La. Admin. Code tit. 50 § II-10305

Current through Register Vol. 50, No. 11, November 20, 2024

Section II-10305 - General Provisions

NOTE: The federal regulation pertaining to this Section is 42 CFR 442 - 483.400 and 435.1008.

A. Scope

1. The standards set forth in this and subsequent sections comply with the Title XIX requirements of the amended Social Security Act. That Act sets the standards for the care, treatment, health, safety, welfare and comfort of Medical Assistance clients in facilities providing ICF/MR services.

2. These standards apply to ICF/MRs certified and enrolled by the Louisiana Department of Health and Hospitals (DHH) for vendor participation.

3. These standards supplement current licensing requirements applicable to ICF/MRs. Any infraction of these standards may be considered a violation of the provider agreement between DHH and the ICF/MR.

4. In the event any of these standards are not maintained, DHH will determine whether facility certification will continue with deficiencies as is allowed under Title XIX regulations or whether termination of the Provider Agreement is warranted. Although vendor payment will not be suspended during the determination period, deficiencies which may affect the health, safety, rights and welfare of Medical Assistance clients must be corrected expeditiously in order for the ICF/MR to continue to participate.

5. If a certified ICF/MR is found to have deficiencies which immediately jeopardize the health, safety, rights and welfare of its Medical Assistance clients, DHH may initiate proceedings to terminate the ICF/MR's certification. In the event of less serious deficiencies, DHH may impose interim sanctions (see §10357, Sanctions).

B. General Admission and Funding Criteria

NOTE: The federal regulation pertaining to this Subsection is 42 CFR 483.440.

1. Capacity. The ICF/MR will admit only the number of individuals that does not exceed its rated capacity as determined by the BHSF's HSS and its capacity to provide adequate programming.

2. Admission Requirements. Except on a short term emergency basis, an ICF/MR may not admit individuals as clients unless their needs can be met and an interdisciplinary professional team has determined that admission is the best available plan for them. The team must do the following:

a. conduct a comprehensive evaluation of each individual that covers physical, emotional, social and cognitive factors; and

b. perform the following tasks prior to admission:

i. define the individual's need for service without regard to the availability of those services; and

ii. review all appropriate programs of care, treatment, and training and record the findings;

c. ensure that the ICF/MR takes the following action if admission is not the best plan but the individual must nevertheless be admitted:

i. clearly acknowledges that admission is inappropriate; and

ii. initiates plans to actively explore alternatives.

3. Prohibitions on Federal Financial Participation

a. Federal funds in the Title XIX ICF/MR program are not available for clients whose individual treatment plans are totally or predominately vocational and/or educational. ICF/MR services are designed essentially for those individuals diagnosed as developmentally disabled; having developmental lags which are considered amendable to treatment in a 24-hour managed care environment where they will achieve maximum growth. Services to treat educational and vocational deficits are available at the community level while the client lives in his own home or in another community level placement and are not considered amendable to treatment in a 24-hour managed care environment.

b. Admissions through the Court System

i. Court ordered admissions do not guarantee Medicaid vendor payment to a facility. A court can order that a client be placed in a particular facility but cannot mandate that the services be paid for by the Medicaid program.

ii. Incarcerated individuals are not eligible for Medicaid. The only instance in which such an individual may qualify is if he/she is paroled or released on medical furlough.

C. Enrollment of Intermediate Care Facilities for the Mentally Retarded in the Medicaid Program

1. An ICF/MR may enroll for participation in the Medical Assistance Program (Title XIX) when all the following criteria have been met:

a. the ICF/MR has received Facility Need Review approval from DHH;

b. the ICF/MR has received approval from DHH/OCDD;

c. the ICF/MR has completed an enrollment application for participation in the Medical Assistance Program;

d. the ICF/MR has been surveyed for compliance with federal and state standards, approved for occupancy by the Office of Public Health (OPH) and the Office of the State Fire Marshal, and has been determined eligible for certification on the basis of meeting these standards; and

e. the ICF/MR has been licensed and certified by DHH.

2. Procedures for Certification of New ICF/MRs. The following procedures must be taken in order to be certified as a new ICF/MR.

a. The ICF/MR shall apply for a license and certification.

b. DHH shall conduct or arrange for surveys to determine compliance with Title XIX, Title VI (Civil Rights), Life Safety, and Sanitation Standards.

c. Facilities must be operational a minimum of two weeks (14 calendar days) prior to the initial certification survey. Facilities are not eligible to receive payment prior to the certification date.

i.Operational is defined as admission of at least one client, completion of functional assessment and development of individual program plan for each client; and implementation of the program plan(s) in order for the facility to actually demonstrate the ability, knowledge, and competence to provide active treatment.

ii. Fire and health approvals must be obtained from the proper agencies prior to a client's admission to the facility.

iii. The facility must comply with all standards of the State of Louisiana Licensing Requirements for Residential Care Providers.

iv. A certification survey will be conducted to verify that the facility meets all of these requirements.

d. A new ICF/MR shall be certified only if it is in compliance with all conditions of participation found in 42 CFR 442 and 42 CFR 483.400 et seq.

e. The effective date of certification shall be no sooner than the exit date of the certification survey.

