He-M 1302.02 - Definitions

He-M 1302.02. Definitions

The words and phrases used in these rules shall mean the following:

(a) "Applicant" means an individual who applies for residence in a Medicaid certified nursing facility.

(b) "Appropriate placement" means an individual's needs are such that he or she meets the minimum standards for admission pursuant to He-M 1302.07 and the individual's needs for treatment do not exceed the level of services which can be delivered in the nursing facility to which the individual is admitted either through nursing facility services alone or, where necessary, through nursing facility services supplemented by specialized services provided by or arranged for by the department.

(c) (c) "Bureaus" means the bureau of developmental services and the bureau of behavioral health of the New Hampshire department of health and human services.

(d) "Developmental disability (DD)" means "mental retardation" as defined in 42 CFR 483.102(b)(3) and as described in the American Association on Mental Retardation's Manual on Classification in Mental Retardation (1983).

(e) "Department" means the New Hampshire department of health and human services.

(f) "Informed decision" means a choice made by an applicant or, where appropriate, the applicant's legal representative, that is reasonably certain to have been made subsequent to a rational consideration on the applicant's part of the advantages and disadvantages of each course of action open to the applicant.

(g) "Licensed medical professional" means a licensed nurse, advanced practice registered nurse, physician, physician assistant, physical therapist, or occupational therapist.

(h) "Mental illness (MI)" means a condition such that:

(1) The disorder is classified in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, as:

a. A schizophrenic, mood, paranoid, panic, or other severe anxiety disorder;

b. A somatoform disorder;

c. A personality disorder;

d. Another psychotic disorder; or

e. Another mental disorder that may lead to a chronic disability;

(2) There is not a primary diagnosis of dementia, including Alzheimer's disease or a related disorder, or a non-primary diagnosis of dementia, unless the primary diagnosis is a mental disorder identified in (1) above;

(3) The disorder has resulted in functional limitations in major life activities within the past 3 to 6 months that would be appropriate for the individual's developmental stage, such that the individual has at least one of the following characteristics on a continuing or intermittent basis:

a. Serious difficulty interacting appropriately and communicating effectively with other persons, including a possible history of altercations, evictions, firing, fear of strangers, avoidance of interpersonal relationships, or social isolation;

b. Serious difficulty in sustaining focused attention for a long enough period to permit the completion of tasks commonly found in work settings or in work-like structured activities occurring in school or home settings, including:

1. Difficulties in concentration;

2. Inability to complete simple tasks within an established time period;

3. Making frequent errors; or

4. Requiring assistance in the completion of simple tasks; or

c. Difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interaction as demonstrated by:

1. Agitation, exacerbated signs and symptoms associated with the illness, or withdrawal from the situation; or

2. Need of intervention by the mental health or judicial system; and

(4) The treatment history indicates that the individual has experienced at least one of the following within the past 2 years:

a. Psychiatric treatment more intensive than outpatient care; or

b. Due to the mental disorder, an episode of significant disruption to the normal living situation:

1. For which supportive services were required to maintain functioning at home or in a residential treatment environment; or

2. Which resulted in intervention by housing or law enforcement officials.

(i) "Nursing facility" means an institution or a distinct part of an institution that is:

(1) Participating in the Medicaid program;

(2) Meeting the requirements of Section 1919 of the Social Security Act, 42 USC 1396 r;

(3) Not primarily an institution for mental diseases (IMD) as defined in 42 CFR 435.1010, or an intermediate care facility for the mentally retarded (ICF/MR) as defined in 42 CFR 440.150; and

(4) Providing one or more of the following:

a. Skilled nursing care and related services for residents who require medical or nursing care;

b. Rehabilitative services for the rehabilitation of injured, disabled or sick individuals; or

c. Health-related care and services to individuals who, because of their mental or physical condition, require care and services that are above the level of room and board, and that can be made available to them only through an institution.

(j) "PASRR office" means that office delegated the functional responsibility by the department of:

(1) Carrying out preadmission screenings; and

(2) Performing reviews pursuant to He-M 1302.13.

(k) "Referral agent" means:

(1) Hospitals;

(2) Nursing facilities;

(3) Area agencies;

(4) Community mental health centers; or

(5) Any other person or entity seeking to place a person in a nursing facility.

(l) "Skilled nursing care" means those health related services, above the level of room and board, which meet the criteria used by the Medicare program for skilled nursing care, per 42 USC 1395 i3.

(m) "Specialized services for DD" means those services that, combined with services provided by the nursing facility, result in a continuous active treatment program, which:

(1) Includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services, and related services; and

(2) Is directed toward the acquisition of the behaviors necessary for the individual to function with as much self determination and independence as possible.

(n) "Specialized services for MI" means those services that, combined with services provided by the nursing facility, result in continuous and aggressive implementation of an individualized plan of care which:

(1) Is developed and supervised by an interdisciplinary team which includes a physician, qualified mental health professionals, and, as appropriate, other professionals;

(2) Prescribes specific therapies and activities for the treatment of persons experiencing an acute episode of serious mental illness which requires intervention by trained behavioral health personnel, and

(3) Is directed toward:

a. Diagnosing and reducing the person's behavioral symptoms that necessitate institutionalization;

b. Improving his/her level of independent functioning; and

c. Achieving a functioning level that permits reduction in the intensity of mental health services to below the level of specialized services at the earliest possible time.

(o) "Terminal condition" means a condition caused by injury, disease, or illness for which there is no reasonable medical probability of recovery and which can be expected to cause death within 2 years as determined by a physician.

#6063 eff 8-1-95; ss by #7920, INTERIM, eff 8-2-03, EXPIRED: 1-29-04

New. #8035, eff 2-7-04, EXPIRED: 2-7-12

New. #10123, INTERIM, eff 4-30-12, EXPIRES: 10-29-12; ss by #10216, eff 10-29-12

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