Louisiana Administrative Code
Title 48 - PUBLIC HEALTH-GENERAL
Part I - General Administration
Subpart 5 - Health Planning
Chapter 115 - Health Resource requirements
Subchapter B - Facility or Service-Specific Criteria and Standards
Section I-11523 - Long Term Care Beds
Universal Citation: LA Admin Code I-11523
Current through Register Vol. 50, No. 9, September 20, 2024
A. Skilled Nursing and Intermediate Care Facilities
1.
Definition/Description
a. In the broadest
sense, long term care includes the complete spectrum of institutional and
non-institutional services which provide health care to persons with chronic
disease or disability requiring care over an extended period of time, or to
persons recovering from the an acute phase of illness requiring continuing
care. Services range from those provided in the home to inpatient or
residential services provided in public or private institutions. The goal of
long term care is to provide persons of all ages with preventive, diagnostic,
medical, rehabilitative, maintenance, or social services, to achieve optimal
physical, social, and psychological functioning.
b. Long Term Care beds may be located in
general acute care hospitals or in nursing homes. A licensed nursing home is a
long term care facility which provides, in addition to food and shelter,
professional attendant and nursing care, 24 hours a day, to the chronically
ill, convalescent, disabled, and the elderly, with a full range of
complementary services (therapeutic, dietary, social, etc.)
c. Nursing homes differ from hospitals in
that they have no facilities for diagnostic services or for acute or emergency
medical care (x-ray, laboratory, or surgical units); however, nursing homes
provide the most complete care possible outside of a hospital, because services
and manpower are located and delivered within the institution in which the
patients reside.
d. Nursing homes
are classified according to the type of care provided. A nursing home may be
certified in one or more of the following levels of care:
2. Skilled Nursing Care Facility (SNF)
a. A skilled Nursing Facility provides
intensive, frequent, and comprehensive nursing care and/or rehabilitation
services ordered by and under the direction of a physician. Services are
provided under the supervision of a registered nurse or licensed practical
nurse on a 24 hour basis. Skilled nursing beds may be located in a general
acute care hospital or in a nursing home.
b. