Compilation of Rules and Regulations of the State of Georgia
Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH
Chapter 111-2 - HEALTH PLANNING
Subject 111-2-2 - CERTIFICATE OF NEED
Rule 111-2-2-.35 - Specific Review Considerations for Comprehensive Inpatient Physical Rehabilitation Services
Universal Citation: GA Rules and Regs r 111-2-2-.35
Current through Rules and Regulations filed through March 20, 2024
(1) Applicability.
(a) A Certificate of Need shall be required
prior to the establishment of a new or the expansion of an existing
Comprehensive Inpatient Physical Rehabilitation Adult Program. An application
for Certificate of Need for a new or expanded Comprehensive Inpatient Physical
Rehabilitation Adult Program shall be reviewed under the General Review
Considerations of Ga. Comp. R. & Regs. r.
111-2-2-.09 and the service-specific
review considerations of this Rule.
(b) A Certificate of Need shall be required
prior to the establishment of a new or the expansion of an existing
Comprehensive Inpatient Physical Rehabilitation Pediatric Program. An
application for Certificate of Need for a new or expanded Comprehensive
Inpatient Physical Rehabilitation Pediatric Program shall be reviewed under the
General Review Considerations of Ga. Comp. R. & Regs. r.
111-2-2-.09 and the service-specific
review considerations of this Rule.
(2) Definitions.
(a) 'Adults' means persons eighteen (18)
years of age and over. However, a Certificate of Need authorized or
grandfathered Comprehensive Inpatient Physical Rehabilitation Adult Program
will not be in violation of the Certificate of Need laws and regulations if it
provides service to a patient older than fifteen years if the provider has
determined that such service is medically necessary, provided that the
treatment days and patient census associated with patients sixteen and
seventeen years of age do not exceed ten percent (10%) of annual treatment days
and annual census, respectively. Rehabilitation programs specifically focused
towards treatment of spinal cord injuries and disorders and which existed prior
to the effective date of this version of Ga. Comp. R. & Regs. r.
111-2-2-.35 shall not be subject to
the adult age limitations; such programs may treat any patient aged twelve (12)
and over.
(b) 'Comprehensive
Inpatient Physical Rehabilitation Programs' means rehabilitation services,
which have been classified by Medicare as an inpatient rehabilitation facility
pursuant to 42 C.F.R. §
412.23(b)(2), provided to a
patient who requires hospitalization, which provides coordinated and integrated
services that include evaluation and treatment, and emphasizes education and
training of those served. The program is applicable to those individuals who
require an intensity of services which includes, as a minimum, physician
coverage twenty-four (24) hours per day, seven (7) days per week, with daily
(at least five (5) days per week) medical supervision, complete medical support
services including consultation, 24-hour-per-day nursing, and daily (at least
five (5) days per week) multidisciplinary rehabilitation programming for a
minimum of three hours per day. For regulatory purposes, the definition
includes a program which asserts its intent to be Medicare-classified as an
inpatient rehabilitation facility no later than twenty-four (24) months after
accepting its first patient. If a program, which has been awarded a CON
pursuant to this Rule, has not been so classified by Medicare within the
timeframe outlined above, the CON issued to that entity shall be
revoked.
(c) 'Expansion' and
'Expanded' mean the addition of beds to an existing CON-authorized or
grandfathered Comprehensive Inpatient Physical Rehabilitation Program. However,
a CON-authorized or grandfathered provider of Comprehensive Inpatient Physical
Rehabilitation in a freestanding rehabilitation hospital may increase the bed
capacity of an existing program by the lesser of ten percent (10%) of existing
capacity or ten (10) beds if it has maintained an average occupancy of
eighty-five percent (85%) for the previous twelve (12) calendar months provided
that there has been no such increase in the prior two years and provided that
the capital expenditures associated with the increase do not exceed the capital
expenditure threshold. If such an increase exceeds the capital expenditure
threshold, the increase will be considered an expansion for which a Certificate
of Need shall be required under these Rules.
