La. Admin. Code tit. 48 § I-11523

Current through Register Vol. 50, No. 9, September 20, 2024

Section I-11523 - Long Term Care Beds

A. Skilled Nursing and Intermediate Care Facilities

1. Definition/Description

a. In the broadest sense, long term care includes the complete spectrum of institutional and non-institutional services which provide health care to persons with chronic disease or disability requiring care over an extended period of time, or to persons recovering from the an acute phase of illness requiring continuing care. Services range from those provided in the home to inpatient or residential services provided in public or private institutions. The goal of long term care is to provide persons of all ages with preventive, diagnostic, medical, rehabilitative, maintenance, or social services, to achieve optimal physical, social, and psychological functioning.

b. Long Term Care beds may be located in general acute care hospitals or in nursing homes. A licensed nursing home is a long term care facility which provides, in addition to food and shelter, professional attendant and nursing care, 24 hours a day, to the chronically ill, convalescent, disabled, and the elderly, with a full range of complementary services (therapeutic, dietary, social, etc.)

c. Nursing homes differ from hospitals in that they have no facilities for diagnostic services or for acute or emergency medical care (x-ray, laboratory, or surgical units); however, nursing homes provide the most complete care possible outside of a hospital, because services and manpower are located and delivered within the institution in which the patients reside.

d. Nursing homes are classified according to the type of care provided. A nursing home may be certified in one or more of the following levels of care:

2. Skilled Nursing Care Facility (SNF)

a. A skilled Nursing Facility provides intensive, frequent, and comprehensive nursing care and/or rehabilitation services ordered by and under the direction of a physician. Services are provided under the supervision of a registered nurse or licensed practical nurse on a 24 hour basis. Skilled nursing beds may be located in a general acute care hospital or in a nursing home.

b. Examples of services include therapy, administration of medication and I.V. fluids, tube feeding, post surgical convalescent care. Skilled care is also referred to as Extended Care.

3. Intermediate Care Facility-Level I (ICF-I). An Intermediate Care Facility, Level I, provides basic nursing services under the direction of a physician to persons who require a lesser degree of care than skilled services, but who need care and services beyond the level of room and board. Examples of services are administration of injections and medication, treatment and care of persons requiring tubes, appliances, surgical dressings, physical therapy, restraints, and personal care.

4. Intermediate Care Facility-Level II (ICF-II). An Intermediate Care Facility, Level II, provides supervised personal care and health related services, under the direction of a physician, to persons needing nursing supervision in addition to help with personal needs. Services can usually be provided by trained aides and orderlies. Examples of services are administration of routine oral medication, stimulation of activities in daily living, supervision or assistance with personal care.

5. Intermediate Care Facility for the Mentally Retarded (ICF-MR)

a. An Intermediate Care Facility for the Mentally Retarded provides residents with professionally developed individual plans to cared, supervision, and therapy, to attain or maintain optimal functioning.

b. (Refer to the section on ICF/MR)

6. Determination of Level of Care

a. The Office of Family Security evaluates the necessity for Skilled and Intermediate Care for Title XIX (Medicaid) recipients through admission review and medical certification. Admission review is based on assurance that the recipient's level of care is the most appropriate for his individual needs, and that there has been a medical and social evaluation and physician certification. As provided in the 1984 Deficit Reduction Act (P. L. 98-369), physician recertification is required every 30, 60 and 90 days after admission to the facility and every 60 days thereafter for recipients residing in Skilled Nursing Facilities. Recipients residing in Intermediate Care Facilities shall be recertified 60 and 180 days after admission, at 12, 18, and 24 months after admission, and annually thereafter. Recertification is authorized by a physician.

7. Payment to Nursing Homes

a. Payment is made to nursing homes according to the type of care provided, as described above.

b. A nursing home must be licensed by the state in order to operate, and must be certified according to federal standards in order to participate in the Medicare and Medicaid programs. Medicare is the federal hospitalization and medical insurance program for the aged and disabled, and Medicaid is the federal-state health care program for the financially needy. Medicare applies only to Skilled Nursing Care, and pays for up to 100 days of care in any single spell of illness, while Medicaid covers both Skilled and Intermediate care levels without limitation on the number of eligible days. Because of its restrictive definition and durational limits of coverage, Medicare covers a relatively small percentage of the total number of people currently in long term care facilities. Medicaid, the major source of nursing home support, pays 60 percent of the nation's total nursing home bill.

