic therapy given in the nursing facility or a hospital;

c. require comprehensive skilled nursing;

d. require that isolation procedures be initiated and maintained as the plan of care dictates.

2. Facility responsibilities to residents at this level of care designation shall:

a. meet the medical nursing needs of residents having MRSA and maintain documentation of such care;

b. have laboratory confirmation of a diagnosis of MRSA done by a laboratory certified by national standards;

c. collect specimens for culture utilizing acceptable techniques or arrange for this to be done by a laboratory. This shall be done as soon as the facility becomes aware of infection and includes but is not limited to drainage from skin lesions, blood, sputum, urine, and aspirations;

d. institute isolation procedures immediately when a resident with indications of MRSA is admitted to the facility or there is an infection identified in-house using the Center for Disease Control (CDC) guidelines. These procedures shall be initiated even if the physician has not seen the resident or been contacted. These procedures shall be fully documented;

e. have physician orders for each resident that are specific for each resident's situation. Standing orders shall not be used without the physicians approval for each individual resident;

f. be expected to insure that IV vancomycin will be initiated under physician order when MRSA has been identified in an active infection with tissue invasion. This therapy can be given within the hospital or in the nursing facility. Exceptions to vancomycin treatment may be made for debilitated and very aged resident(s), a history of sensitivity to this agent, and end state renal disease. Any reason for exception to IV vancomycin therapy must be described in detail the resident's chart and a copy of this documentation provided to Health Standards. There is no assurance that an exception will be granted;

NOTE: The intent for the insertion of the "exception" portion of the Declaration of Emergency document was to remove the appearance of mandating that physicians must treat MRSA residents with IV antibiotics (Vancomycin) under all conditions and circumstances, fully realizing that there would be conditions and circumstances in which Vancomycin could not or would not be given. Payment or reimbursement shall not be made in any case where the resident did not receive the I.V. medication for whatever the reason. Each case requesting an exception will be reviewed on an individual basis. The payment is intended to be reimbursement for the additional expenses of administering IV antibiotics and 24-hour RN coverage. It is not paid just because of the diagnosis of MRSA. Isolation in itself is not a reason for payment for SN-ID, as other diseases require isolation procedures and are not reimbursed as SN-ID.

g. provide IV therapy in the nursing facility only with RN coverage 24 hours a day under a registered nurse employed by the facility and with appropriate laboratory monitoring;

h. provide continuous nursing assessment of any change in the resident's status or therapy;

i. provide aggressive wound care and other indicated nursing care. This must be administered by nurses skilled in these procedures and documentation maintained;

j. provide social services by a masters level social worker and a registered dietician as dictated by the plan of care;

k. provide equipment, supplies, and teaching necessary for significant others to visit the residents;

l. evaluate an individual who is an asymptomatic carrier of MRSA with a complicating problem (example: tracheostomy, gastrostomy, colostomy) for need for IV vancomycin therapy;

m. have policy, procedures, and ongoing education for enhanced universal quality assurance infection control;

n. be responsible for maintaining facility policies updated with current trends in infection control as outlined by the Center for Disease Control;

o. develop specific policies, practices, and precautions for preventing transmission of infection in the facility for protection of residents and employees;

p. have training based on CDC guidelines for MRSA for facility staff responsible for infection control.

3. Requirements for Participation. The facility shall:

a. be currently enrolled to provide nursing services for the treatment of methicillin-resistant staphylococcus aureus; and

b. sign the addendum to the Provider Agreement for participation in the NF-Infectious Disease (MRSA) level of care designation.

4. Certification Requirements. The following medical certification requirements must be met in addition to the Forms 90-L and 148.

a. The facility data submission shall follow the guidelines published for the levels of care.

b. The following additional information requirements must be met:

i. date of onset of MRSA infection;

ii. physicians' orders (specific to each resident's care relating to MRSA infection);

iii. request for a change in level of care to provide treatment for MRSA;

iv. laboratory reports verifying the diagnosis of MRSA;

v. detailed description including measurements of the lesions on tissue involvement; and

vi. documentation that appropriate isolation procedures were carried out (description) from date of the level of care request.

5. Reimbursement Requirements

a. The level of care change request must be approved.

b. Request for changes in the resident's level of care from MRSA level to the former level of care must be completed promptly.

c. The infectious disease reimbursement rate will be paid during the hospital stay.

