La. Admin. Code tit. 50 § II-10357

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

Section II-10357 - Sanctions

A. Noncompliance. When ICF/MRs are not in compliance with the requirements set forth in the ICF/MR Standards for Payment, DHH may impose sanctions. Sanctions may involve:

1. withholding of vendor payments;

2. civil fines;

3. denial of payments for new admissions; or

4. nonfinancial measures such as termination of the ICF/MR's certification as a Title XIX provider.

B. Authority. Public Law 95-142, dated October 25, 1977, permits the federal government's Health Care Financing Administration (HCFA) to impose a fine and/or imprisonment of facility personnel for illegal admittance and retention practices. HCFA is also authorized to terminate an agreement with a Title XIX ICF/MR provider as a result of deficiencies found during their surveys, which are re-reviews of the state's surveys. Furthermore, the federal government's Office of Inspector General (OIG) is authorized to terminate an agreement with a Title XIX ICF/MR provider for willful misrepresentation of financial facts or for not meeting professionally recognized standards of health care.

C. Special Staffing Requirements. When the secretary of DHH determines that additional staffing or staff with specific qualifications would be beneficial in correcting deficient practices, DHH may require a facility to hire additional staff on a full-time or consultant basis until the deficient practices have been corrected. This provision may be invoked in concert with, or instead of, the sanctions cited below.

D. Withholding of Vendor Payments. DHH may withhold vendor payments in whole or in part in the following situations, which are not all inclusive.

1. Delinquent Staffing Report. When the ICF/MR provider fails to timely submit a required, completed staffing report. After DHH notifies the provider of the delinquent report, vendor payment may be withheld until the completed report is received.

2. Unapproved Staffing Shortage. When a staffing report indicates an unapproved staffing shortage, vendor payment may be withheld until staffing is brought into compliance.

3. Incorrect/Inappropriate Charges. When DHH determines that the ICF/MR provider has incorrectly or inappropriately charged clients, families, or responsible parties, or there has been misapplication of client funds, vendor payment may be withheld until the provider does the following:

a. makes restitution; and

b. submits documentation of such restitution to BHSF's Institutional Reimbursement Section.

4. Delinquent Cost Report. When an ICF/MR provider fails to submit a cost report within 90 days from the fiscal year end closing date, a penalty of 5 percent of the total monthly payment for the first month and a progressive penalty of 5 percent of the total monthly payment for each succeeding month may be levied and withheld from the vendor's payment for each month that the cost report is due, not extended, and not received. The penalty is nonrefundable.

NOTE: DHH's Institutional Reimbursement Section may grant a 30-day extension of the 90-day time limit, when requested by the ICF/MR provider, if just cause has been established. Extensions beyond 30 days may be approved for situations beyond the ICF/MR provider's control.

5. Cost Reports Errors. Cost reports errors greater than 10 percent in the aggregate for the ICF/MR provider for the cost report year may result in a maximum penalty of 10percent of the current per diem rate for each month the cost report errors are not correct. The penalty is nonrefundable.

6. Corrective Action for Audit Findings. Vendor payments may be withheld when an ICF/MR facility fails to submit corrective action in response to financial and compliance audit findings within 15 days after receiving the notification letter until such time compliance is achieved.

7. Failure to Respond or Adequately Respond to Requests for Financial/Statistical Information. When an ICF/MR facility fails to respond or adequately respond to requests from DHH for financial and statistical information within 15 days after receiving the notification letter, vendor payments may be withheld until such time the requested information is received.

8. Insufficient Medical Recertification. When an ICF/MR provider fails to secure recertification of a client's need for care and services, the vendor's payment for that individual may be withheld or recouped until compliance is achieved.

9. Inadequate Review/Revision of Plan of Care (IHP). When an ICF/MR provider repeatedly fails to ensure that an adequate plan of care for a client is reviewed and revised at least at required intervals, the vendor's payment may be withheld or recouped until compliance is achieved.

10. Failure to Submit Response to Survey Reports. When an ICF/MR provider fails to submit an acceptable response within 30 days after receiving a Survey Report from DHH, HCFA, OIG and the legislative auditor, vendor payments may be withheld until an adequate response is received, unless the appropriate agency extends the time limit.

