471 Neb. Admin. Code, ch. 12, § 007

Current through September 17, 2024

Section 471-12-007 - NURSING FACILITY (NF) SERVICES

007.01STANDARDS FOR PARTICIPATION FOR NURSING FACILITIES. The nursing facility (NF) must meet:

(A) The Nebraska nursing home licensure, and Medicare and Medicaid certification standards as required by state statutes and 42 CFR 483, Subpart B, or if located outside of Nebraska, similar standards in that state;

(B) The facility type, program and operational definitions; and

(C) The definition of a nursing facility (NF) as defined in this chapter, and in section 1919 of the Social Security Act.

007.02PROVIDER AGREEMENT. To participate as a provider the nursing facility (NF) must meet the standards in this chapter and must complete the appropriate provider agreement. The facility submits the completed and signed form to Medicaid for approval and enrollment as a provider.

007.03MINIMUM DATA SET RESIDENT ASSESSMENT. The nursing facility (NF) must conduct an interdisciplinary assessment of every resident's functional capacity, regardless of payor source. This assessment must utilize the minimum data set (MDS). The facility must submit one copy of each assessment to the Department within 30 days of completion.

007.03(A)REGISTERED NURSE (RN) ASSESSMENT COORDINATOR. Each facility must designate a registered nurse (RN) assessment coordinator. The facility must inform the Department of the name of the assessment coordinator and must promptly inform the Department of any changes. The assessment coordinator must coordinate each assessment with the appropriate participation of health professionals. Each individual who completes a portion of an assessment must sign and certify as to the accuracy of that portion of the assessment. The assessment coordinator must sign and certify the completion of the assessment.

007.03(B)FREQUENCY OF ASSESSMENTS. An assessment must be completed:

(i) Initial admission: Must be completed by 14th day of resident's stay;

(ii) Annual reassessment: Must be completed within 12 months of most recent full assessment;

(iii) Significant change in status reassessment: Must be completed by the end of the 14th calendar day following determination that a significant change has occurred; and

(iv) Quarterly assessment: Must be completed no less frequently than once every three months.

007.03(C)OTHER CHANGES. The facility need not assess the resident if declines in a resident's physical, mental, or psychosocial well-being are attributable to:

(i) Discrete and easily reversible causes documented in the resident's record and for which facility staff can initiate corrective action;

(ii) Short-term acute illness, such as a mild fever secondary to a cold from which facility staff expect full recovery of the resident's pre-morbid functional abilities and health status; or

(iii) Well established, predictive cyclical patterns of clinical signs and symptoms associated with previously diagnosed conditions.

007.03(D)USE OF INDEPENDENT ASSESSORS. If the Department determines, under a survey by the Department of Health and Human Services Regulation and Licensure or otherwise, that assessments are not being completed or that there has been a knowing and willful false certification of information under this section, the Department may require for a period of time specified by the Department that resident assessments under this section be conducted and certified by individuals who are independent of the facility and who are approved by the Department. The facility is responsible for the reasonable payment of the individuals completing the assessment. The cost may be included in cost reports.

007.04COMPREHENSIVE CARE PLAN. The facility must develop a comprehensive care plan for each client that includes measurable objectives and timetables to meet a client's medical, nursing, and psychosocial needs that are identified in a comprehensive assessment. The plan must be:

(A) Developed within seven days after completion of the comprehensive assessment;

(B) Prepared by an interdisciplinary team; and

(C) Periodically reviewed and revised by a team of qualified persons after each assessment, or at least quarterly. The plan must include recommendations of the Level II evaluation, if applicable.

007.05ANNUAL PHYSICAL EXAMINATION. The Department requires that all nursing facility residents have an annual physical examination. The physician, based on their authority to prescribe continued treatment, determines the extent of the examination for clients based on medical necessity. For the annual physical exam, a complete blood count and urinalysis will not be considered routine and will be reimbursed based on the physician's orders. The results of the examination must be recorded in the client's medical record.