8. Alternatives

a. Alternatives to nursing home placement, which can delay or eliminate the need for nursing home placement, include the following: case management services, home health services, adult day medical care, homemaker services, personal care and habilitation services, hospice care, respite care, nutritional services (meals on wheels), volunteer services, transportation services, semi-institutional and semi-independent living arrangements.

b. Developing alternatives to nursing home placement is a priority health issue for this planning period, primarily because many of the aforementioned services are not available currently in all areas of the state. One reason that alternatives to nursing home care are not available to many of the state's citizens is cost. People who may qualify for Medicaid-reimbursed nursing home care often have sufficient income to remain in their own homes, but insufficient funds to pay for home-based services, such as homemakers, day care, etc. Because of eligibility criteria, many persons may not qualify for any subsidized services other than nursing home care. For these reasons, there is nearly twice as much utilization of nursing home services by people over 65 in the poor areas of rural North Louisiana health system care compared to the more urban and economically stable New Orleans/Bayou-River area.

9. Quality of Care

a. There are four quality control mechanisms now in existence for nursing homes:

i. Title XIX (Medicaid Program) conducts a Professional Medical Review (PMR) once yearly. A PMR team (which includes a physician) is located in each health planning district. Each team makes a site visit to review all medical records and patients in each facility, to determine if patients are receiving both quality care and appropriate care. Title XIX also conducts a Utilization Review, simultaneous with a PMR, in which each team determines whether a patient needs the level of care for which he is certified. Six months after the on-site visit the team reviews the treatment plan and discharge plan of each patient to see if the needed level of care is being provided.

(a). Under state law, complaints are made to the secretary of the Department of Health and Human Resources, who reviews such complaints and who then may refer the matter to appropriate office or law enforcement agency for action (R.S. 40: 2009.13 et seq.).

ii. The Ombudsman Program, in the Governor's Office of Elderly Affairs, monitors patient care and assists residents with resolution of problems (R. S. 40:2010.0 et seq.)

iii. The State Licensing and Certification Office reviews each facility annually with its own team. This team has members which the PMR team does not; i.e., dietician, pharmacist. Their concern is with the physical plant and whether the facility is providing the care for which it is licensed. The team monitors a 15 percent sample of patients as to level of care needed/received. The facility is given a time limit to correct infractions.

iv. The Louisiana Nursing Home Association has a Peer Review Committee which conducts voluntary evaluations of the quality of nursing home care for the purpose of "maintaining high standards of excellence in meeting the total needs of the patients they serve." The association surveys each nursing home prior to accepting the facility as a member.

10. Service Area. The service area for a proposed or existing facility is designated as the parish in which the site is located with the following exceptions: The parishes of Ascension, Iberville, Plaquemines and St. John shall be considered to be divided by the Mississippi River into two separate service areas. Therefore, all east bank wards in these parishes will be considered as separate service areas and all west bank wards will be considered as another service area. This methodology identifies the resources and needs of persons most likely to utilize the nursing home beds. It allows the placement of beds in areas which are presently served only by distant or otherwise inaccessible nursing homes.

11. Resource Goals

a. The nursing home bed supply should not be more than 80 ICF I, II and SNF beds (combined) per 1,000 population age 65 + .

i. Beds which are counted include:

(1) licensed but not Section 1122 approved beds,

(2) 1122 approved and licensed beds,and

(3) 1122 approved but not yet licensed beds. The calculation shall include licensed general acute care hospital beds which are Medicare certified as skilled nursing facility beds.

ii. In determining the bed to population ratio for the proposal, Division of Policy, Planning and Evaluation will use population projections for the anticipated opening date (year) of the facility, which shall not exceed two years from the date the application is declared complete.

b. The occupancy rate for the four most recent quarters due to have been reported to Division of Licensing and Certification in the service area should be at least 95 percent.

i. In determining this occupancy rate, beds used in the calculations include:

(1) licensed but not 1122 approved beds and

(2) 1122 approved and licensed beds. This calculation shall include licensed general acute care hospital beds which are Medicare certified as skilled nursing facility beds.

