16.03.10.228 - NURSING FACILITY: COORDINATION OF NURSING FACILITY ELIGIBILITY AND THE NEED FOR SPECIALIZED SERVICES

16.03.10.228. NURSING FACILITY: COORDINATION OF NURSING FACILITY ELIGIBILITY AND THE NEED FOR SPECIALIZED SERVICES

Determinations as to the need for nursing facility care and determinations as to the need for specialized services should not be made independently. Such determinations will often be made on an individual basis, taking into account the condition of the resident and the capability of the facility to which admission is proposed to furnish the care needed. When an individual identified with MI and ID is admitted to a nursing facility, the nursing facility is responsible for meeting that individual's needs, except for the provision of specialized services. (3-19-07)

01. Level of Care. (3-19-07)

a. Individual determinations must be based on evaluations and data as required by these rules. (3-19-07)

b. Categorical determinations. Recognizing that individual determinations of level of care are not always necessary, those categories set forth as examples at 42 CFR 483.130(d) are hereby adopted as appropriate for categorical determinations. When nursing facility level of care is determined appropriate categorically, the individual may be conditionally admitted prior to completion of the determination for specialized services. However, conditional admissions cannot exceed seven (7) days, except for respite admissions which cannot exceed thirty (30) consecutive days in one (1) calendar year. (3-19-07)

02. Specialized Services. Specialized services for mental illness as defined in 42 CFR 483.120(a)(1), and for intellectual disabilities as defined in 42 CFR 483.120(a)(2), are those services provided by the state that due to the intensity and scope can only be delivered by personnel and programs that are not included in the specialized rehabilitation services required of nursing facilities under 42 CFR 483.45. The need for specialized services must be documented and included in both the resident assessment instrument and the plan of care. (3-19-07)

a. Individual determinations must be based on evaluations and data as required by these rules. (3-19-07)

b. Categorical determinations that specialized services are not needed may be made in those situations permitted by 42 CFR 483.130. (3-19-07)

03. Penalty for Non-Compliance. No payment will be made for any services rendered by a nursing facility prior to completion of the Level I screen and, if required, the Level II screen. Failure to comply with PASRR requirements for all individuals admitted or seeking admission may also subject a nursing facility to other penalties as part of certification action under 42 CFR 483.20. (3-19-07)

04. Appeals. Discharges, transfers, and preadmission PASRR determinations may be appealed to the extent required by 42 CFR, Part 483, Subpart E, and under Section 67-5229, Idaho Code. Appeals under this paragraph are made in accordance with the fair hearing provisions in IDAPA 16.05.03, "Contested Case Proceedings and Declaratory Rulings." (3-19-07)

a. A Level I finding of MI or ID is not an appealable determination. It may be disputed as part of a Level II determination appeal. (3-19-07)

b. In the event that the PASRR program is eliminated or made non-mandatory by an act of Congress, the provisions of Section 227 of these rules will cease to be operative on the effective date of any such act, without further action. (3-19-07)

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