007.05(A)BILLING FOR THE ANNUAL PHYSICAL EXAMINATION. If the annual physical examination is performed solely to meet the Medicaid requirement, the physician must submit the appropriate professional claim to the Department. If the physical examination is performed for diagnosis or treatment of a specific symptom, illness, or injury and the client has Medicare or other third party coverage, the physician must submit the claim through the usual Medicare or other third party process.

007.06PHYSICIAN SERVICES. The physician must see the client whenever necessary, but at least once every 30 days for the first 90 days following admission, and at least once every 60 days thereafter. At the time of each visit, the physician must:

(1) Review the client's total program of care, including medications and treatments;

(2) Write, sign, and date progress notes at each visit; and

(3) Sign all orders.

007.06(A)PHYSICIAN TASKS. In accordance with 42 CFR 483.40(f), the Department will allow all but the following required physician tasks in a nursing facility to be satisfied when performed by a nurse practitioner or physician's assistant who is not an employee of the facility but who is working in collaboration with a physician according to Nebraska statute and designation of duties:

(i) Initial certification;

(ii) Admission orders; and

(iii) Admission plan of care.

007.07MEDICAL CARE AND SERVICES. The facility must ensure that admitted Medicaid clients receive appropriate medical care and services. If the appropriate medical care or service cannot be provided using facility staff, the facility must arrange for the care or service to be provided.

007.08DENTAL CARE. Facilities must make arrangements for dental examinations as needed.

007.09FREEDOM OF CHOICE. Each facility must ensure that any client may exercise their freedom of choice in obtaining covered services from any provider qualified to perform the services. Clients participating in Medicaid managed care must comply with the conditions of their managed care plan.

007.10ROOM AND BED ASSIGNMENTS. Facility staff must maintain a permanent record of the client's room and bed assignments. This record must show the dates and reasons for all changes and be maintained in the nurses' notes in the health chart or medical record.

007.11RESIDENTS' RIGHTS. The facility must protect and promote the rights of each resident as defined in 42 CFR 483.10. When the resident is unable to manage their own personal funds, and there is not a guardian or responsible family member, the facility must arrange for, or manage, the personal funds as specified in 42 CFR 483.10(c)(1) thru (8).

007.12BED-HOLDING POLICIES FOR HOSPITAL AND THERAPEUTIC LEAVE. The facility must develop policies as defined in 42 CFR 483.15(d).

007.13INITIAL NOTICE OF BED-HOLDING POLICIES. The facility must provide written information to the client and a family member or legal representative that specifies:

(A) The duration of the bed-hold policy during which the client is permitted to return and resume residence in the facility; and

(B) The facility's policies regarding bed-hold periods which must be consistent with 42 CFR 483.15(d).

007.14NOTICE UPON TRANSFER. At the time of transfer, the facility must provide written notice to the client and a family member or legal representative which specifies the duration of the bed-hold policy.

007.15PERMITTING THE CLIENT TO RETURN TO THE FACILITY. The facility must establish and follow a written policy under which a client whose leave exceeds the bed-hold period is re-admitted to the facility immediately upon availability of a bed if the client:

(A) Requires the services provided by the facility; and

(B) Is eligible for Medicaid nursing facility services.

007.16FACILITY-TO-FACILITY TRANSFER. To transfer any Medicaid client from one facility to another, the transferring facility must:

(A) Obtain physician's written order for transfer;

(B) Obtain written consent from the client, his or her family, or guardian;

(C) Notify the Department that handles the client's case in writing, stating:

(i) The reason for transfer;

(ii) The name of facility to which the client is being transferred; and

(iii) The date of transfer;

(D) Transfer the following to the receiving facility:

(i) Necessary medical, social, and Preadmission Screening and Resident Review (PASRR) information;

(ii) Any non-standard wheelchair and wheelchair accessories, options, or components, including power operated vehicles;

(iii) Any augmentative communication devices with related equipment and software;

(iv) Supports; and

(v) Custom fitted or custom fabricated items; and

(E) Document transfer information in the client's record and discharge summary.

007.17DISCHARGES. At the time of or no later than 48 hours after a client is discharged or expires, the facility must notify the Department that handles the client's case of:

(A) Date of discharge and the place to which the client was discharged; or

(B) Date of death.