12. Adjustments to Resource Goals

a. Circumstances may exist or be created which cause a particular group (see Section on Health Care for Persons with Acquired Immunodeficiency Syndrome) or area to be underserved. When one of the following circumstances exists in a service area, an adjustment to the above resource goals may be justified:

i. Inaccessibility to Minority Groups

(a). It is recognized that certain factors may limit the accessibility of nursing home beds to minority groups. For this reason, a documented claim submitted by the applicant, of inaccessibility of nursing home beds to minority groups, may be considered a special circumstance in the determination of need in the service area. Inaccessibility refers only to situations where there is documented evidence of discrimination against a particular minority in a geographic area. This requirement will be deemed met only when the Title VI or Title VII agency has made a positive finding of systematic discrimination against a minority group on the part of an existing health care facility within the geographic area.

ii. Inaccessibility in High Occupancy Areas

(a). It is recognized that in certain areas of the state nursing home care may not be available. For this reason, a documented claim, submitted by the applicant that nursing home care is not available may be considered a special circumstance in the determination of need in the service area. This requirement shall be deemed met only when the adjusted occupancy rate for all facilities in the service area exceeds 95 percent. The adjusted occupancy rate is computed for each quarter for the four most recent quarters due to have been reported to the Division of Licensing and Certification and is calculated from a base bed inventory which includes licensed but not 1122 approved beds. 1122 approved but not yet licensed beds.

(b). This calculation shall include licensed general acute care beds which are Medicare certified as skilled nursing facility beds.

iii. Inaccessibility Due to Poor Quality Care

(a). It is recognized that in some areas of the state the nursing home care being provided may not be of the quality desired by the residents of that parish. Therefore, in these areas, a documented claim, submitted by the applicant, that nursing home care is not accessible due to the poor quality of care provided in the parish may be considered a special circumstance in the determination of need in the service area. This requirement will be deemed met only when a facility in the service area has been disenrolled by the Office of Family Security as a Medicaid Provider or decertified or delicensed by the Division of Licensing and Certification and the adjusted occupancy rate for the other facilities in the service area is greater than 95 percent. The adjusted occupancy rate is computed for each quarter for the four most recent quarters due to have been reported to Division of Licensing and Certification and is calculated from a base bed inventory which includes licensed but not 1122 approved beds, 1122 approved and licensed beds and 1122 approved but not yet licensed beds.

(b). This calculation shall include licensed general acute care hospital beds which are Medicare certified as skilled nursing facility beds. The beds of the facility which was disenrolled, decertified or delicensed shall be excluded in computing the adjusted occupancy rate and the Section 1122 approval for such facility shall be revoked unless the facility obtains reenrollment, recertification and relicensure within 60 days of the loss of such approvals.

13. Applications for Proposals Based on Inaccessibility Adjustments

a. All applications for proposed or existing facilities based on the foregoing inaccessibility adjustments will be referred by the health planning staff to a committee of knowledgeable professionals who will review and provide written comments to Division of Policy, Planning and Evaluation on such applications. The following committee members are appointed by the governor: the assistant secretary of Office of Family Security, the administrator of Licensing and Certification, the chairman of the Statewide Health Coordinating Council (shall always be a consumer representative), the ombudsman coordinator of the governor's Office of Elderly Affairs, and the director of the Bureau of Civil Rights of DHHR.

b. Division of Policy. Planning and Evaluation shall forward copies of the applications to be reviewed to the above noted committee members as soon as such applications are declared complete. The transmittal will include the date of the public hearing and the decision due date. Division of Policy, Planning and Evaluation shall also forward a summary of the public hearing comments to the committee members.

c. Each committee members will forward individual comments and recommendations to the Division of Policy, Planning and Evaluation. Comments must be received by Division of Policy, Planning and Evaluation at least five working days prior to the decision due date. If available, such comments and recommendations will be included in the staff analysis and considered when a decision is rendered. The number of beds which may be approved in an area deemed inaccessible due to high occupancy shall not exceed the lesser of (1) the average of all the facilities in the service area or (2) 10 percent of the number of beds in the service area. For all other resource goal adjustments based on inaccessibility, the number of beds which may be approved shall not exceed the average of all the facilities in the service area.

NOTE: Specific requirements for meeting these exceptions shall be further established in Section 1122 Policies and Guidelines promulgated by the Division of Policy, Planning and Evaluation.

