Ga. Comp. R. & Regs. R. 111-2-2-.36 - Specific Review Considerations for Long Term Care Hospitals
(1)
Applicability. A Certificate of Need ("CON") shall be required
prior to the establishment of a new or the expansion of an existing Long Term
Care Hospital. An application for Certificate of Need for a new or expanded
Long Term Care Hospital shall be reviewed under the General Review
Considerations of Ga. Comp. R. & Regs. r.
111-2-2-.09 and the service-specific
review considerations of this Rule.
(2)
Definitions.
(a) "Expansion" or "Expanded" means the
addition of beds to an existing CON-authorized or grandfathered Long Term Care
Hospital. A CON-authorized or grandfathered Long Term Care Hospital may
increase the bed capacity of an existing hospital by the lesser of ten percent
(10%) of existing capacity or 10 beds if it has maintained an average occupancy
of eighty-five percent (85%) for the previous twelve (12) calendar months
provided that there has been no such increase in the prior two years and
provided that the capital expenditures associated with the increase do not
exceed the Capital Expenditure Threshold. If such an increase exceeds the
Capital Expenditure Threshold, the increase will be considered an expansion for
which a Certificate of Need shall be required under these Rules.
(b) "Free-standing LTCH" or "Free-standing
LTACH" means a Long Term Care Hospital organized and operated as a
self-contained health care facility.
(c) "Hospital-within-a-Hospital LTCH" or
"Hospital-within-a-Hospital LTACH" means a Long Term Care Hospital co-located
within the same building or the same campus as another CON-Authorized
hospital.
(d) "Long Term Care
Hospital" or "LTCH" or "Long Term Acute Care Hospital" or "LTACH" means a
hospital that is classified as a long term hospital by the Medicare program
pursuant to 42 CFR
412.23(e). These hospitals
typically provide extended medical and rehabilitative care for patients who are
clinically complex and may suffer from multiple acute or chronic conditions.
Services typically include comprehensive rehabilitation, respiratory therapy,
head trauma treatment, and pain management. For regulatory purposes, the
definition includes a hospital which asserts its intent to be
Medicare-classified as a long term hospital within twenty-four (24) months of
accepting its first patient. If an entity, which has been awarded a CON
pursuant to this Rule, has not been so classified by Medicare within this
timeframe, the CON issued to that entity shall be revoked. An entity, which has
had its CON revoked pursuant to this Rule, shall not have the authority to
operate as a general acute care hospital. However, an acute care hospital,
which has been awarded a CON to convert acute care beds for use as a long term
care hospital, may again use such beds for acute care if such beds have not
been Medicare-classified as a long term care hospital within twenty-four (24)
months of accepting its first patient. Furthermore, a hospital that has been
approved through the Certificate of Need process to use all of its short-stay
beds for a Freestanding LTCH shall have such beds removed from the official
inventory of available short-stay beds when the LTCH is certified by Medicare;
provided, however, that the hospital's beds will revert to the official
inventory of available short-stay beds at any point that the facility ceases to
be certified by Medicare as an LTCH.
(e) "New" means a hospital that has not been
classified by the Medicare program as a long term hospital in the previous
twelve (12) months. For purposes of these Rules, an existing hospital which
proposes to be relocated to a location more than three miles from its present
location shall be considered "new".
(f) "Occupancy Rate" means the ratio of beds
occupied by inpatients as reported on the most recent Annual Hospital
Questionnaire divided by the total licensed beds.
(g) "Official State Health Component Plan"
means the document related to Long Term Care Hospitals developed by the
Department, established by the Georgia Health Strategies Council and signed by
the Governor of Georgia.