007.18DISCHARGE PLANNING. Before a client's discharge or deinstitutionalization, the facility staff must document in the medical record the actual implementation date of the discharge plan. Each nursing facility must maintain written discharge planning procedures for all Medicaid clients that describe:

(A) Which staff member of the facility has operational responsibility for discharge planning;

(B) The manner in, and methods by, which the staff member will function, including authority and relationship with the facility's staff;

(C) The time period in which each client's need for discharge planning will be determined, which period may not be later than seven days after the day of admission;

(D) The maximum time period after which the interdisciplinary team reevaluates each client's discharge plan;

(E) The resources available to the facility, the client, and the attending physician to assist in developing and implementing individual discharge plans; and

(F) The provisions for periodic review and reevaluation of the facility's discharge planning program.

007.19INAPPROPRIATE LEVEL OF CARE (LOC). If it is determined that the client's present level of care is inappropriate:

(A) The present facility must provide services to meet the needs of the client and must refer to appropriate agencies for services until an appropriate living situation is available;

(B) The facility must document that other alternatives were explored and the responses;

(C) The facility must make documentation of active exploration for appropriate living situations available to the Department or their agent;

(D) The facility must work cooperatively with the preadmission screening and resident review referral (PASRR) process.

007.20AT THE TIME OF DISCHARGE. At the time of the client's discharge, the facility must:

(A) Provide any information about the discharged client that will ensure the optimal continuity of care to those persons responsible for the individual's post-discharge care.

(B) Include current information on diagnosis, prior treatment, rehabilitation potential, physician advice concerning immediate care, and pertinent social information.

(C) Discharge the following items specifically purchased for and used by the client with the client:

(i) Any non-standard wheelchair and wheelchair accessories, options, and components, including power operated vehicles;

(ii) Any augmentative communication devices with related equipment and software;

(iii) Supports; and

(iv) Custom fitted or custom fabricated items.

007.21APPEALS OF DISCHARGES, TRANSFERS, AND PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) DETERMINATIONS. A resident of a skilled nursing facility (SNF) or a nursing facility (NF) who receives a notice from the skilled nursing facility (SNF) or nursing facility (NF) of the intent to discharge or transfer the resident may appeal to the Department of Health and Human Services for a hearing on this notice. The appeal and hearing must be conducted under 465 NAC 2 and 6. An individual who is adversely affected by any Preadmission Screening and Resident Review (PASRR) determination may appeal to the Department of Health and Human Services for a hearing on the decision. The individual or legal representative will be instructed to contact the Department or contractor for information on appeals and to forward a written request for an appeal to the Department within 90 days of the date of the Preadmission Screening and Resident Review (PASRR) determination notice. The appeal and hearing must be conducted under 465 NAC 2.

007.22PRIOR AUTHORIZATION. Medicaid requires authorization for the following services:

(A) Nursing facility services for clients under the age of 18;

(B) Special needs nursing facility (NF) services;

(C) Out-of-state nursing facilities;

(D) Room and board services for clients receiving hospice in a special needs nursing facility (NF);

(E) Swing bed services; and

(F) Specialized add-on services for clients with intellectual disabilities or related conditions residing in nursing facilities.

007.23PHYSICIAN'S INITIAL CERTIFICATION. The physician must certify the medical necessity for nursing facility level of care (NF LOC) for all admissions. Documentation indicating certification must be maintained in the medical record. The physician must also certify the medical necessity for nursing facility level of care (NF LOC):

(A) For clients who became eligible after admission, the physician must certify medical necessity prior to requesting prior authorization for nursing facility level of care (NF LOC); and

(B) Proof of prior authorization must be maintained in the client's medical record in the facility or building where the client resides or in the client account file.

007.24ADMISSION HISTORY AND PHYSICAL. The client must have a physical examination within 48 hours after admission unless an examination was performed within five days before admission.

007.25SPECIFIC PAYMENTS.

007.25(A)MEDICAID PAYMENT RESTRICTIONS FOR NURSING FACILITIES. The Department must pay for a nursing facility service only when prior authorized, when prior authorization is required.

