He-E 802.04 - Eligibility Criteria for Atypical Services

He-E 802.04. Eligibility Criteria for Atypical Services

(a) Services in a skilled nursing care or atypical services unit shall be available to individuals who meet the clinical eligibility requirements in He-E 802.03 and in this section, and whose clinical assessment required by He-E 802.05(a)(1)b. includes documentation of the individual's rehabilitative potential and goals.

(b) Eligibility for short-term skilled nursing care or rehabilitative services shall be determined in accordance with the following criteria:

(1) The individual requires daily skilled nursing care or rehabilitative services, or both; and

(2) The individual has or is one or more of the following:

a. An acquired, non-degenerative brain injury resulting in residual deficits and disability;

b. An injury which occurred within one year of the date of admission to the skilled nursing care/rehabilitation unit, or in the alternative, has an injury older than one year of such admission which is expected to show significant improvement with treatment based on the assessment in (a) above; or

c. Ventilator-dependent or has other specific needs that require extensive nursing or rehabilitative services 24 hours per day.

(c) Eligibility for atypical non-behavioral long-term care services shall be determined in accordance with the following criteria:

(1) The individual requires daily nursing care or rehabilitative services, or both;

(2) The individual requires one of the covered services listed in He-E 802.09; and

(3) The individual has or is one or more of the following:

a. An acquired, non-degenerative brain injury resulting in residual deficits and disability;

b. An injury which occurred within one year of the date of admission to the non-behavioral unit, or in the alternative, has an injury older than one year of such admission which will show significant improvement with treatment based on the assessment in (a) above; or

c. Ventilator-dependent or has other specific needs that require extensive nursing or rehabilitative services 24 hour per day.

(d) Eligibility for atypical behavioral long-term care services shall be determined in accordance with the following criteria:

(1) The individual meets one or both of the following criteria:

a. Has had a psychiatric evaluation completed by a psychiatrist within 30 days prior to admission to the behavioral unit, and the evaluation indicates:

1. Evidence of current behavioral symptoms; or

2. Evidence of current and severe manifestations of behavioral problems that interfere with daily living situations; or

b. Has been diagnosed with one or more diseases that:

1. Have an impact on the individual's ability to perform activities of daily living (ADLs), cognitive status, mood or behavior status, medical treatments, nursing monitoring or risk of death; and

2. Consist of conditions that are addressed in the current plan of care developed by the NF currently treating the individual or a prospective NF; and

(2) Based on the MDS completed upon admission in accordance with 42 CFR 483.20, has:

a. A combined score that is less than or equal to 2 on the questions relative to:

1. Ability to understand others;

2. Short-term memory; and

3. Cognitive skills for decision making; and

b. An ADL score that is less than or equal to 10.

(e) The following shall apply to eligibility for and authorization for placement in a swing bed:

(1) The bureau shall authorize placement in a swing bed on either a temporary basis or a pending placement basis when there is no NF bed available;

(2) For a temporary placement in a short-term care swing bed:

a. The individual shall meet the eligibility criteria in (b) above; and

b. The bureau shall determine, in consultation with the hospital in which the individual is currently placed, that such temporary placement is appropriate;

(3) For a pending placement in a short-term care swing bed, the individual shall meet the eligibility criteria in (b) above; and

(4) For a pending placement in a long-term care swing bed, the individual shall meet the eligibility criteria in (c) or (d) above.

(Amended by Volume XXXIX Number 16, Filed April 18, 2019, Proposed by #12741, Effective 3/20/2019, Expires 9/16/2019.)

#7751, eff 8-17-02; amd by #8523, eff 1-1-06, amd by #9786, INTERIM, eff 9-20-10; ss and renumbered by #9888-A, eff 3-19-11 (formerly He-E 802.05)

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