471 Neb. Admin. Code, ch. 31, § 004

Current through June 17, 2024

Section 471-31-004 - SERVICE REQUIREMENTS

004.01GENERAL REQUIREMENTS.

004.01(A)MEDICAL NECESSITY. Intermediate care facility for individuals with developmental disabilities (ICF/DD) services must meet the medical necessity requirements in 471 NAC 1, and each client must be determined to meet level of care criteria outlined in this chapter.

004.01(B)PRIOR AUTHORIZATION. Medicaid pays for intermediate care facility for individuals with developmental disabilities (ICF/DD) services only when prior authorized. Each admission must be separately prior authorized.

004.01(C)ADMISSION PROCESS. For all clients seeking Medicaid payment for intermediate care facility for individuals with developmental disabilities (ICF/DD) services, the facility must complete a pre-admission evaluation to determine if the client is Medicaid eligible or has applied for Medicaid, has been diagnosed with an intellectual disability or related condition and whether the facility can provide services to meet the client's needs. In addition, the facility must determine that the client needs and will benefit from active treatment. The facility must conduct or obtain the following as part of the pre-admission evaluation:

(1) Current and comprehensive physician's examination:

(2) A current dental examination completed within 12 months before admission or within one month after the date of admission:

(3) Current and comprehensive functional assessments conducted on the day of and no more than three months prior to the admission:

(4) Psychological evaluation which includes the client's diagnoses, must be completed on or no more than three months prior to admission:

(5) The most recent individual program plan and if school age, the most recent individual education plan. Must have been implemented within the previous twelve months:

(6) Current, within the previous twelve months, habilitative training records:

(7) Current medical records:

(8) Physician certification for the client's need of intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care. Must be signed by the physician:

(9) Physician plan of care, as required by 42 CFR 456.380: and

(10) Independent qualified intellectual disabilities professional (QIDP) assessment

004.01(C)(i)EVALUATIONS. Evaluations conducted must meet requirements found at 42 CFR 456.370(c). All evaluations, assessments, and records obtained must be current with the client's needs at the time of the admission process as required at 42 CFR 456.370(a) and (b).

004.01(C)(ii)ADMISSION DETERMINATION. The facility will review the preadmission evaluation and hold a pre-admission meeting with the client, guardian, and interdisciplinary team (IDT) to determine admission. Personnel from outside the facility that previously provided services to the client should be encouraged to attend, as well. The purpose of the pre-admission meeting is to:

(a) Summarize in writing the findings from the individual functional assessments:

(b) Determine the clients needs without regard to the intermediate care facility for individuals with developmental disabilities (ICF/DD)'s ability to meet those needs;

(c) Determine whether or not the intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care is appropriate and meets the client's needs. If the interdisciplinary team (IDT) determines that intermediate care facility for individuals with developmental disabilities (ICF/DD) services are not appropriate to meet the client's needs, the intermediate care facility for individuals with developmental disabilities (ICF/DD) must refer the client and legal guardian to the Department of Health and Human Services' Developmental Disabilities Division, Service Coordination (DDD SC) to determine the availability of alternative services;

(d) Determine if the client will be admitted to the intermediate care facility for individuals with developmental disabilities (ICF/DD): and

(e) Develop the pre-admission plan if the client is to be admitted.

004.01(C)(iii)(1)ALTERNATIVES. The intermediate care facility for individuals with developmental disabilities (ICF/DD), Medicaid, the client, family, guardian, attending physician, and intermediate care facility for individuals with developmental disabilities (iCF/DD)'s interdisciplinary team (IDT) staff must cooperatively explore alternatives available through Medicaid programs based on the client's total needs.

004.01(C)(iii)PRE-ADMISSION PLAN. The pre-admission plan is the individual program plan (IPP) for the first 30 days after the client is admitted to the intermediate care facility for individuals with developmental disabilities (ICF/DD). The plan must:

(1) Include the client's name, date of birth, and guardianship status;

(2) Document the interdisciplinary team (IDT)'s rationale for admitting the client:

(3) Identify additional needed evaluations:

(4) Identify the client's skills and skill deficits:

(5) Identify baselines which are conducted to determine training needs:

(6) Identify the client's current medical and nutritional status:

(7) Specify the care, services, and referral for additional evaluations to be provided for the first 30 days or until the post-admission evaluation is established;

(8) Include programs and services to be continued from other programs: and

(9) Include a plan to explore alternative, less restrictive services on an ongoing basis.

004.01(C)(iv)PHYSICIAN'S ADMISSION HISTORY AND PHYSICAL. When the client is admitted to the intermediate care facility for individuals with developmental disabilities (ICF/DD), the facility must ensure that:

(1) The client has a physical examination within 48 hours, two working days, after admission, unless an examination was performed within thirty days before admission: and

(2) The history and physical is documented on Form DM-5 or attached to Form DM-5.