B. Intermediate Care Facilities for the Mentally Retarded

1. Definition/Description of Services

a. An Intermediate Care Facility for the Mentally Retarded (ICF/ MR) is one which serves individuals having disabilities attributable to mental retardation or related conditions. The definition of "related conditions" is hinged on legislative language contained in the Developmental Disabilities Services and Facilities Construction Act, P. L. 91-517. This Act, as amended by P.L. 95-602, contains the following definition of developmental disability.

i. The term developmental disability means a severe, chronic disability of a person which:

(a). is attributable to a mental or physical impairment or combination of mental and physical impairments;

(b). is manifested before the person attains age 22;

(c). is likely to continue indefinitely;

(d). results in substantial functional limitations in three or more of the following areas of major life activity:

(i) self-care;

(ii) receptive and expressive language;

(iii) learning;

(iv) mobility;

(v) self-direction;

(vi) capacity for independent living; and

(vii) economic self-sufficiency; and

(e). reflects the person's need for a combination and sequence of special inter-disciplinary, or generic care, treatment, or other services which are individually planned and coordinated.

b. The ICF/MR, referred to as an Intermediate Care Facility-Handicapped or ICF/H by the Office of Family Security, like other Intermediate Care Facilities, must fully meet the licensure requirements of the State. It provides, on a regular basis, health related services to individuals who do not require the degree of care and treatment which a hospital or skilled nursing facility is designed to provide, but who, because of their mental or physical condition, require care and services above the level of room and board that can be made available only in institutional facilities. Among the conditions that might be served in an ICF/MR are: disabilities attributable to mental retardation, cerebral palsy, epilepsy, autism and other conditions as defined in the paragraph above.

c. There is a wide range in the types of facilities which may meet licensing and Title XIX regulatory standards as ICF/MRs. At one end of this range are those facilities that provide domiciliary care. These facilities have a bed capacity of sixteen or more beds. Thus, they constitute the largest ICF/MR facilities and may be referred to as large residential facilities. These facilities exist in a network of publically owned State schools as well as in privately owned arrangements. Group homes and community homes comprise the community based services. The former consists of facilities with a bed capacity between seven and 15 beds while facilities in the latter category have between one and six beds. Elderly persons suffering from mental retardation or related conditions and unable to benefit from active treatment are provided care in nursing homes (SNF, ICF I and ICF II). As of January, 1986 there were 5,104 large residential facility beds, 183 group home beds, and 669 community home beds approved and licensed to serve those with mental retardation and related conditions. In addition, 125 community home beds and 48 residential facility beds were Section 1122 approved but not yet licensed.

2. Issues

a. There has been an ongoing commitment for over 10 years within the Office of Mental Retardation/Developmental Disabilities to reduce the populations of the large state institutions for the mentally retarded. There exists additional impetus at the national level to encourage the development of community-based ICF/MRs with a corresponding reduction in the population of large residential facilities.

b. Successful development of a variety of community-based programs for the developmentally disabled depends heavily on the existence of a stabilizing center for the coordination of activities and provisions of support and consultation services. The State School with its cadre of professional services provides the most efficient and economical base for a regional system of support services for the developmentally disabled.

3. Bed Need

a. According to 1980 census data, Louisiana had a population of 4,206,313. Projections for 1990 indicate a population of over 4,849,038. A three percent prevalence rate has generally been accepted to estimate the number of individuals with mental retardation existing in the general population. However, recent studies and experiences in Louisiana indicate that a one percent prevalence rate is more realistic. Therefore, a one percent prevalence rate was used to project the number of individuals with mental retardation in Louisiana. Hence, in 1980 it was estimated that there were 42,063 individuals with mental retardation, with a projection of 48,490 mentally retarded individuals in 1990. According to many experts, 70 percent of the mentally retarded individuals fall into the category of mild retardation. Fifteen percent are considered moderately retarded and 15 percent are considered severely and profoundly retarded.

b. The emphasis in bed need has shifted from traditionally large domiciliary care facilities to alternative living arrangements. The 1983-85 Developmental Disabilities State Plan delineated four priority areas to meet needs of developmentally disabled individuals, one of which is the development of alternatives to the large domiciliary care facility. Such alternative living arrangements include adoption homes, substitute family care homes, supervised apartments, and independent living services as well as such residential alternatives as community homes and group homes.

c. Under the subcategory of living arrangements outside of the family home, adoptive homes are needed by some developmentally disabled children whose families cannot or will not care for them any longer. Some who are returning from more restrictive placements and need a family-like living environment can benefit most from such arrangements. These specialized adoptive homes must have professional backup and support, and the adoptive parents should be well trained and able to carry out any in-home training specified in the child's individual habilitation plan (IHP).

d. Substitute family care homes are required for a number of disabled children and some adults who need a stable family-like environment when the natural family can no longer care for them or when the individual is returning from a more restrictive placement. Foster care is preferable when there is a chance that the natural family may accept the child back or permanent placement with a family is not feasible. The foster parents should be trained and under contract to provide any in-home training prescribed in the individual's IHP.

