N.J. Admin. Code § 8:85-2.21

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:85-2.21 - Special care nursing facility (SCNF)

(a) A special care nursing facility (SCNF) is a nursing facility or separate and distinct SCNF unit within a Medicaid-certified conventional nursing facility which has been approved by the Department of Health and Senior Services to provide care to New Jersey Medicaid beneficiaries who require intensive nursing facility services beyond the scope of a conventional nursing facility as defined in N.J.A.C. 8:85-2. A SCNF or SCNF unit shall have a minimum of 24 beds.

1. The minimum bed requirement will be waived for SCNFs that were approved by DMAHS prior to November 23, 1994. In addition, the requirement will be waived in those instances where a SCNF's Certificate of Need stipulates a specific number of beds approved by the New Jersey Department of Health and Senior Services.

2. A SCNF receiving reimbursement through the Medicaid program shall not increase its total number of licensed beds for which a SCNF rate of reimbursement is received except upon approval from the Department.

3. A SCNF shall provide intensive medical, nursing and psychosocial management to the seriously ill individual who has potential for measurable and consistent maturation or rehabilitation, or has a technologically and/or therapeutically complex condition which requires the delivery of intensive and coordinated health care services on a 24-hour basis.

(b) A SCNF shall provide the services of an interdisciplinary team, under the direction of a physician specialist, who has training and expertise in the treatment specific to the medical condition and needs of the target population.

1. Within a focused therapeutic program, targeted, when appropriate, at timely discharge to alternative health care settings, such as conventional NF or community-based services, the SCNF shall provide:

i. Aggressive management and treatment to stabilize, improve and monitor current conditions;

ii. Appropriate, intensive rehabilitative therapies and counseling services; and

iii. Coordinated care planning and delivery of required services.

(c) A SCNF shall provide services to Medicaid beneficiaries who have been determined, through the PAS process, to require extended rehabilitation and/or complex care. The individual's progress and overall response to the therapeutic regimen shall determine length of stay.

1. Extended rehabilitation shall be considered for a medically stable individual with a condition whose prognosis indicates the potential for rehabilitative progress which requires a prescribed period of therapeutic treatment and goal-directed services provided by a qualified interdisciplinary team to restore the individual to the highest practical level of physical, cognitive and behavioral functioning. The individual may remain for a period of up to 12 months, with a review after six months. Length of stay will be extended for periods of six months, if continued benefit from the service can be demonstrated.

2. Complex care shall be considered for a medically stable individual judged to have plateaued who demonstrates the need for prolonged, technologically and/or therapeutically complex care. Although the rehabilitative component may be less intense, the individual continues to require focused assessment, coordinated care planning and direct services on a continuing basis provided by an interdisciplinary team with training and expertise in the treatment of the medical conditions and specialized needs of the resident population. The individual may remain for a period of up to two years with review every 12 months. Length of stay will be extended for periods of six months if continued benefit from the service can be demonstrated.

3. Medicaid beneficiaries who are suitably placed in the community, receiving care in appropriate alternative placements or referred for social reasons only shall not be authorized for admission to a SCNF.

(d) Pursuant to 30:4D-6j, contingent upon CMS approval of Federal financial participation under Title XIX of the Federal Social Security Act ( 42 U.S.C. § 1396 et seq.), professional staff designated by the Department shall authorize clinical Medicaid eligibility for SCNF admission for an individual whom a physician diagnoses with HIV infection and HIV-related medical co-morbidities and/or HIV-related psychosocial co-morbidities and/or AIDS-defining illness, provided:

1. The Department has approved the application of the SCNF pursuant to 8:85-1.3 to provide services for beneficiaries diagnosed with HIV infection resulting in HIV-related medical co-morbidities and/or HIV-related psychosocial co-morbidities and/or AIDS-defining illness, which approval shall be evidenced by the SCNF's execution of an agreement with the Department for program participation; and

2. The individual meets the requirements in (c)1 or 2 above and professional staff designated by the Department determine that the individual:

i. Is dependent in several ADL; or

ii. Demonstrates at least intermittent dependency in ADL and has an unstable medical, behavioral, and/or psychosocial condition that affects the individual's ability to be consistently independent in ADL such that the individual requires specialized nursing services for HIV infection resulting in HIV-related medical co-morbidities and/or HIV-related psychosocial co-morbidities and/or an AIDS-defining illness.