004.01(C)(v)PHYSICIAN'S INITIAL CERTIFICATION (FORM DM-5 OR FORM MC-9NF). The physician's certification on Form DM-5. Form MC-9NF, or Nursing Facility Leyel Of Care Determination Form, must be signed within the following time frame:

(a) For clients already eligible for Medicaid at the time of admission. Form DM-5. Form MC-9NF, or Nursing Facility Level Of Care Determination Form must be signed and dated within 30 days before the date of admission, or within 48 hours (two working days) after the date of admission: or

(b) For clients not already determined to be eligible for Medicaid at the time of admission. Form DM-5. Form MC-9NF or Nursing Facility Level Of Care Determination Form must be signed and dated within 30 days before or within 48 hours (two working days) after the date the client's eligibility is determined.

004.01(C)(v)(1)ELIGIBILITY DETERMINATION. The date of eligibility for intermediate care facility for individuals with developmental disabilities (ICF/DD) services is defined as the actual date the eligibility determination is made not necessarily the effective date of Medicaid eligibility. The following circumstances impact Medicaid coverage of intermediate care facility for individuals with developmental disabilities (CF/DD) services:

(a) if Form DM-5, Form MC-9NF, or Nursing Facility Level of Care Determination Form, is signed and dated more than 30 days before the date of eligibility determination, the facility must provide Medicaid with a new or updated Form DM-5, Form MC-9NF. or Nursing Facility Level of Care Determination Form before Medicaid authorizes payment to the facility;

(b) If Form DM-5, Form MC-9NF. or the Nursing Facility Level of Care Determination Form is signed and dated more than 48 hours two working days after admission or eligibility determination, the earliest that payment to the facility could be effective is the date Form DM-5. Form MC-9NF. or the Nursing Facility Level Of Care Determination Form, is signed and dated. Holidays and weekends are not counted if they fall within the 48-hourtime period; and

(c) If the date of Form DM-5. Form MC-9NF. or the Nursing Facility Level of Care Determination Form falls within the required time frame. Medicaid may authorize payment to be effective on the date of admission or the medical eligibility effective date.

004.01(C)(v)(2)SIGNATURE REQUIREMENTS. Form DM-5 must be signed and dated by a physician, if a physician signature stamp is used, the physician must initial the stamped signature. Physician's assistant or registered nurse signature or initials are not acceptable.

004.01(C)(v)(3)RECORD RETENTION. Forms DM-5, MC-9NF, or the Nursing Facility Level of Care Determination Form must be maintained in the client's medical record in the facility where the client resides.

004.01(C)(vi)EMERGENCY ADMISSIONS. In the case of an emergency admission, the intermediate care facility for individuals with developmental disabilities (ICF/DD) facility will follow the admission process according to this chapter. The facility must hold the pre-admission meeting on the day the client enters the facility and will document the reason for the admission. However, the facility is given seyen calendar days to complete the needed assessments to verify the client's need for intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care, health and nutritional needs, skills and skill deficits and training needs.

004.01(C)(vii)ADMISSION NOTIFICATION. The intermediate care facility for individuals with developmental disabilities (ICF/DD) must notify Medicaid within 10 days of admitting a client into the intermediate care facility for individuals with developmental disabilities (iCF/DD).

004.01(D)LEVEL OF CARE.

004.01(D)(i)INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) LEVEL OF CARE CRITERIA. Medicaid applies the following criteria to determine the appropriateness of intermediate care facility for individuals with developmental disabilities (ICF/DD) services on admission and at each subsequent review:

(1) The individual has a diagnosis of an intellectual disability or a related condition, which has been confirmed by prior diagnostic evaluations and standardized tests and sources independent of the intermediate care facility for individuals with developmental disabilities (ICF/DD): and

(2) The individual can benefit from active treatment as defined in 42 CFR 483.440(a) and 471 NAC 31-002. In addition, the following criteria apply:

(a) The individual has a related condition and the independent qualified intellectual disabilities professional (QIDP) assessment identifies the related condition has resulted in substantial functional limitations in three or more of the following areas of major life skills: self-care, receptive and expressive language, learning, mobility, self-direction, or capacity for independent living. These substantial functional limitations indicate that the individual needs a combination of individually planned and coordinated special interdisciplinary care, a continuous active treatment program, treatment, and other services which are lifelong or of extended duration: and

(b) A Medicaid-eligible individual has a dual diagnosis of developmental disability or a related condition and a mental illness. The developmental disability or related condition has been verified as the primary diagnosis by both an independent qualified intellectual disabilities professional (QIDP) and a mental health professional in which their scope of practice allows them to diagnose mental illness: and:

(i) Historically there is evidence of missed developmental stages, due to developmental disability or a related condition:

(ii) There is remission in the mental illness and it does not interfere with intellectual functioning and participation in training programs: and

(iii) The diagnosis of developmental disability or a related condition takes precedence over the diagnosis of mental illness:

(c) When the individual does not have substantial functional limitations in self-care skills, the individual must have substantial functional limitations in at least the life skill area for capacity for independent living along with two other life skill areas.