11. Corrective Action on Complaints. When an ICF/MR fails to submit an adequate corrective action plan in response to a complaint within seven days after receiving the complaint report, vendor payments may be withheld until an adequate corrective action plan is received, unless the time limit is extended by the DHH.

12. Delinquent Utilization Data Requests. Facilities will be required to timely submit utilization data requested by the DHH. Providers will be given written notice when such utilization data has not been received by the due date. Such notice will advise the provider of the date the utilization data must be received by to avoid withholding of vendor payments. The due date will never be less than 10 days from the date the notice is mailed to the provider. If the utilization data is not received by the due date provided in the notice, the medical vendor's payment will be withheld until the utilization data is received.

13. Termination or Withdrawal from the Medicaid Program. When a provider is terminated or withdraws from the Medicaid Program, vendor payment will be withheld until all programmatic and financial issues are resolved.

E. Civil Fines. Louisiana R.S. 40:2199 authorized DHH to impose monetary sanctions on those health care facilities found to be out of compliance with any state or federal law or rule concerning the operation and services of the health care provider.

1. Any ICF/MR found to be in violation of any state or federal statute, regulation, or any Department of Health and Hospitals (DHH) rule adopted pursuant to the Act governing the administration and operation of the facility may be sanctioned as provided in the schedule of fines listed under Paragraph 2 below.

a. Repeat Violation. A repeat violation is defined as a violation of a similar nature as a previously cited violation that occurs within 18 months of the previously cited violation. DHH has the authority to determine when a violation is a repeat violation.

b. Opening or Operating a Facility Without a License. The opening or operation of a facility without a license or registration will be a misdemeanor, punishable upon conviction by a fine of not less than $1,000 nor more than $5,000.

i. Each day's violations will constitute a separate offense.

ii. On learning of such an operation, DHH will refer the facility to the appropriate authorities for prosecution.

c. Any ICF/MR found to have a violation that poses a threat to the health, safety, rights, or welfare of a resident or client may be liable for civil fines in addition to any criminal action that may be brought under other applicable laws.

2. Description of Violations and Applicable Civil Fines

a. Class A Violations. A Class A violation is a violation of a rule or regulation that creates a condition or occurrence relating to the maintenance or operation of a facility that results in death or serious harm to a resident or client.

i. Examples of Class A violations include, but are not limited to, the following:

(a). acts or omissions by an employee or employees of a facility that either knowingly or negligently resulted in the death of a resident or client; and

(b). acts or omissions by an employee or employees of a facility that either knowingly or negligently resulted in serious harm to a resident or client.

ii. Civil fines for Class A violations may not exceed:

(a). $2,500 for the first violation; or

(b). $5,000 per day for repeat violations.

b. Class B Violations. A Class B violation is a violation of rule or regulation in which a condition or occurrence relating to the maintenance or operation of a facility is created that results in the substantial probability that death or serious harm to the client or resident will result if the condition or occurrence remains uncorrected.

i. Examples of Class B violations include, but are not limited to, the following:

(a). medications or treatments improperly administered or withheld;

(b). lack of functioning equipment necessary to care for clients;

(c). failure to maintain emergency equipment in working order;

(d). failure to employ a sufficient number of adequately trained staff to care for clients; and

(e). failure to implement adequate infection control measures.

ii. Civil fines for Class B violations may not exceed:

(a). $1,500 for the first violation; or

(b). $3,000 per day for repeat violations.

c. Class C Violations. A Class C violation is a violation of a rule or regulation in which a condition or occurrence relating to the maintenance or operation of the facility is created that threatens the health, safety, or welfare of a client or resident.

i. Examples of Class C violations include, but are not limited to, the following:

(a). failure to perform treatments as ordered by the physician;

(b). improper storage of poisonous substances;

(c). failure to notify physician and family of changes in condition of the client or resident;

(d). failure to maintain equipment in working order;

(e). inadequate supply of needed equipment;

(f). lack of adequately trained staff necessary to meet clients' needs; and

(g). failure to adhere to professional standards in giving care to the client.

ii. Civil fines for Class C violations may not exceed:

(a). $1,000 for the first violation;

(b). $2,000 per day for repeat violations.

d. Class D Violations. Class D violations are violations of rules or regulations related to administrative and reporting requirements that do not threaten the health, safety, rights, or welfare of a client or resident.

