048-5 Wyo. Code R. § 5-4

Current through April 27, 2019

Section 5-4 - Definitions

(a) "Abbreviated standard survey". "Abbreviated standard survey" as defined by 42 C.F.R. § 488.301, which definition is incorporated by this reference.

(b) "Abuse". "Abuse" as defined by 42 C.F.R. § 488.301, which definition is incorporated by this reference.

(c) "Alternative remedies". The following remedies selected by the Department as alternatives to federally mandated remedies pursuant to 42 C.F.R. § 488.406(a)(8):

(i) Assessment of transfer costs;

(ii) Denial of the Federal share of Medicaid payments;

(iii) Denial of the fifty percent of the State share of Medicaid payments; and

(iv) Reimbursement of resident losses.

(d) "Assessment of transfer costs". The payment by a facility of the actual costs of transferring residents of the facility to other appropriate facilities, selected by the Department, when transfer is part of a remedy.

(e) "Certification of compliance". A determination by the Department, based on the findings and recommendation of the survey agency or the Secretary of HHS, pursuant to 42 C.F.R. Subpart C, that a facility is in substantial compliance with the requirements of participation.

(f) "Certification of noncompliance". A determination by the Department, based on the findings and recommendation of the survey agency or the Secretary of HHS, pursuant to 42 C.F.R. Subpart C, that a facility is in not substantial compliance with the requirements of participation.

(g) "Chapter 1". Chapter 1, Rules for Medicaid Administrative Hearings, of the Wyoming Medicaid Rules.

(h) "Chapter 3". Chapter 3, Provider Participation, of the Wyoming Medicaid Rules.

(i) "Chapter 7". Chapter 7, Wyoming Nursing Home Reimbursement, of the Wyoming Medicaid Rules.

(j) "Closure with transfer of residents". The closure of a facility because of an emergency accompanied by the transfer of all residents to an appropriate facility or facilities.

(k) "Compliance". A facility that meets the requirements of participation.

(l) "Corrective action". The changes or improvements necessary to bring a facility into compliance with the applicable requirements of participation.

(m) "Deficiency". "Deficiency" as defined by 42 C.F.R. § 488.301, which definition is incorporated by this reference.

(n) "Denial of fifty percent of the State share of Medicaid payments". The deduction from and retention by the Department of fifty percent (50%) of the State's share of the facilitys per diem rate. The States share is determined pursuant to 42 U.S.C. § 1396 d(b).

(i) If imposed as a category 2 remedy, the Department shall deny the State share of Medicaid payments for those residents affected by the deficiency(ies).

(ii) If imposed as a category 3 remedy, the Department shall deny the State share of Medicaid payments for all Medicaid residents of a facility.

(iii) Payments that are denied shall not be retroactively paid to a facility.

(o) "Denial of the Federal share of Medicaid payments". The deduction from and retention by the Department of the federal share of the facility's per diem rate. The federal share is the federal medical assistance percentage as determined pursuant to 42 U.S.C. § 1396 d(b).

(i) If imposed as a category 2 remedy, the Department shall deny the federal share of Medicaid payments for those residents affected by the deficiency(ies).

(ii) If imposed as a category 3 remedy, the Department shall deny the federal share of Medicaid payments for all Medicaid residents of a facility.

(iii) Payments that are denied shall not be retroactively paid to a facility.

(p) "Denial of payment for new admissions". The denial of Medicaid payments for all recipients admitted to a facility after a specified date. Payments that are denied shall not be retroactively paid to a facility.

(q) "Department". The Wyoming Department of Health, its agent, designee or successor. The Department is the single state agency appointed pursuant to 42 U.S.C. § 1396 a(a)(5).

(r) "Directed in-service training". Training and education of a facility's staff that is:

(i) Required by the Department;

(ii) In response to a pattern of deficiencies; and

(iii) Is deemed, by the Department, to be likely to correct the pattern of deficiencies.

(s) "Directed plan of correction". A plan of correction developed by the survey agency and implemented pursuant to the supervision of the survey agency.

(t) "Director". The Director of the Department, the Director's agent, designee or successor.

(u) "Division". The Division of Health Care Financing of the Department, its agent, designee or successor.

(v) "Dually participating facility". "Dually participating facility" as defined in 42 C.F.R. § 488.301, which definition is incorporated by this reference.

(w) "Emergency". A situation in which there is a high probability that deficiencies will cause residents immediate serious physical or mental disability, continuation of severe pain or death if not immediately corrected.

(x) "Extended survey". "Extended survey" as defined by 42 C.F.R. § 488.301, which definition is incorporated by this reference.

(y) "Facility". A nursing facility .

(z) "HCFA". The Health Care Financing Administration of HHS, its agent, designee or successor.

(aa) "HHS". The United States Department of Health and Human Services, its agent, designee or successor.

(bb) "Immediate jeopardy". "Immediate jeopardy" as defined in 42 C.F.R. § 488.301, which definition is incorporated by this reference.

(cc) "Informal dispute resolution". A provider's opportunity, upon written request, to dispute the survey findings as set forth in the statement of deficiencies.