004.01(D)(ii)APPROVAL OF THE INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) LEVEL OF CARE. The intermediate care facility for individuals with developmental disabilities (ICF/DD), after determining to admit the client, must submit the following to the Medicaid review team to request approval for Medicaid payment of intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care for the client:

(a) Completed Form MC-9NF, or Nursing Facility Level of Care Determination Form;

(b) The physician's examination or completed Form DM-5. The physician who conducted the examination must sign and date Form DM-5 with the physician's determination of level of care indicated. If the physician's examination is submitted instead of Form DM-5, it must include a clear indication that the physician conducting the examination certifies the client requires intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care;

(c) A current dental examination, completed within 12 months before admission or within one month after the date of admission:

(d) Completed Form DM-5-DD-LTC as instructed in Appendix 471-000-5;

(e) The independent qualified intellectual disabilities professional (QIDP) assessment:

(f) The individual program plan (IPP) and individualized educational plan (lEP), if school-aged, from the previous provider:

(g) Mental health evaluation performed by a mental health professional:

(h) The pre-admission evaluation: and

(i) For out-of-state intermediate care facility for individuals with developmental disabilities (ICF/DD) verification that the client's needs cannot be met by a Nebraska provider. Exceptions may be made by the department in its own discretion for this requirement.

004.01(D)(ii)(1)ONSITE OBSERVATIONS. When Medicaid receives all required documentation, Medicaid reviews all submitted documentation and determines whether the intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care is appropriate, in the event Medicaid determines the documentation available for review does not provide adeguate information to make a determination of whether the intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care is appropriate, Medicaid may conduct onsite observations of the client at the facility, interview facility staff, or request additional information from the intermediate care facility for individuals with developmental disabilities (ICF/DD) facility. If additional information is needed, the intermediate care facility for individuals with developmental disabilities (ICF/DD) must provide the necessary information upon the request of Medicaid. Medicaid will notify the intermediate care facility for individuals with developmental disabilities (ICF/DD) of any decision, and will notify the client as well as the parent or guardian of an adverse decision.

004.01(D)(iii)INAPPROPRIATE LEVEL OF CARE. On admission, and at each subsequent review, the facility must ensure which services provided in the intermediate care facility for individuals with developmental disabilities (ICF/DD) are the least restrictive alternative. The following do not meet criteria for intermediate care facility for individuals with developmental disabilities (ICF/DD) services:

(a) Mental illness is the primary barrier to independent living within a normalized environment; or

(b) The intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care is not the least restrictive alternative, including when the client:

(i) Exhibits skills and needs comparable to those of persons with similar needs living independently or semi-independently in the community;

(ii) Exhibits skills and needs comparable to those of persons at nursing facility (NF) level of care; or

(iii) Is able to function with little supervision or in the absence of a continuous active treatment program.

004.01(D)(iii)(1)INITIAL REVIEW. For those clients who, at the time of initial review, are found to be inappropriate for intermediate care facility for individuals with developmental disabilities (ICF/DD) care, Medicaid limits Medicaid coverage to a maximum of 30 days, beginning with the day Medicaid determines that the level of care is inappropriate.

004.01(D)(iii)(2)CLIENT RESIDING AT THE FACILITY. For those clients who, while residing at an intermediate care facility for individuals with developmental disabilities (ICF/DD), are found to be inappropriate for intermediate care facility for individuals with developmental disabilities (ICF/DD) care in accordance with the provisions of this chapter below, Medicaid limits Medicaid coverage to a maximum of 60 days, beginning with the day the recommendation becomes final.