(d) 'Freestanding Rehabilitation Hospital'
means a specialized hospital organized and operated as a self-contained health
care facility that provides one or more rehabilitation programs and which has
been classified as an inpatient rehabilitation facility by the Medicare program
pursuant to 42 C.F.R. §
412.23(b)(2). For regulatory
purposes, the definition includes a hospital which asserts its intent to be
Medicare-classified as an inpatient rehabilitation facility no later than
twenty-four (24) months after accepting its first patient. If an entity, which
has been awarded a CON pursuant to this Rule, has not been so classified by
Medicare within the timeframe outlined above, the CON issued to that entity
shall be revoked. An entity, which has had its CON revoked pursuant to this
Rule, shall not have the authority to operate as a general acute care
hospital.
(e) 'New' means a Program
that has not been classified by the Medicare program as a rehabilitation
hospital or program in the previous twelve (12) months. Adult programs
described in Ga. Comp. R. & Regs. r.
111-2-2-.35(1)(a)
and pediatric programs described in Ga. Comp. R. & Regs. r.
111-2-2-.35(1)(b)
shall be considered independent programs such that a provider seeking to add a
program not offered by that provider in the previous twelve (12) months shall
be considered to be offering a new program for which a Certificate of Need must
be obtained. For purposes of these Rules, an existing program which proposes to
be relocated to a location more than three (3) miles from its present location
shall be considered "new".
(f)
'Official State Health Component Plan' means the document related to Physical
Rehabilitation Programs and Services developed by the Department, established
by the Georgia Health Strategies Council and signed by the Governor of
Georgia.
(g) 'Pediatric' means
persons seventeen (17) years of age and under. However, a CON-authorized or
grandfathered Comprehensive Inpatient Rehabilitation Pediatric Program will not
be in violation of the CON laws and regulations if it provides service to a
patient younger than twenty-two (22) years if the provider has determined that
such service is medically necessary, provided that the treatment days and
patient census associated with patients eighteen, nineteen, twenty, and
twenty-one years of age do not exceed ten percent (10%) of annual treatment
days and annual census, respectively. Rehabilitation programs specifically
focused towards treatment of spinal cord injuries and disorders and which
existed prior to the effective date of this version of Ga. Comp. R. & Regs.
r. 111-2-2-.35
shall not be subject to the pediatric age limitations; such programs may treat
any patient aged twelve (12) and over.
(h) 'Planning Region' means one of the four
sub-state regions for Physical Rehabilitation Programs and Services as follows:
1. Rehabilitation Region 1, including the
following counties: Dade, Walker, Catoosa, Whitfield, Murray, Gilmer, Fannin,
Union, Towns, Rabun, Stephens, Habersham, White, Lumpkin, Dawson, Pickens,
Gordon, Chattooga, Floyd, Bartow, Cherokee, Forsyth, Hall, Banks, Franklin,
Hart, Elbert, Madison, Jackson, Barrow, Gwinnett, Fulton, Cobb, Paulding, Polk,
Haralson, Carroll, Douglas, DeKalb, Rockdale, Walton, Oconee, Clarke,
Oglethorpe, Greene, Morgan, Newton, Butts, Henry, Clayton, Fayette, Coweta,
Heard, Troup, Meriwether, Pike, Spalding, Lamar, and Upson
2. Rehabilitation Region 2, including the
following counties: Wilkes, Lincoln, Columbia, McDuffie, Warren, Taliaferro,
Hancock, Glascock, Putnam, Jasper, Monroe, Jones, Baldwin, Washington,
Jefferson, Richmond, Burke, Screven, Jenkins, Emmanuel, Johnson, Treutlen,
Montgomery, Wheeler, Telfair, Wilcox, Dodge, Laurens, Pulaski, Bleckley,
Houston, Peach, Twiggs, Wilkinson, Bibb, and Crawford
3. Rehabilitation Region 3, including the
following counties: Harris, Talbot, Taylor, Muscogee, Chattahoochee, Marion,
Schley, Macon, Dooly, Sumter, Webster, Stewart, Quitman, Randolph, Terrell,
Lee, Crisp, Ben Hill, Irwin, Turner, Worth, Dougherty, Calhoun, Clay, Early,
Baker, Mitchell, Colquitt, Miller, Cook, Tift, Berrien, Lanier, Echols,
Lowndes, Brooks, Thomas, Grady, Decatur, and Seminole
4. Rehabilitation Region 4, including the
following counties: Effingham, Bulloch, Candler, Toombs, Tattnall, Evans,
Bryan, Chatham, Liberty, Long, Wayne, Appling, Jeff Davis, Coffee, Bacon,
Pierce, Brantley, McIntosh, Glynn, Camden, Charlton, Ware, Atkinson, and
Clinch
(3) Service-Specific Review Standards.
