C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-67, subsec. 144-101-II-67.01

Current through 2024-51, December 18, 2024

Subsection 144-101-II-67.01 - DEFINITIONS

67.01-1Nursing Facility (NF) means, a Skilled Nursing Facility (SNF) in the Medicare program or a Nursing Facility (NF) in the Maine Care program which meets State licensing and Federal certification requirements for nursing facilities and has a valid agreement with the Department of Health and Human Services (the Department).

"Nursing facility" may include a distinct part of an institution which meets the above requirements.

A NF may not be an institution for mental diseases, nor an institution for the intellectually disabled or persons with related conditions.

67.01-2Nursing Facility Services means services that are:

- primarily professional nursing care or rehabilitative services for injured, disabled, or sick persons;

- needed on a daily basis and as a practical matter can only be provided in a nursing facility;

- ordered by and provided under the direction of a physician; and

- less intensive than hospital inpatient services.

67.01-3Dually-Certified Facility is a facility that is certified to participate in both the Medicare and MaineCare programs. Dually-certified facilities are not limited to distinct parts since all of the beds in the facility are dually-certified.

67.01-4Swing-Bed is a skilled Medicare certified hospital bed that may be used interchangeably as an acute care bed or a skilled nursing facility bed. For additional information pertaining to swing-beds refer to Chapter II, Section 45, of this Manual regarding Hospital Services.

67.01-5Utilization Review is the evaluation of the necessity, appropriateness, and efficiency of the use of services, procedures, and facilities by each participating nursing facility. It includes a review of the appropriateness of admissions, services ordered and provided, continued stays, and discharge practices.

67.01-6Mental Illness (MI) or a mental disorder is:

(a) schizophrenic, mood, paranoid, panic or other severe anxiety disorder; somato form disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability; but

(b) not a primary diagnosis of dementia, including Alzheimer's disease or a related disorder, or a non-primary diagnosis of dementia unless the primary diagnosis is a major mental disorder as defined in Section 67.01-6(a).

67.01-7Intellectual Disability means a diagnosis of Mental Retardation as defined in the most current version of the American Psychiatric Association's Diagnostic and Statistical Manual, that manifested during the developmental period, in accordance with the definition of Intellectual Disability codified in 34-B MRSA §5001(3).

67.01-8Resident Assessment Instrument (RAI) is the assessment tool approved by the Department to provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity. It is comprised of the Minimum Data Set (MDS) and the Resident Assessment Protocols (RAPs). The RAI is not an assessment tool for determination of medical eligibility.

67.01-9Plan of Care (or care plan) includes measurable objectives and timetables related to meeting a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident assessment. The care plan must describe the following:

1) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and

2) Any services that would otherwise be required but are not provided due to the resident's exercise of his or her rights, including the right to refuse treatment. A copy of the Plan of Care is included in the member's medical record.

67.01-10Limited Assistance is a term used to describe an individual's self-care performance in activities of daily living, as defined by the Minimum Data Set (MDS) assessment process. It means although the individual was highly involved in the activity over the last seven (7) days, or twenty-four (24) to forty-eight (48) hours if in a hospital setting, help of the following type(s) was provided:

- Guided maneuvering of limbs or other non-weight-bearing assistance three (3) or more times, or

- Limited assistance (three (3) or more times,) plus weight-bearing support provided only one (1) or two (2) times.

67.01-11One-person Physical Assist requires one (1) person to provide either weight-bearing or non-weight-bearing assistance for an individual who cannot perform the activity independently over the last seven (7) days, or twenty-four (24) to forty-eight (48) hours if in a hospital setting. This does not include cueing.

67.01-12Extensive Assistance means although the individual performed part of the activity over the last seven (7) days, or twenty-four (24) to forty-eight (48) hours if in a hospital setting, help of the following type(s) was provided:

- Weight-bearing support three (3) or more times, or

- Full staff performance during part (but not all) of the last seven (7) days.

67.01-13Total Dependence means full staff performance of the activity during the entire last seven (7) day period across all shifts. Complete non-participation by the resident in all aspects of the Activities of Daily Living (ADLs).

67.01-14Specialized Services for People with Intellectual Disabilities or Other Related Conditions are continuous active treatment programs that include aggressive, consistent implementation of a program of specialized and generic training, treatment, health services, and related services.

67.01-15Specialized Services for People with Mental Illness are mental health services developed by an interdisciplinary team and include specific therapies and activities that are directed at diagnosing conditions, reducing symptoms, and achieving a level of functioning that permits reduction in the intensity of mental health services.