004.01(D)(iii)(2)(a) DEPARTMENT RECOMMENDATION. After Medicaid reviews the client's health, habiiitative, and social needs and determines the client no longer meets criteria for intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care according to this chapter, the following process will take place:

(i) Medicaid will send a notification letter to the client's attending physician and the intermediate care facility for individuals with developmental disabilities (ICF/DD)'s qualified intellectual disabilities professional (QIDP) giving them an opportunity to respond. Based on the responses, Medicaid may take the following actions:

(1) If appropriate justification for continued intermediate care facility for individuals with developmental disabilities (ICF/DD) care is provided within the time frames specified in the letter of notification, the recommendation may be withdrawn; or

(2) In the absence of appropriate or timely justification, the recommendation becomes final;

(ii) Once the responses of the attending physician and intermediate care facility for individuals with developmental disabilities (ICF/DD) qualified intelIectual disabilities professional (QIDP) have been reviewed, Medicaid will send written notification of the decision to the intermediate care facility for individuals with developmental disabilities (ICF/DD), the attending physician, and the intermediate care facility for individuals with developmental disabilities (ICF/DD)'s qualified intellectual disabilities professional (QIDP): and

(iii) If the recommendation is upheld, the intermediate care facility for individuals with developmental disabilities (ICF/DD) must document a specific and appropriate discharge plan in compliance with 42 CFR 483.440(b) to assist the client in preparing for alternate arrangements.

004.01(D)(iii)(2)(b)INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) RECOMMENDATION. Intermediate care facility for individuals with developmental disabilities (ICF/DD) staff must submit requests for a change of level of care between reviews to Medicaid in writing along with supporting documentation. If the client needs to be discharged to an alternative setting:

(i) The intermediate care facility for individuals with developmental disabilities (ICF/DD) must notify the individual, family or legal guardian, and the Department of Health and Human Services' Developmental Disabilities Division, Service Coordination (DDD SC) of the recommendation:

(ii) The intermediate care facility for individuals with developmental disabilities (ICF/DD) must assist the client, family, or legal guardian in seeking appropriate alternatives;

(iii) The intermediate care facility for individuals with developmental disabilities (ICF/DD) must document which other alternatives were explored and the responses:

(iv) The present intermediate care facility for individuals with developmental disabilities (ICF/DD) must provide services to meet the needs of the client and must refer to appropriate agencies for services until the expiration of the 60 day coverage period or until an appropriate alternative is available, whichever comes first;

(v) The intermediate care facility for individuals with developmental disabilities (ICF/DD), and others involved, must make available to the Medicaid review team the documentation of active exploration for appropriate alternatives: and

(vi) Upon receipt of all the necessary information, the intermediate care facility for individuals with developmental disabilities (ICF/DD) must document a specific and appropriate discharge plan in compliance with 42 CFR 483.440(b) to assist the client in preparing for alternate arrangements.

004.01(D)(iii)(2)(c)ADDITIONAL RECOMMENDATIONS. In the event that any State or Federal survey or certification agency determines a client no longer needs or benefits from intermediate care facility for individuals with developmental disabilities (ICF/DD) services, Medicaid will follow the process outlined in 471 NAC 31-004.01(DXiii)(2)(a).

004.01(D)(iv)INTERMEDIATE CARE FACILITY FOR iNDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) LEVEL OF CARE CONTINUANCE. A client who currently resides in an intermediate care facility for individuals with developmental disabilities (ICF/DD) who has been determined inappropriate for that level of care may be approved by the Medicaid review team to continue at the intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care, for a limited period of time. The continuance may be approved when the intermediate care facility for individuals with developmental disabilities (ICF/DD) presents written documentation of its ongoing efforts to obtain an appropriate alternative living situation for the client.

004.01(E)OUT-OF-STATE SERVICES. Medicaid covers out-of-state intermediate care facility for individuals with developmental disabilities (ICF/DD) services in accordance with 471 NAC 1. Evidence must be provided that the client's needs cannot be met by providers in Nebraska, Out-of-State services may also be permitted by department discretion in cases where the client's current living situation is bordering an out-of-state community where an appropriate provider is located.

004.01(F)INDEPENDENT QUALIFIED INTELLECTUAL DISABILITIES PROFESSIONAL (QIDP) ASSESSMENT. The intermediate care facility for individuals with developmental disabilities (ICF/DD) facility must ensure an independent qualified intellectual disabilities professional (QIDP) assessment is completed for all clients during the admission process. The facility is responsible for securing the qualified intellectual disabilities professional (QIDP), including payment for such services. An individual program plan (IPP) is acceptable in lieu of the independent qualified intellectual disabilities professional (QIDP) assessment as long as the individual program plan (IPP) provides accurate and current information regarding the client's strengths and needs. The Individual Program Plan (IPP) cannot have an implementation date of more than 12 months prior to the client's admission to the facility. The facility must ensure:

(1) The qualified intellectual disabilities professional (QIDP) is not associated with the facility in any manner;

(2) The qualified intellectual disabilities professional (QIDP) meets requirements at 42 CFR 480.430 to be considered a qualified intellectual disabilities professional (QIDP);

(3) The qualified intellectual disabilities professional (QIDP) assessment is completed no later than the date of and, no more than three months prior to, the client's admission to the facility; and

(4) The independent qualified intellectual disabilities professional (QIDP) completes the assessment in accordance with requirements at 471 NAC 31-004.01(F)(i).