(dd) "Medicaid". Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act of 1967, as amended.

(ee) "Medicare". The health insurance program for the aged and disabled under Title XVIII of the Social Security Act.

(ff) "Neglect". "Neglect" as defined by 42 C.F.R. § 488.310, which definition is incorporated by this reference.

(gg) "New admission". The admission of a recipient who has never been in a facility or, if previously admitted, ha d been discharged or had voluntarily left the facility. The term does not include:

(i) Residents who were in the facility before the effective date of denial of payment for new admissions, even if they became eligible for Medicaid after that date; or

(ii) Residents who, after a temporary absence, are readmitted to reserved beds.

(hh) "No immediate jeopardy". A situation in which a facility's deficiencies do not pose an imminent threat of serious harm to residents' physical or mental health and safety such that immediate corrective action is necessary.

(ii) "Noncompliance". "Noncompliance" as defined by 42 C.F.R. § 488.301, which definition is incorporated by this reference.

(jj) "Nursing facility". "Nursing facility" as defined by 42 U.S.C. § 1396 r(a), which definition is incorporated by this reference. "Nursing facility" may include a distinct part of a hospital or other institution which is designated to provide nursing facility services.

(kk) "Nursing facility services". "Nursing facility services" as defined by 42 U.S.C. § 1396 d(f), which definition is incorporated by this reference.

(ll) "Per diem rate". A facility's per diem rate as established pursuant to Chapter 7.

(mm) "Plan of correction". A written document submitted to and subject to the approval of the survey agency specifying

(i) The corrective action the facility will take to correct deficiencies; and

(ii) A schedule for implementation and completion of the corrective action (the completion date for corrective action may not be more than sixty days after the date of survey, except that if the deficiencies involve substandard quality of care, the completion date for corrective action may not be more than thirty days after the date of survey, unless otherwise agreed to by the survey agency).

(nn) "Provider agreement". "Provider agreement" as defined by Chapter 3, which definition is incorporated by this reference.

(oo) "Recipient". A person who has been determined eligible for Medicaid.

(pp) "Reimbursement of resident losses". The reimbursement by a facility of a resident's personal funds or the value of property owned by a resident when the statement of deficiencies establishes the funds or property have been lost or misplaced as a result of actions by agents or employees of the facility.

(qq) "Remedy". Any of the actions specified in section 3 which the Department may select and impose pursuant to this Chapter to ensure that a facility is in compliance.

(rr) "Requirements of participation". The requirements for long term care facilities as set forth in 42 C.F.R. Subpart B, which requirements are incorporated by this reference.

(ss) "Reserved bed". Beds in a facility reserved for a resident who is temporarily absent when there are no appropriate vacancies in the facility.

(tt) "Resident". A resident of a facility.

(uu) "Standard survey". "Standard survey" as defined by 42 C.F.R. § 488.301, which definition is incorporated by this reference.

(vv) "Statement of deficiencies". The form, currently HCFA-2567, by which the survey agency notifies a facility of a finding of a deficiency or deficiencies. The statement of deficiencies must include notice of the facility's right to request informal dispute resolution, including the procedures to follow in making such a request.

(ww) "State monitor". An individual, who is an employee or contractor of the survey agency that is appointed by the director, to:

(i) Oversee the implementation of a plan of correction;

(ii) Protect the facility's residents; and

(iii) Report to the survey agency and the Department on whether the facility is operating in compliance with the requirements of participation, properly implementing a plan of correction, or both.

(iv) A monitor shall have no authority to become involved in the actual operation of a facility, except that the monitor may make recommendations to the facility.

(xx) "State Operations Manual (SOM)". The 7000 series of the State Operations Manual as disseminated by HCFA. The SOM is incorporated by this reference. It is available upon request from the survey agency.

(yy) "Submit". To hand-deliver or mail to the Department by certified mail, return receipt requested. If hand-delivered, the date of submission is the date of delivery. If mailed, the date of submission shall be the date of the postmark.

(zz) "Substandard quality of care". Substandard quality of care" as defined by 42 C.F.R. § 488.301, which definition is incorporated by this reference.

(aaa) "Substantial compliance". Substantial compliance" as defined by 42 C.F.R. § 488.301, which definition is incorporated by this reference.

(bbb) "Survey". An abbreviated standard survey, an extended survey or a standard survey.

(ccc) "Survey agency". The Office of Health quality of the Department ,its agent, designee or successor.

(ddd) "Temporary absence" or "temporarily absent". "Temporary absence" or "temporarily absent" as defined by Chapter 7, which definition is incorporated by this reference.

(eee) "Temporary manager". An individual appointed to act as temporary nursing home administrator with authority to (except as otherwise specified by the Director):

(i) Hire, terminate or reassign staff;

(ii) Obligate facility funds;

(iii) Alter facility procedures;

(iv) Manage the facility to correct deficiencies; and

(v) Such other duties and responsibilities as assigned by the Director.

(fff) "Termination of Medicaid provider agreement". Making a facility indefinitely ineligible to receive Medicaid reimbursement for providing nursing facility services to recipients.

048-5 Wyo. Code R. § 5-4