(a) The need for a new or expanded
Comprehensive Inpatient Physical Rehabilitation Program ("CIPR") shall be
determined and applied as follows:
1. The need
for new or expanded Comprehensive Inpatient Physical Rehabilitation Adult
Program in a planning region shall be determined using the following
demand-based need projection:
(i) Determine
the comprehensive inpatient physical rehabilitation utilization rate per 1,000
for the current year for each planning region by dividing the total number of
inpatient physical rehabilitation discharges from licensed providers of
inpatient rehabilitation in the planning region for patients aged eighteen (18)
and over by current year projected resident population (aged 18 and over) for
the planning region and multiplying by 1,000. The source of current year
discharge data for purposes of this Rule include data collected pursuant to
O.C.G.A. §
31-7-280(c)(14),
or in the Department's discretion, discharge data collected on the most recent
Annual Hospital Questionnaire. The source for current and horizon year resident
population shall be resident population projections from the Governor's Office
of Planning and Budget. For the first Horizon Year projection using this Rule,
and for the first horizon year projection only, the utilization rate per 1,000
for each planning region shall be reduced by sixteen percent (16%) to account
for anticipated utilization reduction after full implementation of the Center
for Medicare and Medicaid Services' ("CMS") seventy-five percent (75%)
rule.
(ii) Calculate the projected
horizon year discharges for each planning region by multiplying the planning
region utilization rate obtained in Step (i) by the horizon year resident
population projection (aged 18 and over) for that planning region.
(iii) Determine the comprehensive inpatient
physical rehabilitation average length of stay for the current year for each
planning region by dividing the total number of inpatient physical
rehabilitation discharge days of care from licensed providers of inpatient
rehabilitation in the planning region for patients aged eighteen (18) and over
by the current year inpatient rehabilitation discharges determined in Step
(i).
(iv) Multiply the projected
discharges obtained in Step (ii) by the current year's average length of stay
(aged 18 and over) determined in Step (iii) to determine the horizon year
projected patient days for each planning region.
(v) Divide the product obtained in Step (iv)
by the number of calendar days in the horizon year to obtain the average
projected daily census in each planning region.
(vi) Divide the result obtained in Step (v)
by .85 to determine the number of projected beds utilizing an eighty-five
percent (85%) capacity standard for each planning region.
(vii) Determine the current inventory of
comprehensive inpatient physical rehabilitation beds for adults in the planning
region from Departmental data. For all CIPR providers, which have been licensed
as a Rehabilitation Hospital by the Healthcare Facility Regulation Division,
the current inventory of CIPR beds shall reflect the number of beds reported as
CON-authorized in the Facility Inventory prior to the date of adoption of these
Rules augmented from that time forward only by increases in bed capacity
approved through the CON process (or by exemptions thereto) and by decreases
due to a provider ceasing to provide such services for a period in excess of
twelve (12) months. For purposes of this Rule, the initial inventory shall not
include the beds of licensed Long Term Care Hospitals; the beds of such
facilities shall be included in the applicable Long Term Care Hospital
inventory.
(viii) If the projected
bed need in Step (vi) is greater than the current inventory of adult CIPR beds
in the planning region, the application for the Certificate of Need should
reflect a number of beds equal to or lesser than the resulting unmet bed
need.