004.01(F)(i)QUALIFIED INTELLECTUAL DISABILITIES PROFESSIONAL (QIDP) ASSESSMENT PROCESS. To ensure completion of an accurate, comprehensive assessment, the qualified intellectual disabilities professional (QIDP) must:

(1) Interview and conduct observations of the client in their living environment, and vocational environment, if possible;

(2) Conduct a functional and complete assessment of skills, using an appropriate standardized assessment tool, in order to identify the client's present skills and skill-deficit areas;

(3) Review records to verify the diagnosis of an intellectual disability or related condition, including the most recent psychological assessment, as well as medical records:

(4) Review of available, relevant client records, including medical and programming records, to aid in determining the client's skills, skill-deficits, training needs, and possible assessment needs.

(5) Submit a written report to the facility which summarizes the results of the qualified intellectual disabilities professional (QIDP) assessment The written report must include the following:

(a) The client's name, age, and date of birth:

(b) The client's current address or place of residence:

(c) The client's guardianship status:

(d) The client's current diagnosis and physical disabilities:

(e) Sources of information gathered to complete the assessment:

(f) Any independent assessments or evaluations conducted as part of the assessment process:

(g) Datefs) the assessment was conducted, as well as the date of the written report:

(h) A narrative summarizing the client's skills and skill-deficits, including use of adaptive equipment, with regard to:

(i) Self-care:

(ii) Communication, receptive and expressive:

(iii) Learning abilities:

(iv) Mobility:

(v) Self-direction, adaptive skills, including but not limited to behavior, social skills and decision-making skills:

(vi) Independent living skills, including but not limited to money-handling, daily household tasks, and community access:

(vii) Vocational skills: and

(viii) Recommendations for each skill area for training, treatment needs, further assessment and evaluation needs, needed adaptive equipment, and possible needs for additional services. The recommendations must be determined without regard to the availability of services:

(I) Summary of progress, or lack of progress, in previous service settings:

(k) The qualified intellectual disabilities professional (QIDP)'s determination of the type of service setting needed to meet the client's treatment needs. This determination must not identify a specific facility or provider: and

(I) The qualified intellectual disabilities professional (QIDP)'s name, signature, and address.

004.01(G)INDIVIDUAL PROGRAM PLAN (IPP). Within 30 days of a client's admission to the intermediate care facility for individuals with developmental disabilities (ICF/DD), the interdisciplinary team (IDT) must prepare an individual program plan (IPP). The individual program plan (IPP) must specify long-term goals, short-term objectives, and services to address prioritized needs in a continuum of development: outlining projected progressive, sequential, steps and the developmental consequences, outcomes, of training programs and services. Additionally, the individual program plan (IPP) must address therapeutic leave. Long-term goals and short-term objectives for all formal training to be provided are based on identified needs. Objectives must be person-centered, stated in specific, observable, and measurable terms so the level of skill Acquisition can be assessed. The long-term goal must be the culmination of its short-term objectives. Each client's individual program plan (IPP), functional assessments, and nursing plan of care must be made available to ail relevant staff and the interdisciplinary team (IDT). As soon as the interdisciplinary team (IDT) has formulated a client's individual program plan (IPP), each client must receive a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan (IPP).

004.01(G)(i)REVIEW AND REVISION OF THE INDIVIDUAL PROGRAM PLAN (IPP). The interdisciplinary team (IDT) must review each individual program plan (IPP) at least quarterly, and revise each individual program plan (IPP) as needed. At least annually, the Interdisciplinary Team (IDT) reviews and updates each client's individual program plan (IPP), including ongoing exploration of alternatives. Each interdisciplinary team (IDT) member's assessment must be completed before this annual review. The revisions of the individual program plan (IPP) are based on current needs as identified by the comprehensive functional assessments and the client's response to training, as required by 42 CFR 456.380(c) and 483.440. The qualified intellectual disabilities professional (QIDP) and other interdisciplinary team (IDT) members must each routinely review aspects of the client's active treatment process to determine if the client's needs are effectively addressed and if revisions are needed.

004.01(H)BED HOLDING. Medicaid covers a reserved bed in an intermediate care facility for individuals with developmental disabilities (ICF/DD) during a client's absence, due to hospitalization for an acute condition, and for therapeutically indicated home visits. Coverage of 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:

(3) Therapeutic leave bed holding is limited to reimbursement for 36 days per calendar year, even if the client has a stay in more than one intermediate care facility for individuals with developmental disabilities (ICF/DD) during the calendar year. Bed holding days are prorated when a client is admitted after January 1: and

(4) Facility staff must work with the client as well as parent or guardian to plan the use of the allowed 36 days of therapeutic leave for the calendar year.

