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STANDARDS FOR PAYMENTFORNURSING FACILITIESMEDICAID PROGRAMDepartment of Health and HospitalsBureau of Health Services Financing0Issued January 20, 1996
MEDICAID PROGRAMTABLE OF CONTENTSSTANDARDS FOR PAYMENT FOR NURSING FACILITIESTABLE OF CONTENTSGENERAL PROVISIONSChapter Contents .1-1Certification .1-2Certification of Title XVIII (Medicare)/Skilled Nursing Facilities (SNF).1-2Certification of Title XIX (Medicaid)/Nursing Facilities (NF) .1-2Facility Need Review.1-2Disclosure Requirement.1-3Change in Certification.1-3Provider Enrollment .1-4Effective Date of the Provider Enrollment Agreement .1-4Provider Agreement Time Periods.1-5Change in Ownership .1-6Assignment of Agreement .1-6Continued Participation .1-6Ten Percent Withholding - Release of Payments .1-7Notification to Fiscal Intermediary .1-8Withdrawal From the Medicaid Program.1-9Payment Limitation. 1-10Facility Certification of Non-Compliance . 1-10Certification of Non-Compliance Notice. 1-10Transfer Team . 1-11Recertification of an Involuntary Withdrawal . 1-13Certification Requirements for Swing Bed Hospitals. 1-14ADMINISTRATIONChapter Contents .2-1Introduction.2-2Licensure.2-2Compliance With Federal, State, and Local Laws and Professional Standards.2-2Relationship to Other HSS Regulations.2-2Governing Body.2-4Staffing .2-4Policies and Procedures .2-4In-Service Education Program .2-4Personnel Policies and Procedures.2-5Development and Review of Resident Care Policies .2-5Quality Assurance.2-5Infection Control.2-7Infection Control Program (ICP).2-7ISSUED JANUARY 20, 19962
MEDICAID PROGRAMTABLE OF CONTENTSSTANDARDS FOR PAYMENT FOR NURSING FACILITIESPreventing Spread of Infection.2-7Physical Environment and Sanitation.2-8Favorable Environment For Residents.2-8Hot Water .2-8Isolation Techniques .2-8Housekeeping.2-8Maintenance of Equipment, Building, and Grounds .2-8Nursing Unit.2-9Environment.2-9RESIDENT CARE SERVICESChapter Contents .3-1Administrative Services .3-4Facility Administrator.3-4Restrictions.3-4Assistant Administrator .3-5Physician Services .3-6Medical Director .3-6Physician Supervision, Ongoing Care.3-6Alternate Physicians.3-7Frequency of Visits .3-7Physician Responsibilities .3-7Physician's Signature .3-8Nursing Services. 3-10Director of Nursing Services . 3-10Assistant Director of Nursing. 3-11RN Coverage. 3-11Waiver . 3-12Waiver in a Skilled Nursing Facility or Dually Certified SNF/NF. 3-12Charge Nurse. 3-13Certified Nursing Assistants (CNA) . 3-14Clerical Staff . 3-14Other Nursing Services. 3-14Drug Administration . 3-14Automatic Stop Orders . 3-15Self Administration. 3-15Drug Orders. 3-15Activities of Daily Living (ADL). 3-16Vision and Hearing . 3-16Pressure Sores . 3-16Urinary Incontinence . 3-17Restorative Nursing Care. 3-17ISSUED JANUARY 20, 19963
MEDICAID PROGRAMTABLE OF CONTENTSSTANDARDS FOR PAYMENT FOR NURSING FACILITIESRange of Motion . 3-17Psychological Functioning . 3-17Naso-Gastric-Gastrostomy Tubes . 3-18Accidents. 3-18Nutrition . 3-18Hydration. 3-18Special Needs . 3-19Release of a Body by a Registered Nurse . 3-19Comprehensive Assessment. 3-20Frequency . 3-21Coordination of Assessments With Pre-Admission Screening. 3-21Accuracy of Assessments . 3-21Penalty for Falsification. 3-21Utilization - Resident Assessment Instrument (RAI) . 3-22Comprehensive Care Plan . 3-25Basis for the Comprehensive Care Plan. 3-25Contents of the Comprehensive Plan of Care. 3-26Discharge Summary . 3-27Physician Involvement and Responsibilities in the Comprehensive Plan of Care. 3-27Quarterly Assessment and Optional Progress Notes. 3-28Pharmacy Services. 3-29Pharmacist or Pharmaceutical Consultant. 3-29Pharmaceutical Committee. 3-30Drug Therapy . 3-30Approved Drugs and Biologicals . 3-31Labeling of Drugs and Biologicals. 3-31Storage of Drugs and Biologicals. 3-32Ordering of Medications. 3-33Unnecessary Drugs . 3-33Dietetic Services . 3-34Dietitian . 3-34Dietary Manager . 3-34Dietary Consultant . 3-35Menus . 3-35Food. 3-35Frequency of Meals. 3-36Assistive Devices . 3-36Sanitary Conditions. 3-36Diets. 3-36Social Services. 3-38Social History. 3-38Social Needs Assessment . 3-39ISSUED JANUARY 20, 19964