3. Certification Periods

a. DHH may certify an ICF/MR which fully meets applicable requirements for a maximum of 12 months.

b. Prior to the agreement expiration date, the provider agreement may be extended for up to two months after the agreement expiration date if the following conditions are met:

i. the extension will not jeopardize the client's health, safety, rights and welfare; and

ii. the extension is needed to prevent irreparable harm to the ICF/MR or hardship to its clients; or

iii. the extension is needed because it is impracticable to determine whether the ICF/MR meets certification standards before the expiration date.

D. Ownership

NOTE: The federal regulations pertaining to this Subsection are as follows: 42 CFR 420.205; 440.14; 442.15; 455.100; 455.101; 455.102 and 455.103.

1. Disclosure. All participating Title XIX ICF/MRs are required to supply the DHH Health Standards Section with a completed HCFA Form 1513 (Disclosure of Ownership) which requires information as to the identity of the following individuals:

a. each person having a direct or indirect ownership interest in the ICF/MR of 5 percent or more;

b. each person owning (in whole or in part) an interest of 5 percent or more in any property, assets, mortgage, deed of trust, note or other obligation secured by the ICF/MR;

c. each officer and director when an ICF/MR is organized as a corporation;

d. each partner when an ICF/MR is organized as a partnership;

e. within 35 days from the date of request, each provider shall submit the complete information specified by the BHSF/HSS regarding the following:

i. the ownership of any subcontractor with whom this ICF/MR has had more than $25,000 in business transactions during the previous 12 months; and

ii. information as to any significant business transactions between the ICF/MR and the subcontractor or wholly owned suppliers during the previous five years.

2. The authorized representative must sign the Provider Agreement.

a. If the provider is a nonincorporated entity and the owner does not sign the provider agreement, a copy of power of attorney shall be submitted to the DHH/HSS showing that the authorized representative is allowed to sign on the owner's behalf.

b. If one partner signs on behalf of another partner in a partnership, a copy of power of attorney shall be submitted to the DHH/HSS showing that the authorized representative is allowed to sign on the owner's behalf.

c. If the provider is a corporation, the board of directors shall furnish a resolution designating the representative authorized to sign a contract for the provision of services under DHH's state Medical Assistance Program.

3. Change in Ownership (CHOW)

a. A Change in Ownership (CHOW) is any change in the legal entity responsible for the operation of the ICF/MR.

b. As a temporary measure during a change of ownership, the BHSF/HSS shall automatically assign the provider agreement and certification, respectively to the new owner. The new owner shall comply with all participation prerequisites simultaneously with the ownership transfer. Failure to promptly complete with these prerequisites may result in the interruption of vendor payment. The new owner shall be required to complete a new provider agreement and enrollment forms referred to in Continued Participation. Such an assignment is subject to all applicable statutes, regulations, terms and conditions under which it was originally issued including, but not limited to the following:

i. any existing correction action plan;

ii. any expiration date;

iii. compliance with applicable health and safety standards;

iv. compliance with the ownership and financial interest disclosure requirements;

v. compliance with Civil Rights requirements;

vi. compliance with any applicable rules for Facility Need Review;

vii. acceptance of the per diem rates established by DHH/BHSF's Institutional Reimbursement Section; and

viii. compliance with any additional requirements imposed by DHH/BHSF/HSS.

c. For an ICF/MR to remain eligible for continued participation after a change of ownership, the ICF/MR shall meet all the following criteria:

i. state licensing requirements;

ii. all Title XIX certification requirements;

iii. completion of a signed provider agreement with the department;

iv. compliance with Title VI of the Civil Rights Act; and

v. enrollment in the Medical Management Information system (MMIS) as a provider of services.

d. A facility may involuntarily or voluntarily lose its participation status in the Medicaid Program. When a facility loses its participation status in the Medicaid Program, a minimum of 10 percent of the final vendor payment to the facility is withheld pending the fulfillment of the following requirements:

i. submission of a limited scope audit of the client's personal funds accounts with findings and recommendations by a qualified accountant of the facility's choice to the department's Institutional Reimbursement Section:

(a). the facility has 60 days to submit the audit findings to Institutional Reimbursement once it has been notified that a limited scope audit is required;

(b). failure of the facility to comply with the audit requirement is considered a Class E violation and will result in fines as outlined in §10357, Sanctions;

ii. the facility's compliance with the recommendations of the limit scope audit;

iii. submittal of an acceptable final cost report by the facility to Institutional Reimbursement;

iv. once these requirements are met, the portion of the payment withheld shall be released by the BHSF's Program Operations Section.

e. Upon notification of completion of the ownership transfer and the new owner's licensing, DHH/HSS will notify the Fiscal Intermediary regarding the effective dates of payment and to whom payment is to be made.