(h)
"Planning Region" means one of the four sub-state regions for Long Term Care
Hospitals, as follows:
1. LTCH Region 1,
including the following counties: Dade, Walker, Catoosa, Whitfield, Murray,
Gilmer, Fannin, Union, Towns, Rabun, Stephens, Habersham, White, Lumpkin,
Dawson, Pickens, Gordon, Chattooga, Floyd, Bartow, Cherokee, Forsyth, Hall,
Banks, Franklin, Hart, Elbert, Madison, Jackson, Barrow, Gwinnett, Fulton,
Cobb, Paulding, Polk, Haralson, Carroll, Douglas, DeKalb, Rockdale, Walton,
Oconee, Clarke, Oglethorpe, Greene, Morgan, Newton, Butts, Henry, Clayton,
Fayette, Coweta, Heard, Troup, Meriwether, Pike, Spalding, Lamar, and
Upson
2. LTCH Region 2, including
the following counties: Wilkes, Lincoln, Columbia, McDuffie, Warren,
Taliaferro, Hancock, Glascock, Putnam, Jasper, Monroe, Jones, Baldwin,
Washington, Jefferson, Richmond, Burke, Screven, Jenkins, Emmanuel, Johnson,
Treutlen, Montgomery, Wheeler, Telfair, Wilcox, Dodge, Laurens, Pulaski,
Bleckley, Houston, Peach, Twiggs, Wilkinson, Bibb, and Crawford
3. LTCH Region 3, including the following
counties: Harris, Talbot, Taylor, Muscogee, Chattahoochee, Marion, Schley,
Macon, Dooly, Sumter, Webster, Stewart, Quitman, Randolph, Terrell, Lee, Crisp,
Ben Hill, Irwin, Turner, Worth, Dougherty, Calhoun, Clay, Early, Baker,
Mitchell, Colquitt, Miller, Cook, Tift, Berrien, Lanier, Echols, Lowndes,
Brooks, Thomas, Grady, Decatur, and Seminole
4. LTCH Region 4, including the following
counties: Effingham, Bulloch, Candler, Toombs, Tattnall, Evans, Bryan, Chatham,
Liberty, Long, Wayne, Appling, Jeff Davis, Coffee, Bacon, Pierce, Brantley,
McIntosh, Glynn, Camden, Charlton, Ware, Atkinson, and Clinch
(3)
Service-Specific Review Standards.
(a) The need for new or expanded Long Term
Care Hospital in a LTCH planning region shall be determined using the following
need projection:
1. Determine the total
discharges from general acute care hospitals less LTCH discharges, and less
perinatal and neonatal discharges, and less psychiatric and substance abuse
discharges, and less comprehensive inpatient physical rehabilitation discharges
for the planning region in which the Long Term Care Hospital is or will be
located. The source of discharge data for purposes of this Rule include data
collected pursuant to O.C.G.A. §
31-7-280(c)(14),
or in the Department's discretion, discharge data collected on the most recent
Annual Hospital Questionnaire.
2.
Calculate the discharge rate for each planning region by dividing the number of
current acute care discharges obtained in Step 1 in each planning region by the
corresponding year's resident population projection from the Governor's Office
of Planning and Budget in each planning region.
3. Calculate the projected discharges for
each planning region by multiplying the discharge rate obtained in Step 2 by
the horizon year resident population projection for that planning region and
then reduce that figure by six percent (6%) to account for overlap with
rehabilitation facilities.
4.
Calculate gross beds needed in the horizon year as follows:
(i) Multiply the projected discharges
obtained in Step 3 by a utilization factor of 1.3% to determine the projected
number of acute care discharge who may benefit from services at a
LTCH.
(ii) Multiply the product
obtained in Step 4(i) by the average LTCH length of stay for the most recent
previous three-year period. Beginning with the first need calculation and
continuing until the third complete year of survey data collected pursuant to
this Rule, the Department shall use 28.1 as a proxy for the average LTCH length
of stay for the previous three years.
(iii) Divide the product obtained in Step
4(ii) by 365 to determine the projected daily LTCH census.
(iv) Divide the result obtained in Step
4(iii) by .85 to determine the number of projected LTCH beds utilizing an
eighty-five percent (85%) capacity standard.
5. Determine the current inventory of LTCH
beds in the planning region from Departmental data. For all long term care
hospital providers, which have been licensed as a Long Term Care Hospital by
the Healthcare Facility Regulation Division, the current inventory of LTCH beds
shall reflect the number of beds reported as CON-authorized in the Facility
Inventory prior to the date of adoption of these Rules augmented from that time
forward only by increases in bed capacity approved through the CON process (or
by exemptions thereto) and by decreases due to a provider ceasing to provide
such services for a period in excess of twelve (12) months. For purposes of
this Rule, the initial inventory shall not include the beds of licensed
rehabilitation hospitals even if such hospitals have a reported average length
of stay of greater than twenty-five (25) days for Medicare patients; the beds
of such facilities shall continue to be included in the applicable
Comprehensive Inpatient Physical Rehabilitation inventory.
6. If the projected LTCH bed need in Step
4(iv) is greater than the current inventory of LTCH beds in the planning
region, the application for the Certificate of Need should reflect a number of
beds equal to or lesser than the resulting unmet bed need.
(b) An applicant for a new or expanded Long
Term Care Hospital shall document that the establishment or expansion of its
hospital will not have an adverse impact on an existing and approved long term
care hospital in its planning region. An applicant for a new or expanded Long
Term Care Hospital shall have an adverse impact on existing and approved
hospitals of the same type if it will:
1.
decrease annual utilization of an existing hospital, whose current utilization
is at or above eighty-five percent (85%), to a projected annual utilization of
less than seventy-five percent (75%) within the first twelve (12) months
following the acceptance of the applicant's first patient; or
2. decrease annual utilization of an existing
hospital, whose current utilization is below eighty-five percent (85%), by ten
percent (10%) over the twelve (12) months following the acceptance of the
applicant's first patient.