e. A larger proportion of developmentally disabled children and adults require temporary or permanent community home, or group home, living arrangements because they need round-the-clock supervision and intensive programming. These persons may be in need of this alternative if they are removed from the natural family for periods of time, are returning from an institution or are exhibiting severe behavioral problems. This alternative calls for a staff that has been trained in administering intensive programming, and for the availability of professional back-up support.

f. A number of developmentally disabled adults need supervised apartment or independent living alternatives, which usually entail obtaining necessary support services, such as training in independent living, attendant care, homemaker services, and supervision or assistance in locating accessible housing. These community supports are the key to successful independent living for the otherwise self-sufficient developmentally disabled individuals. The staff providing the supervision must have skills in understanding and meeting these service needs.

4. Types of Facilities Needed. In planning for the expansion of ICF/MR services for the mentally retarded and developmentally disabled, the emphasis will be on smaller, community-based facilities distributed throughout the state. In addition, there is a need for special units or facilities for certain segments of the developmentally disabled population who have special needs because of adaptive difficulties, such as the mentally retarded/emotionally disturbed and the mentally retarded delinquent. In all cases, the facility should be the least restrictive setting for the clients it is designed to serve.

5. Elements of an ICF/MR

a. The following characteristics are required in ICF/MRs. The Office of Mental Retardation/Developmental Disabilities will evaluate proposed new or expanded programs based on these characteristics. In accordance with L. R. S. 28:420, OMR/DD shall approve the program model for the population to be served. Criteria for judging the program model will be based on Title XIX regulations, state licensing requirements and the OMR/DD law.

i. Program Characteristics

(a). Normalization-Care for the developmentally disabled in intermediate care facilities should be provided in a manner which facilitates the individual's training in developmental skills for restoring lost function, acquisition of new skills, or the maintenance of present skills. Therefore, proposals should delineate the manner in which residents will participate in such services as may be specified in their individual habilitation plans. Services must be designed to approximate as nearly as possible the normal patterns of life and conditions of those not developmentally disabled. Through normalization, individuals with disabilities should have available to them the options of everyday life which closely parallel the norms and patterns of the mainstream of society.

(b). Developmental Approach-It has been demonstrated that persons who are developmentally disabled are capable of change and can increase their self-sufficiency when provided with appropriate learning and experimental opportunities. Therefore, services should be offered which are designed to increase the person's ability to cope progressively with more complex situations, increase his/her control over these situations, and help the person live a normal life in the community. Care in such residential settings should be focused through developmental programming.

(c). Least Restrictive Setting-Individuals shall be provided services in ways and settings that are suitable and appropriate to their abilities while least restrictive to their liberties. Generic community resources can be used by most developmentally disabled persons. Specialized services shall be used by the developmentally disabled only when general service programs fail to meet needs appropriately.

(d). Individual Program Planning-Since developmentally disabled persons often have multiple disabilities in a variety of combinations and so are especially vulnerable to neglect, state and federal mandates require that individual program planning be made for each disabled person. The plan shall include: goals toward which a person should be directed; specific activities and services needed to achieve those goals; and evaluation measures to determine and adjust for goal achievement. The plan should cover all services needed by the client/family whether one or several agencies are required to provide all of those services.

(e). Interdisciplinary Program Planning-Diagnosis, evaluation, and individual program planning are best accomplished through a team effort of client, family or significant others, and professionals representing a variety of perspectives and disciplines. The clients and family members are included in the team as active participants in both the planning and decision-making process. The client's individual habilitation plan shall be implemented, followed up, monitored and revised periodically to ensure provision of appropriate quality services.

ii. Facility Characteristics

(a). Facility Types-there are two types of community residential facilities, the group home and the community home. The community home has a bed capacity of six or fewer beds while a group home has a capacity of 15 or fewer beds. ICF/MRs should be as small as possible to provide a home-like environment. Individuals who are severely retarded may be served appropriately in an ICF/MR. Moderately retarded persons with a secondary disability or extreme deficits in adaptive behavior may also be placed in an ICF/MR. In large residential facilities (16 beds and over), individuals of substantially different ages or developmental levels or having special needs, should be housed in small, separate physical units within the facility. Although persons should be provided with ICF/MR placements, services and programs in the region where their families or advocates reside, the individual's habilitative needs should be given priority in considering placement recommendations. Characteristics to be considered in making an ICF/MR placement are adaptive behavior, mobility, physical disability, behavior, medical needs, age range, and level of retardation.