004.01(H)(i)SPECIAL LIMIT. When the limitation for therapeutic leave interferes with an approved therapeutic or habilitative program, the intermediate care facility for individuals with developmental disabilities (ICF/DD) 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; and

(4) The individual program plan (IPP).

004.02COVERED SERVICES.

004.02(A)ANNUAL PHYSICAL EXAMINATION. Medicaid requires that all individuals eligible for Medicaid residing in long-term care facilities have an annual physical examination. The physician or other medical professional, operating within their scope of practice according to State law and based on their authority to prescribe continued treatment, determines the extent of the examination for individuals eligible for Medicaid based on medical necessity. For the annual physical exam, a CBC and urinalysis will not be considered "routine" and is reimbursed based on the medical practitioner's orders. The results of the examination must be recorded in the individuals medical record.

004.02(B)HEALTH CARE SERVICES. The intermediate care facility for individuals with developmental disabilities (ICF/DD) must ensure that intermediate care facility for individuals with developmental disabilities (ICF/DD) clients receive appropriate health care services. If appropriate health care services cannot be provided by facility staff, the care must be contracted from providers who are licensed or certified as applicable.

004.02(B)(i)PHYSICIAN SERVICES.

004.02(B)(i)(1)PHYSICIAN'S OVERALL PLAN OF CARE. Before admission to an intermediate care facility for individuals with developmental disabilities (ICF/DD), or before authorization for payment, a physician must establish a written plan of care for each client. The client's interdisciplinary team must review the client's plan of care at least every 90 days. The plan of care must include:

(a) Diagnoses, symptoms, complaints, and complications indicating the need for admission:

(b) A description of the functional level of the client:

(c) Objectives:

(d) Any orders for:

(i) Medications:

(ii) Treatments:

(iii) Restorative and rehabilitative services:

(iv) Activities:

(v) Therapies:

(vi) Social services:

(vii) Diet: and

(viii) Special procedures designed to meet the objectives of the plan of care:

(e) Plans for continuing care, including review of and modification of the plan of care:

(f) A determination of whether the client needs a medical care plan: and

(g) Plans for discharge.

004.02(B)(i)(2)STANDARDS FOR PHYSICIAN SERVICES. The facility must ensure the availability of physician services 24 hours a day. The physician must develop, in coordination with licensed nursing personnel, a medical care plan for a client if the physician determines the individual requires 24-hour licensed nursing care. This plan must be integrated in the individual program plan. To the extent permitted by state law, the facility may utilize physician assistants and nurse practitioners to provide physician services as described in this section. The facility must provide or obtain preventive and general medical care, as well as annual physical examinations, of each client that at a minimum include the following:

(a) Evaluation of vision and hearing:

(b) immunizations, using as a guide the recommendations of the Public Health Service Advisory Committee on Immunization Practices or of the Committee on the Control of Infectious Diseases of the American Academy of Pediatrics;

(c) Routine screening laboratory examinations, as determined necessary by the physician, and special studies when needed: and

(d) Tuberculosis control, appropriate to the facility's population, and in accordance with the recommendations of the Nebraska Department of Health and Human Services Regulation and Licensure.

004.02(B)(i)(3)PHYSICIAN PARTICIPATION IN THE INDIVIDUAL PROGRAM PLAN. A physician must participate in:

(a) The establishment of each newly admitted client's initial individual program plan as required by 42 CFR 456.380; and

(b) If appropriate, the review and update of an individual program plan as part of the interdisciplinary team (IDT) process either in person or through written report to the interdisciplinary team (IDT).

004.02(B)(i)(4)RECERTIFICATION. The physician, the physician's assistant or nurse practitioner, must recertify in writing the client's continued need for the intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care at least once every 365 days, and at any time the client requires a different level of care. The extended recertification period in no way indicates that one year is the appropriate length of stay for a client in an intermediate care facility for individuals with developmental disabilities (ICF/DD). The interdisciplinary team responsible for the client's care determines the client's length of stay.

004.02(B)(i)(4)(a)DELEGATION. The physician's assistant, or nurse practitioner, may recertify the client's need under the general supervision of a physician when the physician formally delegates this function to the physician's assistant or nurse practitioner.

004.02(B)(i)(4)(b)SIGNATURE. The physician, the physician's assistant, or nurse practitioner must sign, or signature stamp and initial, and date the recertification clearly identifying the medical professional as a physician, physician's assistant, or nurse practitioner. Electronic signatures will also be accepted.