i. Examples of Class D violations include, but are not limited to, the following:

(a). failure to submit written reports of accidents;

(b). failure to timely submit a Plan of Correction;

(c). falsification of a record; and,

(d). failure to maintain clients financial records as required by rules or regulations.

ii. Civil fines for Class D violations may not exceed:

(a). $100 for the first violation;

(b). $250 per day for repeat violations.

e. Class E Violations

i. Class E violations occur when a facility fails to submit a statistical or financial report in a timely manner when such a report is required by rule or regulation.

ii. Civil fines for Class E violations may not exceed:

(a). $50 for the first violation;

(b). $100 per day for repeat violations.

f. Maximum Amount for a Civil Fine

i. The aggregate fines assessed for violations determined in any one month may not exceed $10,000 for a Class A and Class B violations.

ii. The aggregate fines assessed Class C, Class D, and Class E violations determined in any one month may not exceed $5,000.

g. DHH will have the authority to determine whether a violation is a repeat violation and sanction the provider accordingly. Violations may be considered repeat violations by DHH when the following conditions exist:

i. when DHH has established the existence of a violation as of a particular date and the violation is one that may be reasonably expected to continue until corrective action is taken, DHH may elect to treat said continuing violation as a repeat violation subject to appropriate fines for each day following the date on which the initial violation is established, until such time as there is evidence that the violation has been corrected; or

ii. when DHH has established the existence of a violation and another violation that is the same or substantially similar to the cited violation occurs within 18months, the second and all similar subsequent violations occurring within the 18-month time period will be considered repeat violations and sanctioned accordingly.

3. Notice and Appeal Procedure

a. When DHH imposes a sanction on a health care provider, it will give the provider written notice of the imposition. The notice will be given by certified mail and will include the following:

i. The nature of the violation(s) and whether the violation(s) is classified as a repeat violation;

ii. The legal authority that established the violation(s);

iii. The civil fine assessed for each violation;

iv. Inform the administrator of the facility that the facility has 10 days from receipt of the notice within which to request an informal reconsideration of proposed sanction;

v. Inform the administrator of the facility that the facility has 30 days from receipt of the notice within which to request an administrative appeal of the proposed sanction and that the request for an informal reconsideration does not extend the time limit for requesting an administrative appeal; and

vi. Inform the administrator of the facility that the consequences of failing to request an informal reconsideration and/or an administrative appeal will be that DHH's decision is final and that no further administrative or judicial review may be had.

b. The provider may request an Informal Reconsideration of DHH's decision to impose a civil fine. This request must be written and made to DHH within 10 days of receipt of the notice of the imposition of the fine.

i. This reconsideration will be conducted by designated employees of DHH who did not participate in the initial decision to recommend imposition of a sanction.

ii. Oral presentation can be requested by the provider representative, and if requested, will be made to the designated employees.

iii. Reconsideration will be made on the basis of documents and oral presentations made by the provider to the designated employees at the time of the reconsideration.

(a). Correction of the deficient practice for which the sanction was imposed will not be the basis of the reconsideration.

(b). The designated employees will only have the authority to confirm, reduce or rescind the civil fine.

iv. DHH will notify the provider of the results of the reconsideration within 10 working days after the oral presentation.

v. This process is not in lieu of the administrative appeal and does not extend the time limits for filing an administrative appeal.

c. The facility may request an administrative appeal. If an administrative appeal is requested in a timely manner, the appeal will be held as provided in the Administrative Procedure Act (R.S. 49:950 et seq.) An appeal bond will be posted with the Bureau of Appeals as provided in R.S.40:2199(D) or the provider may choose to file a devolutive appeal. A devolutive appeal means that the civil fine must be paid in full within 10 days of filing the appeal.

d. The provider may request judicial review of the administrative appeal decision as provided in the Administrative Procedure Act.