(b). Facility Design-the physical environment should be home-like in terms of furnishings, equipment and availability of privacy. In a large residential facility (16 beds and over) the physical arrangement of the living environment should permit its occupants to be divided into smaller groups (up to 8 persons) in separate living units (apartments, cottages, etc.)

(c). Facility Location-the location of ICF /MRs is important. In order to assure that the location provides maximum support to the facility the following conditions should be present:

(i). the location should be in communities of sufficient size to permit integration of the clients into the community and there should be opportunities for the residents to establish patterns of normal everyday activities;

(ii). the location should provide access to recreational activities, shopping, public education programs, and sheltered workshops;

(iii). the location should be in an area capable of providing the required support services through a qualified and experienced labor force and in settings outside of the residence to ensure separation of life functions;

(iv). in accordance with L. R.S. 28:478 B, there shall be no community home placed within one thousand foot radius of another community home;

(v). the location of the ICF/MR site must be specific and must either be owned by or under an option to be bought, leased, or rented by the provider;

(vi). the capability of the receiving community to support the proposed ICF/MR should be evaluated by the State Office of Mental Retardation/Developmental Disabilities and a written assessment from this office shall be provided to the State Health Planning and Development Agency during project reviews.

iii. Community Support. Providers are encouraged to work with the Office of Mental Retardation/Developmental Disabilities to develop and implement strategies that will foster community acceptance. Prior to the development of a community home, a legal notice shall be published in the local newspaper of the community where the project is to be developed. The notice shall give the proposed site to be used.

iv. Staffing

(a). The following kinds of staff are considered appropriate to various types of ICF/MR programs. A qualified mental retardation professional (QMRP) is a person who has specialized training or one year of experience in treating or working with the developmentally disabled and is one of the following:

(i). Psychologist-Master's degree from an accredited program in psychology. Must have specialized training or one year of experience in treating the developmentally disabled and receive in-service training during the first year of employment in various specialty areas related to the needs of the clients in the facility.

(ii). Educator-Bachelor's degree in education with a minimum of one year of teaching preferred. Must have specialized training or one year of experience in educating the developmentally disabled and receive in-service training during the first year of employment in various specialty areas related to the needs of the clients in the facility.

(iii). Social Worker-Bachelor's or master's degree in social work from an accredited program and one year of experience in direct service with developmental disabilities. A QMRP in social work can also be an individual with a bachelor's degree in a field other than social work with at least three years of social work experience under the supervision of a qualified social worker. Must receive in-service training during the first year of employment in various specialty areas related to the needs of the clients in the facility.

(iv). Physical or Occupational Therapist-Appropriate degree from an accredited program. One year of experience in direct service with developmental disabilities. Must receive in-service training during first year of employment in various specialty areas related to the needs of the clients in the facility.

(v). Speech Pathologist or Audiologist-Degree with license and certification of clinical competence and one year of experience as speech pathologist. Must receive in-service training the first year of employment in various specialty areas related to the needs of the clients in the facility.

(vi). Rehabilitation Counselor-B.S. degree in counseling with one year of experience in counseling and must be certified by the Committee of Rehabilitation Counselor Certification. Must receive in-service training during first year of employment in various specialty areas related to the needs of the clients in the facility.

(vii). Registered Nurse-Licensed with a minimum of one year of experience in nursing. Experience in restorative or rehabilitative nursing preferred. Must receive in-service training during first year of employment in various specialty areas related to the needs of the clients in the facility.

(viii). Therapeutic Recreation Specialist-graduate of accredited program in recreation therapy. One year of experience in therapeutic training required. Must receive in-service training during the first year of employment in various specialty areas related to the needs of the clients in the facility.

[a]. While the administrator of an ICF/MR does not have to be a qualified mental retardation professional, he or she should be qualified in management.

Type of Facility	Staff
Developmental/Medical	Administrator/Program Director (QMRP)
Registered nurse
Paraprofessionals
Developmental/Family-Living	Administrator/Program Director (QMRP)
Trained house-parents or shift staff serving as parent or peer models
Social/Vocational Programs	Administrator/Program Director (QMRP)
Trained houseparents/shift staff serving as parent or peer models
Developmental/Behavioral Training	Administrator/Program Director (QMRP)
Psychologist or educator (QMRP) with expertise in behavior modification training
Houseparents or shift staff with behavior modification experience.