2. The need for new
or expanded Comprehensive Inpatient Physical Rehabilitation Pediatric Program
in a planning region shall be determined using the following demand-based need
projection:
(i) Determine the comprehensive
inpatient physical rehabilitation utilization rate per 1,000 for the current
year for each planning region by dividing the total number of inpatient
physical rehabilitation discharges from licensed providers of inpatient
rehabilitation in the planning region for patients aged seventeen (17) and
under by current year resident population (aged 17 and under) for the planning
region. The source of current year discharge data for purposes of this Rule
include data collected pursuant to O.C.G.A. §
31-7-280(c)(14),
or in the Department's discretion, discharge data collected on the most recent
Annual Hospital Questionnaire.
(ii)
Calculate the projected horizon year discharges for each planning region by
multiplying the planning region utilization rate obtained in Step (i) by the
horizon year resident population projection (aged 17 and under) for that
planning region.
(iii) Determine
the comprehensive inpatient physical rehabilitation average length of stay for
the current year for each planning region by dividing the total number of
inpatient physical rehabilitation discharge days of care from licensed
providers of inpatient rehabilitation in the planning region for patients aged
seventeen (17) and under by the current year inpatient rehabilitation
discharges determined in Step (i).
(iv) Multiply the projected discharges
obtained in Step (ii) by the current year's average length of stay (aged 17 and
under) determined in Step (iii) to determine the horizon year projected patient
days for each planning region.
(v)
Divide the product obtained in Step (iv) by the number of calendar days in the
horizon year to obtain the average projected daily census in each planning
region.
(vi) Divide the result
obtained in Step (v) by .85 to determine the number of projected beds utilizing
an eighty-five percent (85%) capacity standard for each planning
region.
(vii) Determine the current
inventory of comprehensive inpatient physical rehabilitation beds for pediatric
patients in the planning region from Departmental data. For all CIPR providers,
which have been licensed as a Rehabilitation Hospital by the Healthcare
Facility Regulation Division, the current inventory of CIPR beds shall reflect
the number of beds reported as CON-authorized in the Facility Inventory prior
to the date of adoption of these Rules augmented from that time forward only by
increases in bed capacity approved through the CON process (or by exemptions
thereto) and by decreases due to a provider ceasing to provide such services
for a period in excess of twelve (12) months. For purposes of this Rule, the
initial inventory shall not include the beds of licensed Long Term Care
Hospitals; the beds of such facilities shall be included in the applicable Long
Term Care Hospital inventory.
(viii) If the projected bed need in Step (vi)
is greater than the current inventory of pediatric CIPR beds in the planning
region, the application for the Certificate of Need should reflect a number of
beds equal to or lesser than the resulting unmet bed need.
(b) An applicant for a new or
expanded Comprehensive Inpatient Physical Rehabilitation Program shall document
that the establishment or expansion of its program will not have an adverse
impact on existing and approved programs of the same type in its planning
region. An applicant for a new or expanded Comprehensive Inpatient Physical
Rehabilitation Program shall have an adverse impact on existing and approved
programs of the same type if it will:
1.
decrease annual decrease annual utilization of an existing program, whose
current utilization is at or above eighty-five percent (85%), to a projected
annual utilization of less than seventy-five percent (75%) within the first
twelve (12) months following the acceptance of the applicant's first patient;
or
2. decrease annual utilization
of an existing program, whose current utilization is below eighty-five percent
(85%), by ten percent over the twelve (12) months following the acceptance of
the applicant's first patient.
(c) The Department may grant the following
exceptions:
1. The Department may grant an
exception to the need methodology of Ga. Comp. R. & Regs. r.
111-2-2-.35(3)(a)
1. and to the adverse impact standard of Ga.
Comp. R. & Regs. r.
111-2-2-.35(3)(b)
for an applicant proposing a program to be located in a county with a
population of less than 75,000 and to be located a minimum of fifty (50) miles
away from any existing program in the state.
2. The Department may grant an exception to
the need methodologies of either Ga. Comp. R. & Regs. r.
111-2-2-.35(3)(a)
1. or
111-2-2-.35(3)(a)
2. and to the adverse impact standard of Ga.
Comp. R. & Regs. r.
111-2-2-.35(3)(b)
to remedy an atypical barrier to Comprehensive Inpatient Physical
Rehabilitation Programs based on cost, quality, financial access or geographic
accessibility or if the applicant's annual census demonstrates thirty percent
(30%) out of state utilization for the previous two years.