(e) Discharge procedures shall include utilizing Medicaid discharge protocols established by this chapter, and shall be in accordance with the following:

1. The beneficiary shall be discharged upon achievement of maximum benefit from the specialized programming and maximum level of functioning and when the individual's condition can be appropriately managed in either the community or other forms of institutional care.

2. Outpatient treatment and supported community services may be needed to assist in community integration.

3. When a beneficiary residing in a SCNF unit of a conventional NF is determined by Department staff to no longer require special programming, yet continues to require conventional NF services, the beneficiary shall be accepted for placement into a conventional NF bed in the facility. If a conventional NF bed within the facility is not available within a reasonable time, the SCNF shall assist the individual in finding placement in another conventional nursing facility. The SCNF shall be afforded 30 to 60 days from the date of the determination to effect transfer of the beneficiary to a bed within the facility's conventional bed allocation or arrange transfer to another conventional NF.

(f) The SCNF shall provide all required services, as defined in this subchapter.

1. A SCNF shall provide those medical services as defined in N.J.A.C. 8:85-2.3, with the following modifications and/or additions:

i. A freestanding SCNF shall have a designated medical director who is board eligible/certified in a medical specialty as targeted by the medical diagnoses, medical conditions and/or resident population of the SCNF. The medical director shall also function as a primary care attending physician. If a medical group provides medical services, a member of that group shall be designated as the medical director.

(1) In lieu of the requirements contained in (f)1i above, a freestanding SCNF may have a designated medical director who is a licensed physician and was serving as medical director prior to November 23, 1994.

ii. For each resident there shall be a designated primary care physician specialist who is board eligible/certified in a medical specialty determined by the medical diagnoses, medical conditions and or resident population;

iii. Responsibilities of the primary care physician include but are not limited to:

(1) History, physical exam and diagnosis on admission and a comprehensive physical exam conducted on a yearly basis;

(2) Medical assessment shall reflect a correlation of the staging of existing diagnosis and premorbid conditions to the prognosis for rehabilitation.

(3) Each resident shall be examined and evaluated as required by the individual's condition as designated by the medical care plan.

2. A SCNF shall provide those nursing services as defined in 8:85-2.2 with the following modifications and/or additions:

i. A freestanding SCNF shall have a director of nurses or a nursing administrator who is a registered professional nurse in the State of New Jersey and possesses a Master's Degree or a Baccalaureate Degree in Nursing and has a minimum of two years experience as a nursing administrator or who has at least two years of supervisory experience in either an acute or long-term care setting.

(1) In lieu of the education and experience requirements of (f)2i above, the director of nurses or nursing administrator shall have served in that capacity prior to November 23, 1994.

(2) A SCNF unit within a conventional NF whose director of nursing does not meet the qualifications of (e)2i above shall have a nurse manager who meets the qualifications assigned full time to the unit.

ii. Registered professional nurses certified in intravenous therapy shall be available on a 24 hour basis.

iii. Two and one-half hours of basic nursing services by registered professional nurses, licensed practical nurses and certified nurse aides as defined in 8:85-2.2 shall be provided per beneficiary per day. Additional nursing services in a SCNF up to a maximum of three hours may be provided due to technically complex nursing needs and/or intensive rehabilitative/restorative nursing care needs. A SCNF which is an identifiable unit within a conventional NF shall calculate the nurse staffing level separate and apart from the nurse staffing level of the conventional beds.

iv. Provision of additional nursing services as defined in 8:85-2.2 does not apply to nurse staffing rules in a SCNF. The additional nursing services described at 8:85-2.2(a) are included in the three hours.