MEDICAID PROGRAMTABLE OF CONTENTSSTANDARDS FOR PAYMENT FOR NURSING FACILITIESParticipation in Interdisciplinary Staffing. 3-39Social Services Progress Notes . 3-39Activity Services. 3-41Resident Activity Director. 3-41Activities Assessments . 3-42Activity Service Progress Notes. 3-42Medical Records . 3-43Availability of Records. 3-43Availability of Medical Records to Facility Staff. 3-44Confidentiality. 3-44Protection of Records. 3-44Retention of Records. 3-44Components of Medical Records . 3-44Active Medical Charts . 3-44Medical Files. 3-44Contents of Medical Records . 3-45Ancillary Services. 3-47Dental Services. 3-47Radiology and Other Diagnostic Services . 3-47Laboratory Services . 3-48Specialized Rehabilitative Services . 4-49Non-Emergency Transportation for Medical Appointments . 3-50Attendants During Travel . 3-50Hospice Services. 3-51Hospice Admission Criteria. 3-51Provider Responsibilities . 3-51Medicaid Reimbursement. 3-52Admission Review. 3-53Provider of First Choice. 3-54Mental Health Rehabilitation Services . 3-55Mental Health Definitions . 3-55Specialized Services for Mental Illness . 3-55Services of a Lesser Intensity for Mental Illness. 3-56Criteria for Participation in Program. 3-56NURSE AIDE TRAINING AND COMPETENCY EVALUATION PROGRAMChapter Contents .4-1OBRA Requirements.4-2Nurse Aides Not Subject to Fees or Costs.4-2Disqualification of Facilities From Offering Nurse Aide Training .4-2Location of Training.4-3Training Program Content.4-3ISSUED JANUARY 20, 19965
MEDICAID PROGRAMTABLE OF CONTENTSSTANDARDS FOR PAYMENT FOR NURSING FACILITIESOrientation Program.4-3Core Curriculum .4-3Unit Objectives.4-4Nurse Aide Trainee Activities .4-4Ongoing Training.4-4Retraining Required.4-4Curriculum Approval.4-5Qualifications of Instructors.4-5Non-Nursing Facility-Based Programs.4-5Nursing Facility-Based Programs .4-5Program Trainer (PT).4-6Minimum Curriculum Requirements.4-6Core Curriculum .4-7State Review of Compliance With Program Requirements. 4-10Initial Post-Approval and Ongoing Review. 4-10Minimum Program Performance Standards . 4-10Competency Evaluation. 4-11Reporting of Individuals Deemed Competent . 4-12Registry . 4-13Renewal of Certification. 4-14Certification by Reciprocity . 4-14Verification. 4-14Allegations of Nurse Aide Wrong-Doing. 4-14Right to Request Administrative Hearing. 4-15Basic Provisions. 4-15Right to Counsel. 4-15Appearance in Representative Capacity . 4-15Results of Preliminary Conference. 4-16Notice of Administrative Hearing . 4-16Conduct of Hearing. 4-16Witnesses and Subpoena. 4-17Continuance or Further Hearings . 4-18Record of Hearing. 4-18Decision. 4-18Failure to Appear . 4-19VENDOR PAYMENTSChapter Contents .5-1Vendor Payments.5-2Residents Receiving Care Under Title XIX (Medicaid) Only.5-2Retroactive Payment .5-2Resident Personal Care Income.5-2ISSUED JANUARY 20, 19966
MEDICAID PROGRAMTABLE OF CONTENTSSTANDARDS FOR PAYMENT FOR NURSING FACILITIESResidents Receiving Care Under Title XVIII (Medicare) .5-2Timely Filing for Reimbursements.5-3Temporary Absence of the Resident - Not Evacuation.5-3Temporary Absence Due to Evacuation.5-4Resident Deposits .5-5Refunds to BHSF Medicaid Program .5-5A Non-Participating Facility .5-5A Participating Facility.5-5Refunds to Residents .5-5Services and Supplies.5-7Services and Supplies Included.5-7Medical Supplies . 5-11Incontinent Care and Supplies. 5-11Catheters. 5-11Laundry . 5-11Oxygen . 5-12Services and Supplies Excluded. 5-12Requests for Items and Services. 5-13Ventilator Equipment. 5-13Multiple Billing and Arrangements for Services NotIncluded in the Vendor Payment . 5-13Oxygen Concentrator. 5-14Colostomy Bags and Colostomy Equipment. 5-14Payor of Last Resort. 5-14Sitters. 5-14Cost Reports. 5-16Submittal of Cost Reports. 5-16Initial Cost Report. 5-16Subsequent Cost Reports . 5-16Changes in Ownership. 5-16New Facilities. 5-17Final Cost Reports. 5-18Due Date Extensions. 5-18Basis of Accounting. 5-18Related Party Transactions . 5-18Cost Report Form.
STANDARDS FOR PAYMENT FOR NURSING FACILITIES MEDICAID PROGRAM Department of Health and Hospitals Bureau of Health Services Financing Issued January 20, 1996 0 . MEDICAID PROGRAM TABLE OF CONTENTS STANDARDS FOR PAYMENT FOR NURSING FACILITIES ISSUED JANUARY 20, 1996 2