004.02(B)(i)(4)(c)RECORDS. Facility staff must maintain the recertification in the client's medical record in the facility where the client resides.

004.02(B)(i)(4)(d)RECORD RETENTION. The physician must record recertifications accomplished by on-site visits to the facility in the client's medical record. The physician is paid according to 471 NAC 18 for a nursing home visit. The physician must use the appropriate procedure codes when billing Medicaid for this service.

004.02(B)(ii)NURSING SERVICES.

004.02(B)(ii)(1)STANDARDS FOR NURSING SERVICES. The facility must provide clients with nursing services in accordance with their needs. These services must include:

(a) Participation in the pre-admission evaluation and in the development, review, and update of an individual program plan as part of the interdisciplinary team fIDT) process;

(b) The development, with a physician, of a medical care plan of treatment for a client when the physician has determined that a client requires such a plan;

(c) For those clients certified as not needing a medical care plan, a review of their health status which must:

(i) Be by direct physical examination:

(ii) Be by a licensed nurse;

(iii) Be on a Quarterly or more frequent basis depending on need;

(iv) Be recorded in the record; and

(v) Result in any necessary action (including referral to a physician to address health problems;

(d) Other nursing care as prescribed by the physician or as identified by needs;

(e) implementing, with other members of the interdisciplinary team (IDT), appropriate protective and preventive health measures which include, but are not limited to:

(i) Training clients and staff as needed in appropriate health and hygiene methods:

(ii) Control of communicable diseases and infections, including the instructions of other personnel in methods of infection control; and

(iii) Training direct care staff in detecting signs and symptoms of illness or dysfunction, first aid for accidents or illness, and basic skills required to meet the health needs of the clients; and

(f) The nursing plan of care as part of the individual program plan (IPP) must be revised as necessary, but reviewed at least quarterly.

004.02(B)(ii)(2)STANDARDS FOR NURSING STAFF. Nurses providing services in the facility must have a current license to practice in the state. The facility must employ, or arrange for, licensed nursing services sufficient to care for client's health needs, including those clients with medical care plans.

004.02(B)(ii)(2)(a)ADDITIONAL REQUIREMENTS. The facility must utilize registered nurses as appropriate and required by state law, to perform the health services specified in this section. If the facility utilizes only licensed practical or vocational nurses to provide health services, it must have a formal written arrangement with a registered nurse to be available for verbal or onsite consultation to the licensed practical or vocational nurse. Non-licensed nursing personnel who work with clients under a medical care plan must do so under the supervision of licensed nursing personnel.

004.02(B)(iii)DENTAL CARE. All intermediate care facility for individuals with developmental disabilities (ICF/DD) clients must have a dental evaluation:

(a) Within 12 months before admission or within one month after admission: and

(b) At least annually thereafter.

004.02(B)(iii)(1)STANDARDS FOR DENTAL SERVICES. The facility must provide, or make arrangements for, comprehensive diagnostic and treatment services for each client from qualified personnel. This includes licensed dentists and dental hygienists either through organized dental services in-house or through arrangement If appropriate, dental professionals must participate, in the development, review, and update of an individual program plan as part of the interdisciplinary team (IDT) process either in person or through written report to the interdisciplinary team (IDT). The facility must provide education and training in the maintenance of oral health.

004.02(B)(iii)(2)COMPREHENSIVE DENTAL DIAGNOSTIC SERVICES. Comprehensive dental diagnostic services include:

(a) A complete extraoral and intraoral examination, using all diagnostic aids necessary to properly evaluate the client's oral condition, not later than one month after admission to the facility, unless the examination was completed within 12 months before admission:

(b) Periodic examination and diagnosis performed at least annually, including radiographs, when indicated and detection of manifestations of systemic disease: and

(c) A review of the results of examination and entry of the results in the client's dental record.

004.02(B)(iii)(3)COMPREHENSIVE DENTAL TREATMENT. The facility must ensure comprehensive dental treatment services which include:

(a) The availability for emergency dental treatment on a 24-hour-a-day basis by a licensed dentist: and

(b) Dental care needed for relief of pain and infections, restoration of teeth, and maintenance of dental health.

004.02(B)(iii)(4) DOCUMENTATION OF DENTAL SERVICES. If the facility maintains an in-house dental service, the facility must keep a permanent dental record for each client, with a dental summary maintained in the client's living unit, if the facility does not maintain an in-house dental service, the facility must obtain a dental summary of the results of dental visits and maintain the summary in the client's medical record.