6. Distribution of ICF/MR Beds

a. The incidence of mental retardation does not occur uniformly throughout the population. Causes for mild and moderate retardation (nearly 85 percent of the mentally retarded population) often have socioeconomic implications. Because of the desirability of making client placements which will permit the return of mentally retarded clients to the community where their families or advocates reside, ICF/MR beds should be distributed in a manner which parallels somewhat the distribution of the mentally retarded population.

b. At present, there is no data available to be used in sketching the actual geographic distribution of persons who are mentally retarded. Until such data is available, bed need projections will be based on prevalence rates and occupancy rates at existing facilities in the region.

7. Quality of Care

a. The following quality control mechanisms are in existence for ICF/MRs.

i. All Section 1122 applications for new or expanded ICF/MR projects are reviewed by the Office of Family Security (OFS) to determine if the proposed developer has had prior experience in the operation of an ICF/MR and, if so, has demonstrated an ability to provide quality care. The applications are reviewed by the Division of Licensing and Certification (DLC) to determine if the project appears in conformity with Title XIX regulations and state licensing laws. The application is reviewed by the Office of Mental Retardation/Developmental Disabilities (OMR/DD) to determine if the most appropriate program components are in place.

ii. All projects are monitored at least twice yearly by Department of Health and Human Resources review teams.

iii. The following Inter-Agency Agreement on Procedures Relative to Quality Assurance in ICF/MRs is to be followed.

(a). The Office of Family Security and Division of Licensing and Certification will forward to Office of Mental Retardation/Developmental Disabilities regional offices a copy of the monitoring reports on each provider, within 30 days.

(b). If deficiencies are identified, OMR/DD will meet with the provider to discuss their corrective action plan. OMR/DD regional offices will follow-up to the providers in writing with an offer of specific technical assistance with a carbon copy to OFS and DLC. OMR/DD regional offices will advise the central office of any technical assistance needs which exceed the resources of the region.

(c). OMR/DD regional offices will keep a record on each provider reflecting deficiencies noted in each monitoring report. The provider's record will also contain references to all technical assistance offered to the provider. Also noted in the record will be the provider's willingness to work with OMR/DD in correcting deficiencies. OFS and DLC will receive carbon copies of all relevant OMR/DD correspondence with providers.

(d). OFS and DLC will reflect in their subsequent monitoring reports the extent to which deficiencies were corrected and the extent to which OMR/DD was contacted for technical assistance. OFS will take appropriate action including sanctions if indicated.

8. Service Area. The service area for a proposed or existing facility is designated as the one of 8 OMR/DD planning regions in which the facility or proposed facility is or will be located.

9. Resource Goals

a. In accordance with the department's policy of least restrictive environment, there is no currently identified need for additional facilities with 16 or more beds. Beds may be transferred from one existing residential facility to another.

b. The bed to population ratio for community and group homes may at no time exceed .36 per 1000 population in each service area. In determining the bed to population ratio for a proposal, Division of Policy, Planning and Evaluation will use population projections for the anticipated opening date (year) of the facility which in no case shall exceed two years from the date the application is declared complete.

c. The occupancy rate for community homes in the service area must be 80 percent or greater in order for another community home to be approved.

d. The occupancy rate for group homes in the service area must be 85 percent or greater in order for another group home to be approved.

e. In determining the occupancy rate, beds used in the calculations are 1122 approved and licensed beds.

f. Community or group homes will be determined to meet the above resource goals where mandated by courts.

g. A distinct part of a publicly supported facility other than an intermediate care facility will be determined to meet the above resource goals provided that the distinct part:

i. meets all requirements for an intermediate care facility;

ii. is an identifiable unit, such as an entire ward or contiguous ward, a wing, floor, or building;

iii. consists of all beds and related facilities in the unit;

iv. houses all recipients for whom Title XIX payments are being claimed; and

v. is clearly identified.

h. Capital costs must not exceed the amount that a cost-conscious buyer would pay.

i. Authorization. Subchapter I, Part 100 of P. L. 98-21 provides a mandate for cost containment pursuant to Section 1122 of the Social Security Act. Utilizing the wording of the Provider's Reimbursement Manual, there is an expectation that the provider seeks to minimize costs and that its actual costs do not exceed what a cost-conscious buyer pays for a given item or service. If costs are determined to exceed the level that such buyers incur, in the absence of clear evidence that the higher costs were unavoidable, the excess costs are not reimbursable.

ii. In an effort to contain capital costs involved in operating ICF/ MR facilities to reasonable levels the following procedure has been designed to establish the maximum amount that a cost conscious buyer would be expected to pay in capital costs.