007.25(B)INITIAL CERTIFICATION. The Department must approve payment to a facility for services rendered to an eligible client beginning on the latest date:

(i) The client is admitted to the facility;

(ii) The client's eligibility is effective, if later than the admission date; or

(iii) Of the intellectual disability screen.

007.25(C)DEATH ON DAY OF ADMISSION. If a client is admitted to a facility and dies before midnight on the same day, the Department allows payment for one day of care.

007.25(D)INAPPROPRIATE FOR NURSING FACILITY CARE. For those clients who, at the time of medical review determination, no longer meet nursing facility (NF) criteria for nursing facility (NF) services, the medical review must limit Medicaid payment for up to a maximum of 30 days, beginning with the date the medical review determines that nursing facility (NF) care is inappropriate. Time-limited authorizations exceeding 30 days may be made based on the client's potential for discharge as determined by the medical review.

007.25(E)EFFECT OF PREADMISSION SCREENING AND RESIDENT REVIEW (PASSR). Medicaid payment is available for nursing facility services provided to Medicaid-eligible clients who, as a result of Preadmission Screening and Resident Review (PASRR):

(1) Were found to require the nursing facility level of care (NF LOC); or

(2) Were found inappropriate for nursing facility care but through the 30-month choice have elected to remain in a nursing facility (NF).

007.25(E)(i)PREADMISSION SCREENING NOT PERFORMED. When a preadmission screening and resident review (PASRR) is not performed before admission, Medicaid payment for nursing facility services is available only for services provided after the preadmission screening and resident review (PASRR) is completed.

007.25(F)ITEMS INCLUDED IN PER DIEM RATES. The following items are included in the per diem rate:

(i)Routine services: Routine nursing facility (NF) services include regular room, dietary, and nursing services; social services and activity program as required by certification standards; minor medical supplies; oxygen and oxygen equipment; the use of equipment and facilities; and other routine services;

(ii)Injections: The patient's physician must prescribe all injections. Payment is not authorized for the administration of injections, since giving injections is considered a part of routine nursing care and covered by the long term care facility's reimbursement. Payment is authorized to the drug provider for drugs used in approved injections. Syringes and needles are necessary medical supplies and are included in the per diem rate;

(iii)Transportation: The facility is responsible for ensuring that all clients receive appropriate medical care. The facility must provide transportation to client services that are reimbursed by Medicaid. The reasonable cost of maintaining and operating a vehicle for patient transportation is an allowable cost and is reimbursable under the long term care reimbursement plan;

(iv)Contracted services: The nursing facility must contract for services not readily available in the facility:

(1) If the service is provided by an independent licensed provider who is enrolled in Medicaid the provider must submit a separate claim for each person served; and

(2) If the service is provided by a certified provider of medical care the nursing facility is responsible for payment to the provider. This expense is an allowable cost;

(v)Single room accommodations: Medicaid residents should be afforded equal opportunity to remain in or utilize single-room accommodations. Any facility that prohibits or requires an additional charge for Medicaid utilization of single-room accommodations must make an appropriate adjustment on its cost report to remove the additional cost of single-room accommodations. The facility must not make an additional charge for a therapeutically required single room nor is the facility required to make a cost report adjustment for this type of room. Each facility must have a written policy on single-room accommodations for all payers.

007.25(G)ITEMS NOT INCLUDED IN PER DIEM RATES. Items for which payment may be made to nursing facility (NF) providers and are not considered part of the facility's Medicaid per diem are listed below. To be covered, the client's condition must meet the criteria for coverage for the item as outlined in the appropriate Medicaid provider chapter:

(i) Any non-standard wheelchairs and wheelchair accessories, options, and components, including power-operated vehicles needed for the client's permanent and full time use. Standard wheelchairs are considered necessary equipment in a nursing facility to provide care and part of the per diem;

(ii) Air fluidized bed units and low air loss bed units; and

(iii) Negative pressure wound therapy.