L. Skilled Infectious Disease; Tuberculosis Multiple Drug Resistant Tuberculosis. This is a Medicaid program (Title XIX) which was developed in conjunction with the TB Control Section of the Department of Public Health. The purpose of the program is to meet the needs of Louisiana citizens who require specialized care for the treatment of tuberculosis of the respiratory tract who are sputum positive for the Tuberculosis germ and who cannot be treated on an out-resident basis for whatever reason.

1. Determination of SN-ID; Tuberculosis. The resident shall:

a. be referred to the nursing facility only by the Tuberculosis Section of the Louisiana Department of Public Health;

b. have a diagnosis of active tuberculosis of the respiratory tract;

c. have an infection caused by the Mycobacterium tuberculosis or Mycobacterium bovis, but not by other mycobacterial species (atypical Tuberculosis);

d. require 24 hour specialized skilled nursing care;

e. be treated under the umbrella of guidelines from the Tuberculosis Section of the Department of Public Health and monitored by the regional tuberculosis clinician;

f. require that immediate isolation procedures be initiated and that the resident not be released from isolation until three sputum smears collected on consecutive days have been negative for acid-fast bacilli. Thereafter, sputum will be monitored at least biweekly or whenever symptoms recur or worsen. If the sputum smear again becomes positive for acid-fast bacilli, isolation will be immediately re-instituted;

g. be admitted and discharged by the public health officer;

h. have 24 hour security guard when needed.

2. Facility Responsibilities

a. The nursing facility shall be approved by the Tuberculosis Section of the Public Health Department to care for SN-ID Tuberculosis residents.

b. The approval shall include as having appropriate "Source-Control Methods" ventilation systems to prevent Tuberculosis bacilli transmission in accordance with federal, state, and local regulations for environmental discharges.

c. Shall monitor at appropriate intervals the ventilation system to maintain effective control of possible transmission of the Tuberculosis bacilli.

d. Initiate, update, and maintain vigorous infection control policy and procedures to manage the infectious/contagious disease process according to current trends established by the Centers for Disease Control and Prevention.

e. Shall employ or contract with an engineer or other professional with expertise in ventilation or other industrial hygiene. This person shall work closely with the Infection Control Committee in the control of airborne infections.

f. Achieve, maintain, and document compliance with all requirements outlined in the Minimum Standards for Nursing Facilities and the enhanced requirements for SN-ID.

g. Shall inform the Regional Tuberculosis Clinician if the resident becomes intolerant of Tuberculosis medications or refuses Tuberculosis medications.

3. Facility Requirements for Participation

a. The facility shall be enrolled as a provider of the Nursing Facility/Infectious Disease (SN-ID) program with appropriate Provider Agreements to participate.

b. The facility shall be currently enrolled to provide nursing facility services to the level of care designation for the treatment of tuberculosis.

c. The facility has been designated by Tuberculosis Control of the Public Health Department to provide SN-ID Tuberculosis care to those residents referred by them.

M. The following medical certification requirements shall be met in addition to the Forms 148, 90-l and PASARR.

1. The facility data submission shall follow the guidelines established for the level of care.

2. The following additional information requirements must be met:

a. outside information consisting of summary of drug therapy prior to admission, past, and present history of non-tubercular illness such as diabetes, previous drug reactions, laboratory test results, and any previous eye or VII cranial nerve tests (auditory and equilibrium);

b. physician orders specific to Infection Control for tuberculosis and other infectious diseases including but not limited to HIV and Staphylococcus Aureus/Methicillin resistant staph Aureus infections;

c. documentation to support that appropriate isolation procedures were implemented on admission.

3. Reimbursement Requirements

a. The 90-L, level of care, and PASARR must be approved by the Department of Health and Hospitals, Health Standards Section.

b. Request for change in level of care when the resident is discharged from the SN-ID Tuberculosis level shall be submitted within five working days.

c. The SN-ID TB reimbursement rate is not applicable to residents who have a non-pulmonary/respiratory diagnosis or who have atypical mycobacteriosis or who have a conversion of skin test without positive sputum.

d. The SN-ID tuberculosis reimbursement rate will be paid during a hospital stay up to the customary ten day bed hold policy.