E. Provider Agreement. In order to participate as a provider of ICF/MR services under Title XIX, an ICF/MR must enter into a provider agreement with DHH. The provider agreement is the basis for payments by the Medical Assistance Program. The execution of a provider agreement and the assignment of the provider's Medicaid vendor number is contingent upon the following criteria.

NOTE: Federal regulations pertaining to this subsection are as follows: 42 CFR 431.107, 442.10, 442.12, 442.13, 442.15, 442.16, 442.100 and 442.101.

1. Facility Need Review Approval Required. Before the ICF/MR can enroll and participate in Title XIX, the Facility Need Review Program must have approved the need for the ICF/MR's enrollment and participation in Title XIX. The Facility Need Review process is governed by Department of Health and Hospitals regulations promulgated under authority of Louisiana R.S. 40:2116.

a. The approval shall designate the appropriate name of the legal entity operating the ICF/MR.

b. If the approval is not issued in the appropriate name of the legal entity operating the ICF/MR, evidence shall be provided to verify that the legal entity that obtained the original Facility Need Review approval is the same legal entity operating the ICF/MR.

2. The ICF/MR's Medicaid Enrollment Application. The ICF/MR shall request a Title XIX Medicaid enrollment packet from the Medical Assistance Program Provider Enrollment Section. The information listed below shall be returned to that office as soon as it is completed:

a. two copies of the Provider Agreement Form with the signature of the person legally designated to enter into the contract with DHH;

b. one copy of the Provider Enrollment Form (PE 50) completed in accordance with accompanying instructions and signed by the administrator or authorized representative;

c. one copy of the Title XIX Utilization Review Plan Agreement Form showing that the ICF/MR accepts DHH's Utilization Review Plan;

d. copies of information and/or legal documents as outlined in Subsection D (Ownership) of this section;

3. The Effective Date of the Provider Agreement. The ICF/MR must be licensed and certified by the BHSF/HSS in accordance with provisions in 42 CFR 442.100 - 115 and provisions determined by DHH. The effective date of the provider agreement shall be determined as follows.

a. If all federal requirements (health and safety standards) are met on the day of the BHSF/HSS survey, then the effective date of the provider agreement is the date the on-site survey is completed or the day following the expiration of a current agreement.

b. If all requirements are specified in Subparagraph a above are not met on the day of the BHSF/HSS survey, the effective date of the provider agreement is the earliest of the following dates:

i. the date on which the provider meets all requirements; or

ii. the date on which the provider submits a corrective action plan acceptable to the BHSF/HSS; or

iii. the date on which the provider submits a waiver request approved by the BHSF/HSS; or

iv. the date on which both ii and iii above are submitted and approved.

4. The ICF/MR's "Per Diem" Rate. After the ICF/MR facility has been licensed and certified, a per diem rate will be issued by the department.

5. Provider Agreement Responsibilities. The responsibilities of the various parties are spelled out in the Provider Agreement Form. Any changes will be promulgated in accordance with the Administrative Procedure Act.

6. Provider Agreement Time Periods. The provider agreement shall meet the following criteria in regard to time periods.

a. It shall not exceed 12 months.

b. It shall coincide with the certification period set by the BHSF/HSS.

c. After a provider agreement expires, payment may be made to an ICF/MR for up to 30 days.

d. The provider agreement may be extended for up to two months after the expiration date under the following conditions:

i. it is determined that the extension will not jeopardize the client's health, safety, rights and welfare; and

ii. it is determined that the extension is needed to prevent irreparable harm to the ICF/MR or hardship to its clients; or

iii. it is determined that the extension is needed because it is impracticable to determine whether the ICF/MR meets certification standards before the expiration date.

7. Tuberculosis (TB) Testing as Required by the OPH. All residential care facilities licensed by DHH shall comply with the requirements found in Section 3, Chapter II, of the State Sanitary Code regarding screening for communicable disease of employees, residents, and volunteers whose work involves direct contact with clients. For questions regarding TB testing, contact the local office of Public Health.

8. Criminal History Checks. Effective July 15, 1996, the Office of State Police will perform criminal history checks on nonlicensed personnel of health care facilities, in accordance with R.S. 40:1300.51-R.S. 40:1300.56.

La. Admin. Code tit. 50, § II-10305

Promulgated by the Department of Health and Human Resources, Office of Family Security, LR 13:578 (October 1987), amended by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 25:679 (April 1999).

AUTHORITY NOTE: Promulgated in accordance with R.S. 46:153.