4. Collection of Fines

a. Fines are final when:

i. an appeal is not requested within the specified time limits;

ii. the facility admits the violations and agrees to pay the fine; or

iii. the administrative hearing affirms DHH's findings of violations and time for seeking judicial review has expired.

b. When civil fines become final, they will be paid in full within 10 days of their commencement unless DHH allows a payment schedule in light of documented financial hardship. Arrangements with DHH for a payment schedule must commence within 10 days of the fines becoming final. Interest will begin to accrue at the current judicial rate on the day the fines become final.

c. If payment of assessed fines is not received within the prescribed time period after becoming final and the provider is a Medicaid provider, DHH will deduct the full amount plus the accrued interest from money otherwise due to the provider as Medicaid reimbursement in its next (quarterly or monthly) payment. If the provider is not a Medicaid provider, DHH will institute civil actions as necessary to collect fines due.

d. No provider may claim imposed fines or interest as reimbursable costs, nor increase charges to residents, clients, or patients as a result of such fines or interest.

e. Civil fines collected will be deposited in the Health Care Facility Fund maintained by the state treasury.

F. Termination of Certification (Decertification) of an ICF/MR. An ICF/MR may voluntarily or involuntarily lose its participating status in the Medical Assistance Program.

NOTE: Federal regulations pertaining to this Subsection are 42 CFR 442.12 - 442.117.

1. Reasons for a Decertification of an ICF/MR

a. The ICF/MR may voluntarily withdraw from the program for reasons of its own. The owner and administrator will submit a written notice of withdrawal to the DHH's HSS at least 60 days in advance.

b. A new owner may decide against participation in the program. A written 60-day notice of withdrawal will be submitted to DHH's HSS.

c. DHH may decertify an ICF/MR for failure to comply with Title XIX standards, thus canceling the facility's provider agreement.

d. DHH may decertify an ICF/MR if deficiencies pose immediate jeopardy to the client's health, safety, rights, or welfare.

e. The ICF/MR may allow its provider agreement to expire. A written 60-day advance notice of withdrawal will be submitted to the DHH's HSS.

f. DHH may cancel the provider agreement if and when it is determined that the ICF/MR is in material breach of the contract.

2. Recertification of an Involuntarily Decertified ICF/MR. After involuntary decertification, an ICF/MR cannot participate as a Medical Assistance provider unless the following conditions are met:

a. the reasons for the decertification or nonrenewal of the contract no longer exist;

b. reasonable assurance exists that the factors causing the decertification will not recur;

c. the ICF/MR demonstrates compliance with the required standards for a 60-day period prior to reinstatement in a participating status; and

d. a professional medical review reports that clients are receiving proper care and services.

3. Denial of Payments for New Admissions

a. New Admissions. New admissions refer to the admission of a person who has never been a Title XIX client in the ICF/MR or, if previously admitted, had been discharged or had voluntarily left the ICF/MR. This term does not include the following:

i. individuals who were in the ICF/MR before the effective date of denial of payment for new admissions, even if they become eligible for Title XIX after that date.

ii. individuals who, after a temporary absence from the ICF/MR, are readmitted to beds reserved for them in accordance with the admission process.

b. Basis for Denial of Payment. DHH may deny payment for new admissions to an ICF/MR that no longer meets applicable requirements as specified in these standards.

i. ICF/MR's deficiencies do not pose immediate jeopardy (serious threat). If DHH finds that the ICF/MR's deficiencies do not pose immediate jeopardy to clients' health, safety, rights, or welfare, DHH may either terminate the ICF/MRs provider agreement or deny payment for new admissions.

ii. ICF/MR's deficiencies do pose immediate jeopardy (serious threat). If DHH finds that the ICF/MRs deficiencies do pose immediate jeopardy to clients' health, safety, rights, or welfare, and thereby terminates the ICF/MR's provider agreement, DHH may additionally seek to impose the denial of payment for new admissions.

c. DHH Procedures. Before denying payments for new admissions, DHH will be responsible for the following:

i. providing the ICF/MR a time frame of up to 60days to correct the cited deficiencies and comply with the standards for ICF/MRs;

ii. giving the ICF/MR notice of the intent to deny payment for new admissions and an opportunity to request an Informal Reconsideration if the facility has not achieved compliance at the end of the 60-day period;

iii. providing an informal hearing if requested by the ICF/MR that included the following:

(a). giving the ICF/MR the opportunity to present before a State Medicaid official not involved in the initial determination, evidence or documentation, in writing or in person, to refute the decision that the ICF/MR is out of compliance with the applicable standards for participation; and

(b). submitting a written decision setting forth the factual and legal basis pertinent to a resolution of the dispute.

iv. providing the facility and the public at least 15days advance notice of the effective date of the sanction and reasons for the denial of payments for new admissions should the informal hearing decision be adverse to the ICF/MR.