N. Rehabilitation and Complex Levels of Care

1. These levels of care were developed to provide services and care to residents who have sustained severe neurological injury or who have conditions which have caused significant impairment in their ability to independently carry out activities of daily living. Residents shall have, based upon a physicians assessment, the potential for regaining a level of functioning which is feasible. Significant practical improvement must be expected in a prescribed or predetermined period of time. An expectation of complete independence in the activities of daily living is not necessary, but there must be a reasonable expectation of improvement that will be of practical value to the resident measured against his/her condition at the start of care.

2. Rehabilitation services are designed to reduce the resident's rehabilitation and medical needs while restoring the person to an optimal level of physical, cognitive, and behavioral function within the content of the person, family, and community.

3. Complex care services are designed to provide care for residents who have a variety of medical/surgical concerns requiring a high skill level of nursing, medical and/or rehabilitation interventions to maintain medical/functional stability.

O. Rehabilitation and Complex Levels of Care

1. These levels of care were developed to provide services and care to residents who have sustained severe neurological injury or who have conditions which have caused significant impairment in their ability to independently carry out activities of daily living. Residents shall have, based upon a physician = s assessment, the potential for regaining a level of functioning which is feasible. Significant practical improvement must be expected in a prescribed or predetermined period of time. An expectation of complete independence in the activities of daily living is not necessary, but there must be a reasonable expectation of improvement that will be of practical value to the resident measured against his/her condition at the start of care.

2. The health conditions of the individuals who qualify for either of these levels of care are too medically complex or demanding for a typical skilled nursing facility, but no longer warrant care in an acute setting. Reimbursement is available under the Title XIX program for a period not to exceed 90 days if medical eligibility criteria established by the department have been met. Extensions may be requested in 30-day increments up to a maximum of three extensions based on documentation contained in progress reports. Level of care certification cannot exceed a total of six months. The Health Standards Section shall review the documentation submitted by the facility and determine if the applicant meets the criteria for admission certification and continued stay at these levels of care.

3. The rehabilitation and complex levels of care shall utilize the Consumer Price Index for All Urban ConsumersC Southern Region, All Items Economic Adjustment Factors, as published by the United States Department of Labor to give yearly inflation adjustments. This economic adjustment factor is computed by dividing the value of All Items index for December of the year preceding the rate year (July 1 through June 30) by the value of the All Items index one year earlier (December of the second preceding year). This factor, All Items, will be applied to the total base which excludes fixed cost. Rebasing and interim adjustments to rates shall be calculated in the same manner as for regular nursing facilities.

4. Annual financial and compliance audits are required from the providers of these services. Additional cost reporting documents as requested by the department may also be required. Providers are required to segregate these costs from all other nursing facility costs and submit a separate annual cost report for each level of care (rehabilitation and complex care services). Medicare cost principles found in the Provider Reimbursement Manual (HIM-15) shall be used to determine allowable costs.

P. Criteria for Certification of SN Rehabilitation and SN-Complex Level of Care, and Provision of Services

1. Medical Eligibility Criteria for Certification of SN-Rehabilitation Level of Care. Residents seeking skilled services at the SN Rehabilitation level of care shall meet all of the following criteria:

a. require an intense, individualized rehabilitation program designed to address severe neurological deficits (not due to a psychiatric disorder) caused from an injury or neurological condition which shall have occurred within six months from the date of admission;

b. have a severe loss of function (not secondary to behavioral deficits) in activities of daily living, mobility, and communication with the potential for significant practical improvement as measured against his/her condition prior to rehabilitation;

c. shall be capable of participating in a minimum of two hours of active (not passive) rehabilitation (OT, PT, ST) per day;

d. require a minimum of 5.5 hours of nursing care per day. Monitoring of behaviors by attendants cannot be considered as meeting the required nursing hours;

e. require aggressive medical support and a coordinated program of care delivered through a multidisciplinary team approach;

f. demonstrate documented, measurable progress toward the reduction of physical, cognitive and/or behavioral deficits to qualify for continued funding at this level of care.

