Mont. Admin. r. 37.5.602 - DEFINITIONS

The following definitions shall apply to nursing facilities participating in the Medicaid program, and to the certification of nursing facilities for participation in the Medicaid program by the state survey agency, as provided for at 42 CFR parts 442, 483 and 488. The following definitions shall also be applicable to the informal dispute resolution process required by 42 CFR 488.331, and outlined in this subchapter. These definitions are in addition to those found in the CFR:

(1) "Actual harm" means the facility's failure to comply with any federal or state standard or condition for participation in the Medicaid program resulted in harm to a resident in one of the following ways:

(a) an identifiable and substantial impairment of cognitive or psychological functioning or emotional well being;

(b) an identifiable and substantial impairment of any bodily organ or function;

(c) permanent or temporary disfigurement; or

(d) death.

(2) "Avoidable" means capable of being prevented through the application of an ongoing process of assessment, planning, intervention, monitoring, and evaluation that is consistent with currently accepted standards of practice for facilities.

(3) "Centers for Medicare and Medicaid Services (CMS)" means the federal agency that contracts with the state survey agency to perform nursing facility surveys on its behalf.

(4) "Complaint survey" or "complaint investigation survey" means a survey of a nursing facility conducted by the state survey agency following receipt of a complaint or allegation that the nursing facility has violated a federal or state standard or condition for participation in the Medicaid program. The purpose of a complaint survey is to determine compliance with federal and state standards and conditions for participation in the Medicaid program.

(5) "Deficiency citation" means the state survey agency's determination of a facility's failure to meet any federal or state standard or condition for participation in the Medicaid program, as recorded by the state survey agency on the form designated for this purpose by the Centers for Medicare and Medicaid Services (CMS).

(6) "Department" means the Department of Public Health and Human Services provided for in 2-15-2201, MCA.

(7) "Facility" or "nursing facility" means a nursing facility or a distinct part of a nursing facility that participates in the Medicaid program.

(8) "Immediate jeopardy" means a situation in which immediate corrective action is necessary because the facility's failure to comply with any federal or state standard or condition for participation in the Medicaid program has caused, or is likely to cause, serious injury, harm, impairment or death to a resident.

(9) "Informal dispute resolution (IDR)" means the process required by 42 CFR 488.331 by which a facility is given an informal opportunity, at the facility's request, to dispute a deficiency citation.

(10) "Minimal harm" means the facility's failure to comply with any federal or state standard or condition for participation in the Medicaid program resulting in harm to a resident in one of the following ways:

(a) an identifiable, but less than substantial, impairment of cognitive or psychological functioning or emotional well being; or

(b) an identifiable, but less than substantial, impairment of any bodily organ or function.

(11) "Potential for more than minimal harm" means actual harm is likely to occur due to the facility's failure to comply with any federal or state standard or condition for participation in the Medicaid program.

(12) "Presiding official" means an individual appointed or hired by the department to preside over or conduct informal dispute resolution proceedings. The presiding official may not have been directly involved in the certification survey regarding which informal dispute resolution has been requested.

(13) "Resident" means an individual residing in a nursing facility.

(14) "Revisit" or "survey revisit" means a follow-up survey conducted by the state survey agency subsequent to the citation of a deficiency for the purpose of determining whether the facility now meets the requirements for participation in the Medicaid program.

(15) "Scope and severity" of a deficiency refers to a determination of the state survey agency regarding:

(a) whether a cited deficiency constitutes:

(i) no actual harm with a potential for minimal harm;

(ii) no actual harm with a potential for more than minimal harm but not immediate jeopardy;

(iii) actual harm that is not immediate jeopardy; or

(iv) immediate jeopardy to resident health or safety; and

(b) whether a cited deficiency:

(i) is isolated;

(ii) constitutes a pattern; or

(iii) is widespread.

(16) "Serious" means having important or dangerous consequences, as in the phrase "a serious injury".

(17) "Standard survey" means the survey of each nursing facility conducted by the state survey agency at least every 15 months in accordance with 42 CFR part 488, subpart E. The purpose of a standard survey is to determine compliance with federal and state standards and conditions for participation in the Medicaid program.

(18) "State survey agency" means the Department of Public Health and Human Services to the extent that the department conducts Medicaid surveys of facilities on behalf of and under contract with the federal CMS pursuant to 53-6-106, MCA, section 1864 of the Social Security Act ( 42 USC 1395 aa), and 42 CFR 488.10 and 488.11.

(19) "Substandard quality of care" means any deficiency citation related to 42 CFR 483.13, resident behavior and facility practices; 43 CFR 483.15, quality of life; or 42 CFR 483.25 quality of care that constitutes:

(a) immediate jeopardy to resident health or safety;

(b) a pattern of or widespread actual harm that is not immediate jeopardy; or

(c) a widespread potential for more than minimal harm that is not immediate jeopardy, with no actual harm.

(20) "Substantial compliance" means a level of compliance with the federal or state standards or conditions for participation in the Medicaid program such that any identified deficiencies pose no greater risk to resident health or safety than the potential for causing minimal harm.

(21) "Tag" means the reference number utilized by the state survey agency on the statement of deficiencies to designate a standard or condition of participation with which a facility is out of compliance. Each tag corresponds to one or more federal regulations pertaining to the standards and conditions for participation in the Medicaid program.

(22) "Unavoidable" means not capable of being prevented through the application of an ongoing process of assessment, planning, intervention, monitoring, and evaluation that is consistent with currently accepted standards of practice for facilities. An unavoidable decline occurs when appropriate interventions have been consistently implemented, but despite these interventions, the resident's condition has declined.

Notes

Mont. Admin. r. 37.5.602

NEW, 2004 MAR p. 736, Eff. 4/9/04.

53-6-109, 53-6-113, MCA; IMP, 53-6-106, 53-6-109, 53-6-113, MCA;