(1) Sixty percent of the additional hours of care under iii above shall be provided by registered professional nurses, and forty percent shall be provided by licensed practical nurses. There shall be a minimum of one registered professional nurse, one licensed practical nurse and one certified nurse aide on each shift.

v. Responsibilities of the nursing staff, in concert with other members of the interdisciplinary team, include, but are not limited to:

(1) Expertise and understanding of the physiologic impact, prognosis and treatment needs specific to the medical condition or specialized needs of the target population to enhance integration of the resident and family goals with adjustment and rehabilitation.

(2) Utilization and application of specialized equipment essential to provide services required for the care and treatment of the SCNF population.

(3) Comprehensive and coordinated program of restorative and rehabilitative nursing services to prevent complications and promote and/or restore the individual's physical, psychosocial function to a realistic level.

(4) Individual/family education and instruction of self care to promote optimum level of health in preparation for discharge to a less restrictive environment.

(5) Evaluation and management of moderate to extreme emotional and behavioral disorders related to illness.

3. A SCNF shall provide those social services as required by 8:85-2.6, with the following modifications and/or additions:

i. The social services coordinator shall possess a Master's Degree or Baccalaureate Degree in Social Work from a college or university accredited by the Council on Social Work and have at least two years of full time social work experience in a health care setting.

ii. An average of at least 50 minutes of social work services per week for each resident. This is equal to one half-time equivalent social worker for every 24 residents.

iii. In a SCNF with more than 48 beds, one of the direct care social workers shall be designated as the Director of Social Services.

iv. Responsibilities of the social service staff, in concert with other members of the interdisciplinary team, include, but are not limited to:

(1) Knowledge of alternative care programs and resources in the community to assist the resident/family with appropriate discharge planning.

(2) Maintain a library of information and resources pertinent to the resident's diagnosis, educational/vocational training needs and applications to community based programs.

(3) Facilitate on-going collaboration and coordination among health care providers, the resident and the family to promote long-range social and health care planning.

(4) Coordinate programming with community-based resources to facilitate continuity of care and assimilation into community/family environment.

(5) On-going supportive intervention with the resident/family in dealing with the confusion, anger, fear, depression, guilt and conflict associated with illness.

4. A SCNF shall provide resident activities required by 8:85-2.5, with the following modifications and/or additions:

i. The director of resident activities shall possess a Master's Degree or Baccalaureate Degree from an accredited college or university with a major area of concentration in recreation, creative arts therapy, occupational therapy or therapeutic recreation. In addition, three years of experience in a clinical, residential or community-based therapeutic recreation program is required.

(1) In lieu of (f)4i above, the individual shall have served as director of resident activities prior to November 23, 1994; or

(2) In lieu of (f)4i above, hold current certification from the National Certification Council for Activity Professionals (National Certification Council for Activity Professionals, 520 Stewart, Park Ridge, Illinois 60068) or the National Council of Therapeutic Recreation Certification (National Council of Therapeutic Recreation Certification, P.O. Box 16126, Alexandria, Virginia 22302).

ii. An average of at least 100 minutes of resident activity services per week for each resident. This is equal to one full-time equivalent resident activities staff for every 24 residents. This staff person shall serve as the Director of Resident Activities.

iii. For each additional 24 beds, the facility shall provide the services of a full-time resident activities assistant.

iv. Responsibilities of the resident activities staff, in concert with other members of the interdisciplinary team, shall include, but are not limited to:

(1) Utilization of all possible community, social, recreational, public and voluntary resources to promote the resident's ties with community life.

(2) Provision of therapeutic resident activities which endorse the therapeutic plan of care.

(3) Incorporation of family-centered activities which provide a supportive, therapeutic environment to give residents and families an opportunity to work together toward achieving common goals.