007.25(H)PAYMENTS TO OTHER PROVIDERS. Items for which payment may be authorized to non-nursing facility (NF) providers and are not considered part of the facility's Medicaid per diem are listed below. To be covered, the client's condition must meet the criteria for coverage for the item as outlined in the appropriate Medicaid provider chapter. The provider of the service may be required to request prior authorization of payment for the service:

(i) Legend drugs, over-the-counter (OTC) drugs, and compounded prescriptions, including intravenous solutions and dilutants;

(ii) Personal appliances and devices, if recommended in writing by a physician, such as eye glasses and hearing aids;

(iii) Orthoses;

(iv) Prostheses; and

(v) Ambulance service.

007.25(I)MAY BE CHARGED TO RESIDENT'S FUNDS. Items that may be charged to residents' funds and are not considered as part of the facility's Medicaid per diem are:

(i) Telephone;

(ii) Television and radio for personal use, except cable service;

(iii) Personal comfort items, including smoking materials, notions, and novelties, and confections;

(iv) Cosmetic and grooming items and services that are specifically requested by the client and are in excess of the basic grooming items provided by the facility;

(v) Personal clothing;

(vi) Personal reading matter;

(vii) Gifts purchased on behalf of the client;

(viii) Flowers and plants;

(ix) Social events and entertainment offered outside the scope of the activities program required by certification;

(x) Non-covered special care services such as privately hired nurses or aides specifically requested by the client or family;

(xi) Specially prepared or alternative food requested instead of the food generally prepared by the facility, as required by certification; or

(xii) Single room, except when therapeutically required.

007.25(J)OTHER. The facility must meet the following requirements:

(i) The facility must not charge a client for any item or service not requested by the resident.

(ii) The facility must not require a resident to request any item or service as a condition of admission or continued stay.

(iii) The facility must inform the client requesting an item or service for which a charge will be made that there will be a charge for the item or service and what the charge will be.

007.25(K)PAYMENT FOR BED-HOLDING. The Department makes payments to reserve a bed in a nursing facility (NF) during a client's absence due to hospitalization for an acute condition and for therapeutically-indicated home visits. Therapeutically-indicated home visits are overnight visits with relatives and friends or visits to participate in therapeutic or rehabilitative programs. Payment for bed-holding is subject to the following conditions:

(1) A held bed must be vacant and counted in the census. The census must not exceed licensed capacity;

(2) Hospital bed-holding is limited to reimbursement for 15 days per hospitalization. Hospital bed-holding does not apply if the transfer is to the following: nursing facility, hospital nursing facility, swing-bed, a Medicare-covered special needs facility stay, or to hospitalization following a Medicare-covered special needs facility stay;

(3) Therapeutic leave bed-holding is limited to reimbursement for 18 days per calendar year. Bed-holding days are prorated when a client is a resident for a partial year;

(4) A transfer from one facility to another does not begin a new 18-day period;

(5) The client's comprehensive care plan must provide for therapeutic leave;

(6) Facility staff must work with the client, the client's family, or guardian to plan the use of the allowed 18 days of therapeutic leave for the calendar year; and

(7) Qualifying hospital and therapeutic leave days will be reimbursed at the facility's bed-hold rate.

007.25(K)(i)SPECIAL LIMITS. When the limitation for therapeutic leave interferes with an approved therapeutic or rehabilitation program, the facility may submit a request for special limits of up to an additional six days per calendar year to Medicaid. Requests for special limits must include:

(1) The number of leave days requested;

(2) The need for additional therapeutic bed-holding days;

(3) The physician's orders;

(4) The comprehensive plan of care; and

(5) The discharge potential.

007.25(K)(ii)REPORTING. It is mandatory that the nursing facility (NF) report all bedholding days monthly. Facilities must report bedholding days. The nursing home days are adjusted to the actual number of days the client was present in the facility at 12:00 midnight.

471 Neb. Admin. Code, ch. 12, § 007

Amended effective 10/20/2015.

Amended effective 12/19/2018

Amended effective 6/28/2020

Amended effective 12/23/2020

Amended effective 6/26/2021

Amended effective 6/6/2022