67.01-16Unstable: A medical condition is unstable when it is fluctuating in an irregular way and/or is deteriorating and affects the resident's ability to function independently. These changes must require medical treatment and professional nursing observation assessment and management at least once every eight (8) hours. The change or decline in physical health requires increased physician involvement and should result in communication with the physician for adjustments in treatment and medication. Evidence of fluctuating vital signs, lab values, and physical symptoms and plan of care adjustments must be documented in the medical record. The loss of function resulting from a temporary disability from which full recovery is expected does not qualify as instability as defined under this Section.

67.01-17Assessment Form: The form approved by the Department for medical eligibility determination or advisory assessments required in this Section. The definitions, scoring mechanisms and time-frames included in this form are outlined in Section 67.02-3. This form is also known as the Medical Eligibility Determination (MED) form. The Assessment Form does not include the Minimum Data Set (MDS).

67.01-18Residence: means an individual's permanent dwelling. If the individual does not have a permanent dwelling, the nursing facility shall be considered his/her residence.

67.01-19Cognition is the ability to recall what is learned or known and the ability to make decisions regarding tasks of daily life. Cognition is evaluated in terms of:

1. Memory: short-term and long-term memory;

2. Memory/recall ability during last seven (7) days, or twenty-four (24) to forty-eight (48) hours if in a hospital; and

3. Cognitive skills for daily decision making on a scale including: independent; modified independence; moderately impaired; severely impaired.

A "threshold" score for "cognition" on the eligibility Assessment Form is equal to a score of one (1) for loss of short term memory and one (1) or two (2) of items A-D or E, no items for memory/recall ability, and a score of two (2) or three (3) for cognitive skills for decision making.

67.01-20Problem Behavior refers to wandering with no rational purpose; verbal abuse; or physical abuse; or socially inappropriate/disruptive behavior. A "threshold" score for problem behavior on the eligibility Assessment Form is equal to a score of two (2) or three (3) in one (1) of these four (4) criteria and occurs at least four (4) days per week.

67.01-21Authorized Entity shall mean the organization authorized by the Department to perform specified functions pursuant to a signed contract or other approved signed agreement.

67.01-22Acquired Brain Injury (ABI) is an insult to the brain resulting directly or indirectly from trauma, anoxia, or vascular lesions, or infection, which: is not of a degenerative or congenital nature; can produce a diminished or altered state of consciousness resulting in impairment of cognitive abilities or physical functioning; can result in the disturbance of behavioral or emotional functioning; can be either temporary or permanent; and can cause partial or total functional disability or psychosocial maladjustment ( 22 M.R.S. §3086).

67.01-23Frequent Change in Care Setting shall mean three (3) or more moves from one care setting to another care setting, including the following settings: home, residential care facility, nursing facility or other specialized facility, excluding hospitals, within a nine (9) month period. Hospital admissions/discharges are not counted as a change in care setting or move. Each change in care setting counts as one (1) move, e.g. - moving from home to NF counts as one (1) move; - moving from home to NF and back home counts as two (2) moves. (A change in the "level of care" within a facility is not a "change in care setting" under this Section.)

67.01-24Member in this Section is an individual who meets financial and other eligibility requirements set forth in the MaineCare Eligibility Manual and has also been determined to meet the eligibility requirements of this Section and is prior authorized to receive services. For purposes of making health care decisions, a member may be represented by his or her "guardian," "agent" or "surrogate," as these terms are defined in 18-A MRSA Sec.5 - 801.

67.01-25Significant Change means a major change in the member's status that is not self-limiting, impacts on more than one (1) area of functional or health status, and requires multi-disciplinary review or revision of the authorized plan of care. A significant change assessment is appropriate if there is a consistent pattern of change with either two (2) or more areas of improvement, two (2) or more areas of decline, or would impact the member's NF level of care.

67.01-26Rehabilitation Potential is the documented expectation by a physician of measurable, "functionally significant improvement" (the demonstrable, measurable increase in the individual's ability to perform specific tasks or motions that contribute to independence outside the therapeutic environment) in the individual's condition in a reasonable, predictable period of time as the result of the prescribed treatment plan. The physician documentation of rehabilitation potential must include the reasons used to support the physician expectation and must follow guidelines detailed in MaineCare Benefits Manual (MBM), Chapter II, Section 90, Physician Services.

67.01-27Other Related Conditions(ORC) means (i) cerebral palsy or epilepsy or (ii) any other condition, other than mental illness, found to be closely related to intellectual disability because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of a person with an intellectual disability, and requires treatment or services similar to those required for those persons. Further, the condition must manifest before the person reaches age 22 years, be likely to continue indefinitely, and result in functional limitations in three (3) or more of the following areas of major life activity: self-care, understanding and use of language, learning, mobility, self-direction, and capacity for independent living.

67.01-28Ventilator Care includes all medically necessary care required to manage conditions requiring the intervention of a mechanical ventilator, including but not limited to: regular assessment and treatment by a pulmonologist, respiratory therapist, or other health care professional trained in respiratory therapy and nursing care.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-67, subsec. 144-101-II-67.01