2. Exclusionary Criteria for SN-Rehabilitation Services. Residents meeting any one of the following criteria do not qualify for this level of care:

a. the resident has already participated in a comprehensive rehabilitation effort on an inpatient basis either in an acute care setting or other type of rehabilitation facility;

b. the resident has a neurological condition which is considered to be progressive in nature and where no practical improvement can be expected (e.g., Huntington's Chorea);

c. the resident requires medication adjustment or attention to psychological problems related to a neurological condition or injury but has the ability to carry out the basic activities of daily living;

d. the resident lives out of state and has access to rehabilitation services in his/her state of residence;

e. the resident does not have sufficient mental alertness to actively participate in the program;

f. the resident has a major psychiatric disorder (schizophrenia, manic-depression, etc.) which precludes active participation;

g. the resident with an uncomplicated CVA whose needs can be met at the skilled level of care.

3. Medical Eligibility Criteria for Certification of SN-Complex Level of Care. Residents seeking skilled services at the complex level of care shall meet all of the following criteria:

a. have a neurological injury/condition resulting in severe functional, cognitive and/or physical deficits which shall have occurred within six months from the date of admission;

b. require a level of care and services which are not able to be provided in a typical skilled nursing facility or on an outpatient basis. Facility documentation must specify why an alternative setting is inappropriate or inadequate to meet the needs of the resident;

c. require a minimum of 4.5 hours of nursing care per day;

d. shall be capable of participating in a minimum of two hours of active (not passive) rehabilitation per day.

4. Provision of Therapy Services for SN Rehabilitation and Complex Level of Care. Therapy services must be rendered on a per resident basis by a licensed therapist. Skilled therapy services must meet all of the following conditions:

a. the services must be directly and specifically related to an active written treatment plan designed by the physician after any needed consultation with a multidisciplinary team including a licensed therapist(s);

b. therapies shall be available and provided at least five days per week. If the resident is unable to participate or refuses to participate, the facility shall document the reason for nonparticipation and shall promptly notify the Health Standards Section;

c. the services must be of a level of complexity and sophistication, or the condition of the resident must be of a nature that requires the judgment, knowledge, and skills of a licensed therapist(s);

d. the services must be provided with the expectation, based on the assessment made by the physician of the resident's restoration potential, that the condition of the resident will improve materially in a reasonable and generally predictable period of time, not to exceed 90 days, or the services must be necessary for the establishment of a safe and effective maintenance program which can be continued after discharge;

e. the services must be considered under accepted standards of medical practice to be specific and effective treatment for the resident's condition;

f. the services must be reasonable and necessary for the treatment of the resident's condition; this includes the requirement that the amount, frequency, and duration of the services must be reasonable and not able to be provided in a less restrictive setting such as outpatient. Documentation by the facility must support that rehabilitation services are actually needed on an inpatient basis. When the resident has behavior or physical limitations that cannot be modified any further, the level of care shall be discontinued. There must be significant practical improvement as measured against the condition or injury prior to the episode which resulted in admission - significant improvement being the ability to self-perform activities of daily living;

g. therapy cannot be provided at the skilled level of care. The medical record shall document why the therapy cannot be provided at a lower level of care;

h. recreational therapies shall not be included when determining compliance with the required number of hours of therapy a day.

5. Criteria for Discharge from the Rehabilitation and Complex Levels of Care

a. there is evidence in the medical record that the resident has achieved stated goals;

b. medical complications preclude an intensive rehabilitation effort. Any regression or deterioration in the resident's medical condition shall immediately be reported to the Health Standards Section;

c. multidisciplinary therapy is no longer needed;

d. no additional practical improvement in function is anticipated;

e. the resident's functional status has remained unchanged for 14 days;

f. the resident has received services for 90 days;

g. if the resident exhibits inability or refuses to participate in therapy, this shall constitute termination of rehabilitation services and/or recertification for level of care. Discharge shall be initiated when the resident fails to participate in five consecutive therapy sessions during a two-week period;

h. the resident has an established behavior management plan.

Q. Documentation Requirements for Vendor Payment

1. Documentation Requirements for the Determination of Medical Eligibility for Vendor Payment. The following documentation requirements shall be submitted to the Health Standards Section for consideration of medical certification at either the rehabilitation or complex levels of care:

a. Form 148 (Notification of Admission/Change);

b. Form 90-L (Request for Level of Care Determination);

c. Level I PAS/RAS (Pre-admission Screening/ Re-admission Screening);

d. history of current condition;

e. presenting problems and current needs;

f. if transferring from an acute care hospital, all therapy evaluations, therapy progress reports, physician's orders and physician progress notes;

g. assessments done by facility field evaluators;

h. evaluations done by all facility therapists participating in the individual treatment plan;

i. preliminary plan of care including services to be rendered; plan should specify frequency, responsible discipline, and projected time frame for completion of each goal.