004.02(C)ITEMS COVERED PER DIEM PAYMENTS. The following items are included in the per diem payment made by Medicaid to the intermediate care facility for individuals with developmental disabilities (ICF/DD):

004.02(C)(i)RQUTINE SERVICES. Routine intermediate care facility for individuals with developmental disabilities (ICF/DD) services include regular room, dietary, and nursing services: social services and active treatment program as required by any applicable federal and state certification standards: minor medical supplies; oxygen and oxygen equipment: the use of equipment and facilities; and other routine services. Examples of items which routine services may include are:

(1) All general nursing services, including administration of oxygen and related medications: collection of all laboratory specimens as ordered by the physician, such as blood and urine; hand-feeding: incontinency care; tray service; normal personal hygiene which includes bathing, skin care, hair care, excluding professional barber and beauty services, nail care, shaving, and oral hygiene; enema;

(2) Active treatment: The facility must provide a continuous active treatment program, as determined necessary by each client's interdisciplinary team, including physical therapy, occupational therapy, speech therapy, recreational therapy, and pre-vocational services and related supplies to include, but not limited to, augmentative communication devices with related equipment and software, as described in each client's Individual Plan of Care;

(3) Items which are furnished routinely and relatively uniformly to all residents. These items include gowns, linens, water pitchers, basins, and bedpans:

(4) Items stocked at nursing stations on each floor or in each home in gross supply and distributed or used individually, including alcohol, applicators, cotton balls. Band Aids, incontinency care products, oxygen and oxygen equipment, colostomy supplies, catheters, irrigation equipment, tape, needles, syringes. I.V. equipment, supports, hydrogen peroxide, over the counter enemas, tests, tongue depressors, hearing aid batteries, facial tissue, personal hygiene items;

(5) Items which are used by individual residents, but are reusable and expected to be available, such as; ice bags, bed rails, canes, crutches, walkers, standard wheelchairs, gerichairs, traction equipment, alternating pressure pad and pump, and all other durable medical equipment not listed in 471 NAC 31-004.03(A)(ii);

(6) Nutritional supplements and supplies used for oral, enteral, or parenteral, feeding;

(7) Laundry services, including personal clothing;

(8) Cost of providing basic cable television service, including applicable installation charge, to individual rooms. This is not a mandatory service; and

(9) Repair of medically necessary facility owned and purchased durable medical equipment and their maintenance,

004.02(C)(ii)INJECTIONS. The resident'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.

004.02(C)(iii)TRANSPORTATION. The facility is responsible for ensuring that all clients receive appropriate medical care. The facility must provide transportation to client services which are reimbursed by Medicaid including, but not limited to. medical and dental services. 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.

004.03NON-COVERED SERVICES.

004.03(A)ITEMS NOT INCLUDED IN PER DIEM RATES. Medicaid may cover services provided in an intermediate care facility for individuals with developmental disabilities (ICF/DD) which are not included in the per diem payment outlined in 471 NAC 31-004.02(C). Coverage of additional items and services is provided in accordance with each specific NAC Title 471 Chapter.

004.03(A)(i)PAYMENTS TO INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) PROVIDER SEPARATE FROM THE PER DIEM RATE. items for which payment may be made to intermediate care facility for individuals with developmental disabilities (ICF/DD) 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 471 NAC 7.

(1) Non-standard wheelchairs and wheelchair accessories, options, and components, including power operated vehicles:

(2) Air fluidized bed units and low air loss bed units: and

(3) Negative pressure wound therapy.

004.03(A)(ii)PAYMENTS TO OTHER PROVIDERS. Items for which payment may be authorized to non-intermediate care facility for individuals with developmental disabilities (ICF/DD) 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.

(1) Legend drugs, over the counter drugs and compounded prescriptions, including intravenous solutions and dilutants:

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

(3) Orthoses as defined in 471 NAC 7:

(4) Prostheses as defined in 471 NAC 7: and

(5) Ambulance services required to transport a client to obtain and after receiving Medicaid-covered medical care which meets the definitions in 471 NAC 4.

004.03(A)(ii)(5)(a)AMBULANCE SERVICES MEDICAL NECESSITY. To be covered, ambulance services must be medically necessary and reasonable. Medical necessity is established when the client's condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the client's health, whether or not such other transportation is actually available, Medicaid does not make payment for ambulance service.

004.03(A)(ii)(5)(b)NON-EMERGENCY AMBULANCE SERVICES. Non-emergency ambulance transports to a physician or practitioner's office, clinic, or therapy center are covered when the client is bed confined before, during and after transport and when the services cannot or cannot reasonably be expected to be provided at the client's residence (including the intermediate care facility for individuals with developmental disabilities (ICF/DD)).

471 Neb. Admin. Code, ch. 31, § 004

Amended effective 10/20/2015.

Amended effective 12/26/2021