3. The Department may grant an exception to
the need methodologies of Ga. Comp. R. & Regs. r.
111-2-2-.35(3)(a)
1. or Ga. Comp. R. & Regs. r.
111-2-2-.35(3)(a)
2. in a planning area which has no existing
provider provided that the applicant demonstrates a need for the service based
on patient origin data.
(d) A new Comprehensive Inpatient Physical
Rehabilitation Program shall have the following minimum bed sizes based on type
of program offered:
1. A new Comprehensive
Inpatient Physical Rehabilitation Adult Program shall have a minimum bed size
of twenty (20) beds in a freestanding rehabilitation hospital already offering
another Comprehensive Inpatient Physical Rehabilitation Program, twenty (20)
beds or in an acute-care hospital, and forty (40) beds for a new freestanding
rehabilitation hospital not already offering another Comprehensive Inpatient
Physical Rehabilitation Program.
2.
A new Comprehensive Inpatient Physical Rehabilitation Pediatric Program shall
have a minimum of 10 beds in a freestanding rehabilitation hospital already
offering another Comprehensive Inpatient Physical Rehabilitation Program, 10
beds in an acute-care hospital, and forty (40) beds for a new freestanding
rehabilitation hospital not already offering another Comprehensive Inpatient
Physical Rehabilitation Program.
(e) An applicant for a new Comprehensive
Inpatient Physical Rehabilitation Program shall demonstrate the intent to meet
the standards of the Commission on Accreditation of Rehabilitation Facilities
("CARF") applicable to the type of Program to be offered within eighteen (18)
months of offering the new service.
(f) An applicant for an expanded
Comprehensive Inpatient Physical Rehabilitation Program shall be accredited by
the CARF for the type of Program which the applicant seeks to expand prior to
application. The applicant must provide proof of such accreditation.
(g) An applicant for a new freestanding
rehabilitation hospital shall demonstrate the intent to meet the licensure
Rules of the Healthcare Facility Regulation Division for such
hospitals.
(h) An applicant for an
expanded freestanding rehabilitation hospital shall demonstrate a lack of
uncorrected deficiencies as documented by letter from the Healthcare Facility
Regulation Division.
(i) An
applicant for a new or expanded Comprehensive Inpatient Physical Rehabilitation
Program shall have written policies and procedures for utilization review. Such
review shall consider, but is not limited to, factors such as medical
necessity, appropriateness and efficiency of services, quality of patient care,
and rates of utilization.
(j) An
applicant for a new or expanded freestanding rehabilitation hospital shall
document the existence of referral arrangements, including transfer agreements
with an acute-care hospital(s) within the planning region to provide emergency
medical treatment to any patient who requires such care. If the nearest
acute-care hospital is in an adjacent planning region, the applicant may
document the existence of transfer agreements with that hospital in lieu of
such agreements with a hospital located within the planning region.
(k) An applicant for a new or expanded
Comprehensive Inpatient Physical Rehabilitation Program shall foster an
environment that assures access to services to individuals unable to pay and
regardless of payment source or circumstances by the following:
1. providing evidence of written
administrative policies and directives related to the provision of services on
a nondiscriminatory basis;
2.
providing a written commitment that un-reimbursed services for indigent and
charity patients in the service will be offered at a standard which meets or
exceeds three percent (3%) of annual gross revenues for the service after
Medicare and Medicaid contractual adjustments and bad debt have been deducted;
and
3. providing documentation of
the demonstrated performance of the applicant, and any facility in Georgia
owned or operated by the applicant's parent organization, of providing services
to individuals unable to pay based on the past record of service to Medicare,
Medicaid, and indigent and charity patients, including the level of
un-reimbursed indigent and charity care.
(l) Reserved.
(m) An applicant for a new or expanded
Comprehensive Inpatient Physical Rehabilitation Program shall agree to provide
the State Health Department with requested information and statistical data
related to the operation of such a Program on a yearly basis, or as needed, and
in a format requested by the Department.
O.C.G.A. §§ 31-2et seq., 31-6 et seq.
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