2. Documentation of Progress. The facility shall document, in detail, progress in meeting goals.

a. Progress reports shall be submitted to the Health Standards office every 30 days. Progress reports shall address the resident's ability to self-perform activities of daily living. If there is no progress in this area, it shall be so stated.

b. Active discharge planning shall be addressed in all progress reports. If the established goal is to return home, involvement by family members or significant others shall be noted in progress reports.

c. It is not necessary that progress reports recapitulate events resulting in admission.

d. It is the responsibility of the facility to promptly notify the Health Standards Section when goals have been achieved or the resident is not making progress toward meeting established goals, regardless of the amount of time in the program.

R. Facility Responsibilities for Participation. The facility seeking to provide services under the rehabilitation and complex level of care must meet all of the following requirements:

1. be licensed to provide nursing facility services and shall admit and maintain residents requiring any nursing facility level of care designation;

2. have a valid Medicaid Program provider agreement for provision of nursing facility services;

3. have entered into a contractual agreement with the Bureau of Health Services Financing to provide rehabilitation and complex care services;

4. be accredited by the Joint Commission on Accreditation on Health Care Organizations (JCAHO) and by the Commission on Accreditation of Rehabilitation Facilities (CARF);

5. have appropriate rehabilitation services to manage the complex functional and psychosocial needs of the residents and appropriate medical services to evaluate and treat the pathophysiologic process. The staff shall have intensive specialized training and skills in rehabilitation;

6. provide an interdisciplinary team of professionals to direct the clinical course of treatment. This team shall include, but is not limited to a physician, registered nurse, physical therapist, occupational therapist, speech/language therapist, respiratory therapist, psychologist, social worker, recreational therapist, and case manager;

7. ensure that the health and rehabilitation needs of every resident in certified for rehabilitation/complex level of care shall be under the supervision of a licensed physiatrist, board-certified or board-eligible in physical medicine and rehabilitation;

8. have policies and procedures to ensure that a licensed physician visits and assesses each resident's care frequently but no less than weekly;

9. have formalized policies and procedures to furnish necessary medical care in cases of emergency and provide 24-hour-a-day access to services in an acute care hospital;

10. have established policies to screen residents who are not appropriate for the program according to the Medicaid medical eligibility criteria or whose needs the facility cannot meet;

11. have each resident assigned to a facility case manager to monitor, measure, and document goal attainment and functional improvement. The case manager shall be responsible for cost containment and appropriate utilization of services. Coverage should stop when further progress toward the established rehabilitation goals are unlikely or can be achieved in a less intensive setting;

12. assure that discharge planning is an integral part of the rehabilitation program and should begin upon the resident's admittance to the facility. Plans of care must be individualized and aggressive with regard to the projected time frame for discharge. When progress notes show that the resident has not made significant, measurable progress from one review period to the next or that the condition cannot be modified any further, Medicaid will not authorize further reimbursement for rehabilitation. Significant progress should be the ability to self-perform or require only minimal to moderate assistance to perform activities of daily living;

13. provide private rooms for residents demonstrating extraordinary medical and/or behavioral needs. Dedicated treatment space shall be provided for all treating disciplines including the availability of distraction-free individual treatment rooms and areas;

14. provide 24-hour nursing services to meet the medical and behavioral needs with registered nurse coverage 24 hours per day, seven days a week. Management of the resident's daily activities shall be under the direct supervision of a registered nurse;

15. provide appropriate methods and procedures for dispensing and administering medications and biologicals that are in accordance with the organizations issuing the facility's accreditations;

16. have formalized policies and procedures for ongoing staff education in rehabilitation, respiratory, specialized medical services, and other related clinical and nonclinical issues. Staff education shall be provided on a regular basis;

17. provide dietary services to meet the comprehensive nutritional needs of the residents. These services shall be provided under the direction of a registered dietician who shall consult a minimum of two hours per month;

