55 Pa. Code § 1181.548 - What happens if active treatment is required

OBRA-87 permits the Secretary of Health and Human Services to define the meaning of "active treatment," but provides that its meaning may not include those services which a nursing facility is required to provide or arrange for its residents under OBRA-87 (42 U.S.C.A. § 1396r(e)(7)(G)(iii)). Health and Human Services has issued draft definitions which significantly limit determinations that an individual requires active treatment but has not yet established official criteria for the preadmission screening programs. The Department has adopted the Health and Human Services draft definitions under its authority under OBRA-87. See 42 U.S.C.A. § 1396r(e)(7)(A).

(1) Active treatment. The Health and Human Services draft defines active treatment as follows:

(i) For individuals with mental illness. The implementation of an individualized plan of care developed under and supervised by a physician, provided by a physician and other qualified mental health professionals, that prescribes the specific therapies and activities for the treatment of persons experiencing an acute episode of severe mental illness, which necessitates supervision by trained mental health personnel.

(ii) For individuals with mental retardation or other related conditions. A continuous program which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services that is directed toward the acquisition of the behaviors necessary for the client to function with as much self determination and independence as possible and the prevention or deceleration of regression or loss of current optimal functional status. Active treatment does not include services to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous active treatment program. See 42 CFR 435.1009 (relating to definitions relating to institutional status).

(2) Who determines if it is required. The Department is required under OBRA-87 to determine, with respect to individuals who are mentally ill or mentally retarded-including those with other related conditions-and require nursing facility services, whether those individuals require active treatment for their condition. The Department is required to base this determination on the data collected as part of the evaluation process conducted by the Department of Aging. Department staff who will be responsible for issuing the determination on the need for active treatment are listed in Appendix H.

(3) Persons needing active treatment admitted to a nursing facility. An individual determined by the preadmission screening process to require active treatment may be admitted to a provider nursing facility if the individual is determined to require the level of services provided by a nursing facility. The Department may, nevertheless, determine that an individual does not require the level of services provided by a nursing facility, because, for example, they require a different level of services provided by another facility, such as an ICF/MR, institution for mental diseases (IMD) or acute care hospital. The Department may recommend alternative placements for those individuals. However, for an individual of advanced age-65 years of age or older on the date of admission, who is competent to make an independent decision and is not a danger to himself or others-for example, not assaultive or self-destructive, or both-and who requires the services which a nursing facility is required to provide under OBRA-87, the Department may determine that the individual requires the level of services provided by a nursing facility where the individual chooses to receive that care in a nursing facility.

(4) Information and services available to those needing active treatment but denied admission to provider nursing facilities. An individual may require active treatment but be determined to be ineligible for admission to a provider nursing facility under OBRA-87. That individual may obtain information from the county MH/MR agency and other local resources to assist in the determination of an appropriate plan of care and an appropriate placement to meet the individual's needs. The county MH/MR agency will provide an individual who is mentally ill or mentally retarded with information on available programs, including information on costs and financial support, as well as on services covered by the MA Program and other programs administered by the Commonwealth. For an individual who has another related condition, the Department will provide information on local agencies which help individuals obtain care, as well as on services covered by the MA Program and other programs administered by the Commonwealth.

(5) Persons requiring active treatment and admitted to nursing facilities; receiving active treatment while in the nursing facility. If an individual determined to need nursing facility services and active treatment is admitted to a provider nursing facility, the provider is not required to provide or arrange for active treatment for that individual. A facility may provide or arrange for active treatment.

Notes

55 Pa. Code § 1181.548