d. Duration of Denial of Payments and Subsequent Termination

i. Period of Denial. The denial of payments for new admissions will continue for 11 months after the month it was imposed unless, before the end of that period, DHH determines:

(a). the ICF/MR has corrected the deficiencies or is making a good faith effort to achieve compliance with the standards for ICF/MR participation; or

(b). the deficiencies are such that it is now necessary to terminate the ICF/MR's provider agreement.

ii. Subsequent Termination. DHH must terminate an ICF/MR's provider agreement under the following conditions:

(a). upon finding that the ICF/MR has been unable to achieve compliance with the standards for participation during the period that payments for new admissions had been denied;

(b). effective the day following the last day of the denial of payments;

(c). in accordance with the procedures for appeal of termination set forth in §10355, Appeals.

4. Examples of Situations Determined to Pose Immediate Jeopardy (Serious Threat). Listed below are some examples of situations determined to pose immediate jeopardy (serious threat) to the health, safety, rights, and welfare of clients in ICF/MR. These examples are not intended to be all inclusive. Other situations adversely affecting clients could constitute sufficient basis for the imposition of sanctions.

a. Poisonous Substances. An ICF/MR fails to provide proper storage of poisonous substances, and this failure results in death of or serious injury to a client or directly threatens the health, safety, or welfare of a client.

b. Falls. An ICF/MR fails to maintain required direct care staffing and/or a safe environment as set forth in the regulations, and this failure directly causes a client to fall resulting in death or serious injury or directly threatens the health, safety, or welfare of a client.

EXAMPLES : Equipment not properly maintained or personnel not responding to a client's request for assistance.

c. Assaults

i. By Other Clients. An ICF/MR fails to maintain required direct care staffing and fails to take measures when it is known that a client is combative and assaultive with other clients, and this failure causes an assault upon another client, resulting in death or serious injury or directly threatens the health, safety, and welfare of another client.

ii. By Staff. An ICF/MR fails to take corrective action (termination, legal action) against an employee who has a history of client abuse and assaults a client causing death or the situation directly threatens the health, safety, and welfare of a client.

d. Physical Restraints Results in Permanent Injury. ICF/MR personnel improperly apply physical restraints contrary to published regulations or fail to check and release restraints as directed by regulations or physician's written instructions, and such failure results in permanent injury to a client's extremity or death or directly threatens the health, safety and welfare of a client.

e. Control of Infections. An ICF/MR fails to follow or meet infection control standards as ordered in writing by the physician, and this failure results in infections leading to the death of or serious injury to a client or directly threatens the health, safety, and welfare of a client.

f. Medical Care

i. An ICF/MR fails to secure proper medical assistance for a client, and this failure results in the death of or serious injury to the client.

ii. A client's condition declined and no physician was informed, and this failure directly threatens the health, safety, or welfare of the client. This would also include the following:

(a). failure to follow up on unusual occurrences of negative findings;

(b). failure to obtain information regarding appropriate care before and after a client's hospitalization;

(c). failure to timely hospitalize a client during a serious illness.

iii. ICF/MR personnel have not followed written physician's orders, and this failure directly threatens the health, safety, or welfare of a client. This includes failure to fill prescriptions timely.

g. Natural Disaster/Fire. An ICF/MR fails to train its staff members in disaster/fire procedures as required by state rules and regulations for licensing of ICF/MRs or an ICF/MR fails to meet staffing requirements, and such failures result in the death of or serious injury to a client during natural disaster, fire or directly threatens the health, safety, or welfare of a client.

h. Decubitus Ulcers (Bed Sores). An ICF/MR fails to follow decubitus ulcer care measures in accordance with a physician's written orders, and such failure results in the death of, serious injury to, or discomfort of the client or directly threatens the health, safety, and welfare of a client.

i. Elopement. An ICF/MR fails to provide necessary supervision of its clients or take measures to prevent a client with a history of elopement problems from wandering away and such failure results in the death of or serious harm to the client or directly threatens the health, safety, and welfare of the client. Examples of preventive measures include, but are not limited to:

i. documentation that the elopement problem has been discussed with the client's family and the Interdisciplinary Team; and,

ii. that personnel have been trained to make additional efforts to monitor these clients.

j. Medications

i. An ICF/MR knowingly withholds a client's medications and such actions results in the death of or serious harm to the client or directly threatens the health, safety, and welfare of the client.

