Section 51343.1 - Intermediate Care Facility Services for the Developmentally Disabled Habilitative(a) Intermediate care facility services for the developmentally disabled habilitative (ICF-DDH) are covered subject to prior authorization by the Department of Health Services for the ICF-DDH level of care. Authorizations may be granted for up to six months. Requests for prior authorization of admission to an ICF-DDH or for continuation of services shall be initiated by the facility on forms designated by the Department. Certification documentation required by the Department of Developmental Services must be completed by regional center personnel and submitted with the Treatment Authorization Request form. The attending physician shall sign the Treatment Authorization Request form and shall certify to the Department that the beneficiary requires this level of care.(b) The request for reauthorization shall be received by the appropriate Medi-Cal consultant on or before the first working day following the expiration of a current authorization. Certification shall be redetermined and a new certification form shall be completed by regional center personnel and shall be attached to the request for authorization. One day of authorization shall be denied for each day the reauthorization request is late.(c) The Medi-Cal consultant shall deny any authorization request or reauthorization request, or shall cancel any authorization in effect when services or placement are not appropriate to the health and developmental needs of the beneficiary. Where the reauthorization request is denied, or an existing authorization is cancelled, the facility shall be notified by the most expeditious means. A copy of the denial letter and the denied Treatment of Authorization Request shall serve as the official notice of action and shall be returned to the provider. Payment will be made up to 15 days following the postmark date of the denial letter.(d) Prior to the transfer of a beneficiary between facilities, the receiving facility shall originate an initial Treatment Authorization Request signed by the attending physician. This Treatment Authorization Request must be approved by a DHS Medi-Cal consultant prior to admission except in cases of emergency as specified in Section 51056.(e) Covered services shall be limited to individuals who are defined as developmentally disabled in Welfare and Institutions Code, Section 4512. In determining the need for intermediate care facility services for the developmentally disabled habilitative, the following criteria shall be considered: (1) The complexity of the beneficiary's medical problems is such that skilled nursing care on an ongoing but intermittent basis is needed. Individuals shall be placed in an ICF-DDH only if their predominant skilled nursing needs are predictable and advance arrangements can be made for licensed nurses to provide needed services at prescribed intervals. Individuals who require skilled nursing procedures on an "as needed basis" are not candidates for placement in an ICF-DDH.(2) Medication may be mainly supportive or stabilizing but still requires professional nurse evaluation on an intermittent basis.(3) The beneficiary needs specialized developmental, training and habilitative program services which are not available through other levels of care.(4) The extent to which provision of specialized developmental, training and habilitative program services can be expected to result in a higher level of beneficiary functioning and a lessening dependence on others in carrying out daily living activities or in the prevention of regression.(5) The beneficiary must have two or more developmental deficits as measured on standardized evaluation forms prescribed and furnished by the Department of Developmental Services in any one of the following two domains: (B) Social-emotional domain: 1. Aggression--has had one or more violent episodes causing minor physical injury within the past year or has resorted to verbal abuse and threats but has not caused physical injury within the past year.2. Self-injurious behavior--behavior exists but result only in minor injuries which require first aid.3. Smearing feces--smears once a week or more but less than once a day.4. Destruction of property.5. Running or wandering away.6. Temper tantrums, or emotional outbursts.7. Unacceptable social behavior--positive social participation is impossible unless closely supervised or redirected.(6) Beneficiaries shall not have any of the following extreme developmental deficits in the socio-emotional area: (A) Aggression--has had violent episodes which have caused serious physical injury in the past year.(B) Self-injurious behavior--causes severe injury which requires physician attention at least once per year.(C) Smearing--smears at every opportunity.(7) Beneficiaries shall not be admitted to or approved for service in an intermediate care facility for the developmentally disabled habilitative if those beneficiaries have a decubitis ulcer.(8) Beneficiaries shall not be admitted with clinical evidence of an active communicable disease that is required to be reported in accordance with Section of Title 172500 of Title 17 of he California Administrative Code.(9) Beneficiaries shall not be admitted to an ICF/DDH for purposes of respite care with the exception of clients enrolled in a federally approved home and community-based care program under Section 1915(c) of the Social Security Act.(f) There shall be a written plan of care for each beneficiary, which shall be established by a physician prior to the beneficiary's admission to the facility and reviewed and evaluated at least every 90 days by all personnel involved in the care of the individual. The plan of care shall meet the requirements of 42 Code of Federal Regulations 456.380 and shall be signed and dated by the physician at least every 90 days.(g) Each beneficiary shall have received a comprehensive medical and social evaluation within 12 months prior to admission. A psychological evaluation must have been completed within three months prior to admission. Medical, psychological and social evaluations shall meet the requirements of 42 Code of Federal Regulations 456.370.(h) Each beneficiary shall receive a complete dental examination within one month following admission unless such an examination was done within six months prior to admission. In either case, a comprehensive report prepared by the dentist shall be completed and entered into the beneficiary's record. Each beneficiary shall be reexamined as needed but at least annually.(i) There shall be a periodic review, no less often than annually, of all care and services provided to beneficiaries receiving intermediate care facility services for the developmentally disabled habilitative by the State Medical Review Team in accordance with the requirements of 42 Code of Regulations 456.602 through 456.604.(j) Each beneficiary shall receive preventive health services that includes physical examinations, immunizations and tuberculosis control in accordance with 42 Code of Regulations 442.477.(k) Regardless of frequency of contact, the attending physician shall recertify, at least every 60 days, the beneficiary's need for continued care in accordance with the procedures specified by the Director. The facility shall attach a physician's signed statement at the time of billing as proof of this recertification. This statement shall be completed in the format specified by the Department.(l) Medi-Cal beneficiaries in the facility shall be seen by their attending physicians no less often than every 60 days. An alternative schedule of not more than 90 days elapsed time may be proposed subject to approval by the Medi-Cal consultant.(m) Services shall be provided at a level consistent with that described in the beneficiary's individual service plan.(n) Payment for service shall be made in accordance with Section 51510.2.(o) Leave of absence from intermediate care facilities for developmentally disabled habilitative residents is covered up to a maximum of 73 days in a calendar year. Payment shall be made in accordance with Section 51535.Cal. Code Regs. Tit. 22, § 51343.1
1. New section filed by the Department of Health Services with the Secretary of State on 8-1-84 as an emergency; effective upon filing. Submitted to OAL for printing only pursuant to Government Code Section 11343.8 (Register 85, No. 19).
2. Certificate of Compliance including amendment filed by the Department of Health Services with the Secretary of State on 11-28-84. Submitted to OAL for printing only pursuant to Government Code Section 11343.8 (Register 85, No. 25).
3. Editorial correction of subsection (e)(2) (Register 95, No. 45). Note: Authority cited: Sections 14105, 14108 and 14124.5, Welfare and Institutions Code; and Sections 208.3, 208.4 and 1267.7, Health and Safety Code. Reference: Sections 14108 and 14132, Welfare and Institutions Code; and Section 1250, Health and Safety Code.
1. New section filed by the Department of Health Services with the Secretary of State on 8-1-84 as an emergency; effective upon filing. Submitted to OAL for printing only pursuant to Government Code Section 11343.8 (Register 85, No. 19).
2. Certificate of Compliance including amendment filed by the Department of Health Services with the Secretary of State on 11-28-84. Submitted to OAL for printing only pursuant to Government Code Section 11343.8 (Register 85, No. 25).
3. Editorial correction of subsection (e)(2) (Register 95, No. 45).