18. provide families/significant others the opportunity to participate in the coordination and facilitation of service delivery and individual treatment plan;

19. provide nonmedical and nonemergency medical transportation services and arrange for medical transportation services to meet the medical/social needs of the residents;

20. provide initial and ongoing integrated, interdisciplinary assessments to develop treatment plans which should address medical/neurological issues such as sensorimotor, cognitive and perceptual deficits, communicative capacity, affect/mood, interpersonal and social skills, behaviors, ADLs, recreation/leisure skills, education/vocational capacities, sexuality, family, legal competency, adjustment to disability, post-discharge services environmental modifications, and all other areas deemed relevant for the individual;

21. assure that the interdisciplinary team meets in conference at least every 14 days to update the individual treatment plan but as often as necessary to address the changing needs of the client;

22. provide appropriate consultation services to meet the needs of clients, including, but not limited to, audiology, orthotics, prosthetics, or any other specialized services;

23. establish a protocol for ongoing contact with professionals in vocational rehabilitation education, mental health, developmental disabilities, Social Security, medical assistance, head injury advocacy groups and any other relevant community agencies;

24. establish protocols to provide for a close working relationship with acute care hospitals capable of caring for persons with brain and upper spinal cord injuries to provide post discharge follow-up, in-service education and on-going training of treatment protocols to meet the needs of residents;

25. establish written policies and procedures to address referrals coming from out of state. The facility must provide written explanation as to what steps were taken to obtain services within the state of residence and why the services were not available or inadequate to meet the needs of the resident. The facility shall seek reimbursement for all level of care services from the state of residence or referral prior to making application for Louisiana Medicaid.

S. Change in Level of Care Within a NF. The facility shall be responsible for submitting current medical information to the HSS Regional Office for approval of level of care change when recommended by the attending physician. Form 149-B shall be completed when making the request for change. This procedure shall be followed whether the change is within the facility or requires a move to another facility. The facility shall have five working days to submit Form 149-B to the Health Standards Section for both upgrade and downgrade in level of care. The effective date of medical certification will be the date the physician signs the Form 149-B. If the facility fails to submit the request timely, the certification will be the date the Form 149-B is received in the HSS Regional Office. A statement from the physician in lieu of Form 149-B is not acceptable when requesting level of care change. If applicable, notice is also required when a resident transfers to Medicare skilled level. The state will pay co-insurance beginning on the twenty-first day.

1. -2.t. Reserved.

u. require staff to attend specialized training on ventilator assisted care if the facility provides SN-TDC services to Medicaid recipients from birth through age 25. The training will be conducted by a contractor designated by the department. The facility shall also cooperate with ongoing monitoring conducted by the contractor. Training content includes:

i. the special health needs of, and risks to ventilator-dependent recipients;

ii. the proper use and maintenance of equipment in use or new to the facility;

iii. current, new, or unusual health procedures and medications;

iv. diagnoses and treatments specific to pediatrics and in the development and nutritional needs of recipients;

v. emergency intervention;

vi. accessing school services for ventilator-assisted recipients; and

vii. discharge planning where families express interest in a recipient returning home.

2. v.- 3.e. Reserved.

T. Change in Level of Care Within a NF. The facility shall be responsible for submitting current medical information to the HSS Regional Office for approval when the attending physician recommends a change in the level of care. Form 149-B shall be completed when making the request for a level of care change. This procedure shall be followed whether the change is within the facility or whether the change requires a transfer to another facility. A statement from the physician, in lieu of Form 149-B, is not acceptable.

1. The facility shall have 20 working days to submit Form 149-B to the Health Standards Section for both upgrades and downgrades in level of care. If submitted within the 20working day time frame, the effective date of change in medical certification will be the date the physician signs the Form 149-B.

2. If the facility fails to timely submit the request, the effective date of the medical certification will be the date the Form 149-B is received in the HSS Regional Office.

3. The completion of the Form 149-B is also required when a resident transfers to Medicare skilled level.

4. The Medicaid Program will pay co-insurance beginning on the twenty-first day.

La. Admin. Code tit. 50, § II-10155

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 22:34 (January 1996), LR 23:970 (August 1997), 24:457 (March 1998), LR 29:911 (June 2003).

AUTHORITY NOTE: Promulgated in accordance with R.S. 46:153.