The applicant shall provide evidence of projected impact by taking into account existing planning region market share of hospitals of the same type and future population growth or by providing sufficient evidence that the current population is underserved by the existing Long Term Care Hospitals within the planning region.
(c) The Department may grant an exception to
the need methodology of Ga. Comp. R. & Regs. r.
111-2-2-.36(3)(a)
and to the adverse impact standard of Ga. Comp. R. & Regs. r.
111-2-2-.36(3)(b)
for an applicant proposing a program to be located in a county with a
population of less than 75,000 and to be located a minimum of fifty (50) miles
away from any existing program in the state; or to remedy an atypical barrier
to the services of a Long Term Care Hospital based on cost, quality, financial
access or geographic accessibility. The Department may grant an exception to
the need methodologies of either Ga. Comp. R. & Regs. r.
111-2-2-.36(3)(a)
and to the adverse impact standard of Ga. Comp. R. & Regs. r.
111-2-2-.36(3)(b)
if the applicant's annual census demonstrates thirty percent (30%) out of state
utilization for the previous two years.
(d) A new or expanded Long Term Care Hospital
shall have the following minimum bed sizes:
1.
A new freestanding LTCH shall have a minimum bed size of forty (40)
beds.
2. A new
Hospital-within-a-Hospital LTCH shall have a minimum bed size of twenty (20)
beds.
3. The minimum number of beds
for the expansion of an existing Long Term Care Hospital, including satellite
locations, shall be ten (10) beds or ten percent (10%) of the total current
authorized bed capacity of the Long Term Care Hospital, whichever is
less.
(e) An applicant
for a new Long Term Care Hospital shall demonstrate the intent to meet the
standards of the Joint Commission or another nationally recognized health care
accreditation body within twenty-four (24) months of accepting its first
patient. An applicant for an expanded Long Term Care Hospital shall be Joint
Commission-certified or certified by another nationally recognized health care
accreditation body as of the date of its application and shall furnish proof of
the certification as a part of the Certificate of Need application
process.
(f) An applicant for a new
Long Term Care Hospital shall demonstrate the intent to meet the Licensure
Rules of the Healthcare Facility Regulation Division for such hospitals. An
applicant for an expanded Long Term Care Hospital shall demonstrate a lack of
uncorrected deficiencies as documented by letter from the Healthcare Facility
Regulation Division.
(g) An
applicant for a new or expanded Long Term Care Hospital shall have written
policies and procedures for utilization review. Such review shall consider, but
is not limited to, factors such as medical necessity, appropriateness and
efficiency of services, quality of patient care, and rates of
utilization.
(h) An applicant for a
new or expanded Long Term Care Hospital shall document the existence of
referral arrangements, including transfer agreements, with an acute-care
hospital(s) within the planning region to provide emergency medical treatment
to any patient who requires such care. If the nearest acute-care hospital is in
an adjacent planning region, the applicant may document the existence of
transfer agreements with that hospital in lieu of such agreements with a
hospital located within the planning region.
(i) An applicant for a new or expanded Long
Term Care Hospital shall foster an environment that assures access to services
to individuals unable to pay and regardless of payment source or circumstances
by the following:
1. providing evidence of
written administrative policies and directives related to the provision of
services on a nondiscriminatory basis;
2. providing a written commitment that
un-reimbursed services for indigent and charity patients in the service will be
offered at a standard which meets or exceeds three percent (3%) of annual gross
revenues for the service after Medicare and Medicaid contractual adjustments
and bad debt have been deducted;
3.
providing documentation of the demonstrated performance of the applicant, and
any facility in Georgia owned or operated by the applicant's parent
organization, of providing services to individuals unable to pay based on the
past record of service to Medicare, Medicaid, and indigent and charity
patients, including the level of un-reimbursed indigent and charity
care;
4. providing documentation of
current or proposed charges and policies, if any, regarding the amount or
percentage of charges that charity patients, self pay patients, and the
uninsured will be expected to pay; and
5. agreeing to participate in the Medicare
and Medicaid programs if such programs reimburse for such services.
(j)
Reserved.
(k) An
applicant for a new or expanded Long Term Care Hospital shall agree to provide
the Department with requested information and statistical data related to the
operation of such a Program on a yearly basis, or as needed, and in a format
requested by the Department.
Notes
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