5. A SCNF shall provide, directly in the facility, the rehabilitation services as required by 8:85-2.4 on an intensive level which are specifically targeted to meet the goals of the prescribed treatment plan.

i. Rehabilitative therapies shall include, but shall not be limited to:

(1) Physical therapy;

(2) Occupational therapy;

(3) Speech/language pathology; and

(4) Cognitive or remedial therapies (including neuropsychological treatment)

ii. Rehabilitation services shall focus on developing and/or restoring maximum levels of function within the limits of the resident's impairment. Through collaboration with other members of the interdisciplinary team, a comprehensive rehabilitation plan shall be developed which:

(1) Identifies rehabilitation needs and establishes realistic criteria for measuring the need for continued rehabilitative services;

(2) Projects targeted outcomes (goals) and defines the parameters to measure response to treatment goals; and

(3) Establishes realistic time frames to meet outcome criteria.

6. Mental health services provided by a licensed psychiatrist, psychologist or other appropriately credentialed professional shall be provided to residents with mental health disorders in accordance with 8:85-2.9.

7. A SCNF that provides ventilator management of New Jersey Medicaid eligible children or adults shall provide respiratory therapy services beyond the scope of N.J.A.C. 8:85-2, which shall include, but not be limited to:

i. A respiratory care practitioner who is currently licensed by the New Jersey State Board of Respiratory Care be available on the premises on a 24 hour basis.

ii. Respiratory life support systems must be provided inclusive of, but not limited to:

(1) Mechanical ventilators (pressure/volume/time cycled), (portable/stationary); and

(2) Oxygen therapy delivery systems.

iii. Administration of medically prescribed respiratory care which includes, but is not limited to:

(1) Nasopharyngeal aspiration;

(2) Maintenance of natural and mechanical airways;

(3) Insertion and maintenance of artificial airways;

(4) Aerosol treatment;

(5) Administration of nebulized bronchodilators;

(6) IPPB;

(7) Oxygen therapy;

(8) Mechanical ventilation with/without supplemental oxygen;

(9) Monitoring of blood gases;

(10) Under the direction of the pulmonologist, the respiratory therapist applies weaning parameters and provides direct supervision during the weaning process;

(11) Postural drainage and chest percussion; and

(12) Breathing exercise and respiratory rehabilitation.

iv. Medically prescribed respiratory therapy may be provided to non-ventilator dependent children or adults who, due to cardio-respiratory deficiencies and/or abnormalities, require:

(1) Apparatus for cardio-respiratory support and control;

(2) Respiratory rehabilitation/chest physiotherapy;

(3) Maintenance of natural airway patency;

(4) Insertion and maintenance of artificial airway;

(5) Measurement of cardio-respiratory volume, pressure and flow;

(6) Drawing and analyzing samples of arterial, capillary and venous blood;

(7) Administration of aerosolized respiratory medications such as nebulized bronchodilators or antiprotozoals;

(8) Assessment, intervention, and evaluation by a registered professional nurse; and/or

(9) Protocols for weaning the individual from assisted respiration and/or self care when clinically indicated and ordered by the physician or advanced practice nurse.

N.J. Admin. Code § 8:85-2.21

Amended by R.1996 d.147, effective 3/18/1996.
See: 27 N.J.R. 3314(a), 28 N.J.R. 1535(a).
Recodified from N.J.A.C. 10:63-2.21 and amended by R.2005 d.389, effective 1/17/2006.
See: 36 N.J.R. 4700(a), 37 N.J.R. 1185(a), 38 N.J.R. 674(a).
Rewrote the section.
Amended by R.2007 d.391, effective 12/17/2007.
See: 38 N.J.R. 4795(a), 39 N.J.R. 5338(a).
Added new (d); recodified former (d) and (e) as (e) and (f); in (f)1i(1), substituted "(f)1i" for "(e)1i"; in (f)2i(1), substituted "(f)2i" for "(e)2i"; and in (f)4i(1) and (f)4i(2), substituted "(f)4i" for "(e)4i".