NOTE: The client does have the right to refuse medications. Such refusal must be documented in the client's record and brought to the attention of the physician and ID team.

ii. medication omitted without justification;

iii. excessive medication errors;

iv. improper storage of narcotics or other prescribed drugs, mishandling of drugs or other pharmaceutical problems.

k. Environment/Temperature. An ICF/MR fails to reasonably maintain its heating and air-conditioning system as required by regulations, and this failure results in the death of, serious harm to, or discomfort of a client or creates the possibility of death or serious injury. Isolated incidents of breakdown or power failure will not be considered immediate jeopardy.

l. Improper Treatments

i. ICF/MR personnel knowingly perform treatment contrary to a physician's order, and such treatment results in the death of or serious injury to the client or directly threatens the health, safety, and welfare of the client.

ii. An ICF/MR fails to feed clients who are unable to feed themselves as set forth in physician's instructions.

NOTE: Meals should be served at the required temperature.

iii. An ICF/MR fails to obtain a physician's order for use of chemical or physical restraints; the improper application of a physical restraint; or failure of facility personnel to check and release the restraints periodically as specified in state regulations.

m. Life Safety. An ICF/MR knowingly fails to maintain the required Life Safety Code System such as the following:

i. properly functioning sprinklers, fire alarms, smoke sensors, fire doors, electrical wiring;

ii. practice of fire or emergency evacuation plans; or

iii. stairways, hallways and exits free from obstruction; and noncompliance with these requirements results in the death of or serious injury to a client or directly threatens the health, safety, and welfare of a client.

n. Staffing. An ICF/MR consistently fails to maintain minimum staffing that directly threatens the health, safety, or welfare of a client. Isolated incidents where the facility does not maintain staffing due to personnel calling in sick or other emergencies are excluded.

o. Dietary Services. An ICF/MR fails to follow the minimum dietary needs or special dietary needs as ordered by a physician, and failure to meet these dietary needs threatens the health, safety or welfare of a client. The special diets must be prepared in accordance with physician's orders or a diet manual approved by the American Dietary Association.

p. Sanitation. An ICF/MR fails to maintain state and federal sanitation regulations, and those violations directly affect and threaten the health, safety, or welfare of a client.

EXAMPLES : Strong odors linked to a lack of cleanliness; Dirty buildup on floors and walls; Dirty utensils, glasses and flatware; Insect or rodent infestation

q. Equipment and Supplies. An ICF/MR fails to provide equipment and supplies authorized in writing by a physician as necessary for a client's care, and this failure directly threatens the health, safety, welfare or comfort of a client.

r. Client Rights

i. An ICF/MR violates its clients' rights and such violations result in the clients' distress to such an extent that their psychosocial functions are impaired or such violations directly threaten their psychosocial functioning. This includes psychological abuse.

ii. The ICF/MR permits the use of corporal punishment.

iii. The ICF/MR allows the following responses to clients by staff members and employment supervisors:

(a). physical exercise or repeated physical motions;

(b). excessive denial of usual services;

(c). any type of physical hitting or other painful physical contacts except as required by medical, dental, or first aid procedures necessary to preserve the individual's life or health;

(d). requiring the individual to take on an extremely uncomfortable position;

(e). verbal abuse, ridicule, or humiliation;

(f). requiring the individual to remain silent for a long period of time;

(g). denial of shelter, warmth, clothing or bedding; or

(h). assignment of harsh physical work.

iv. The ICF/MR fails to afford the client with the opportunity to attend religious services.

v. The ICF/MR denies the client the right to bring his or her personal belongings to the program, to have access, and to acquire belongings in accordance with the service plan.

vi. The ICF/MR denies a client a meal without a doctor's order.

vii. The ICF/MR does not afford the client with suitable supervised opportunities for interaction with members of the opposite sex, except where a qualified professional responsible for the formulation of a particular individual's treatment/habilitation plan writes an order to the contrary and explains the reasons.

NOTE: The secretary of DHH has the final authority to determine what constitutes "immediate jeopardy" or serious threat.

La. Admin. Code tit. 50, § II-10357

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 25:701 (April 1999).

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