(a). The Division of Policy, Planning and Evaluation shall, at the beginning of each fiscal year, obtain from the Division of Rate Administration, Office of Management and Finance, statistics on budgeted annual capital costs of newly approved facilities over the previous three year period grouped by urban/rural setting, facility type, facility size, and ownership arrangement.

(b). Reasonable Capital Cost will be computed by generating categories of facilities based on setting, facility type, facility size, and ownership arrangement; computing the mean budgeted capital cost for each category; and adding the value of one standard deviation.

(c). There are two adjustments which are made in the procedure described above for computing reasonable capital cost when warranted by circumstances.

(d). Whenever a category of facilities contains a Department of Housing and Urban Development sponsored facility, the capital cost of that facility will not be considered in computing the mean value for the category.

(e). On those infrequent occasions when an application is received for a facility in a category containing fewer than three values, reasonable capital costs cannot validly be based on the mean and standard deviation. In this circumstance allowable capital costs will be determined in one of two ways, depending on whether the facility and equipment are owned or leased.

(f). In the case of owned property and building, allowable capital costs shall be based on fair market value, including conversion costs and development costs, provided that the nature and size of the building and property are consistent with the nature of the programs to be provided. In the event that the fair market value is not known, it shall be established as the competitive market value. In the event that neither of these values can be determined, fair market value shall be estimated in consultation with an appropriate vendor other than one utilized by the applicant. These three values will be applied in the same sequence to establish the allowable cost of equipment.

(g). In the case of leased facilities and equipment in a category containing fewer than three values, reasonable cost shall be established as 16 percent of the fair market value plus an inflation factor (see definitions). When the lease is for land and/or buildings, an additional 11% of annual rent shall be added to cover vacancy time and property management and an amount equal to conversion costs amortized over the term of the lease shall be added. In the event that there is a lease for furnishings, equipment or chattel properly considered a capital expense item, the amount of the lease shall be averaged over its term to arrive at the amount to be budgeted as a capital cost.

iii.Section 1122 certification shall be for actual capital costs only up to the reasonable cost limit unless the provider can provide clear evidence that higher costs cannot be avoided.

iv. An applicant whose capital costs exceed the reasonable capital cost limit is not limited in the kinds and amounts of evidence which he may present to prove the higher costs cannot be avoided. However, the following types of evidence shall be considered clear evidence" when they support the applicant's claim.

(a). Documentation of special or unique program features that demand costly equipment, specially designed features of physical plant, expanded grounds, or other requirements that will drive capital costs up.

(b). Construction industry recognition that construction costs in the geographic location of the applicant facility are significantly higher than in other areas of the state, such as the Locality Adjustments of the Dodge Construction Systems Costs.

v. In carrying out the above procedure, the following definitions shall apply:

(a).Appropriate Vendor-is a vendor who sells property or equipment similar to that for which fair market value is being determined.

(b).Capital Cost-for the purpose of generating the annual mean, is that portion of the basic support component comprised of costs associated with buildings, land and equipment. More specifically it includes:

(i). in the case of proprietor owned facilities and equipment: depreciation, debt service, and property tax plus any amount of these cost elements associated with a central office that has been allocated to the facility's budget; and

(ii). in the case of leased facilities and equipment: lease amount plus any amount of capital cost elements associated with a central office that has been allocated to the facility's budget.

(c).Facility Size-is determined by the number of beds and consists of two categories, those with six beds or less and those with more than six beds.

(d).Facility Type-consists of two classifications, those that accommodate nonambulatory residents and those limited to ambulatory residents.

(e).Inflation Factor-applies in lease arrangements only and consists of a 5 percent annual increase in rental rate averaged over the lease term. Thus, for a three year lease it would amount to 10 percent/3 years 3.33 percent.

(f).Ownership Arrangement-consists of three categories, owned, leased and mixed. The mixed category consists of those facilities in which some of the property and equipment is leased and some is owned, provided that neither owned nor leased amounts of annual capital costs shall be in an amount less than $100.

(g).Urban/Rural-an urban location is any location within one of Louisiana's Metropolitan Statistical Areas. Any other location shall be considered rural.

La. Admin. Code tit. 48, § I-11523

Promulgated by the Department of Health and Human Resources, Office of Management and Finance, LR 13:246 (April 1987).

AUTHORITY NOTE: Promulgated in accordance with P. L. 93-641 as amended by P. L. 96-79, and R.S. 36:256(b).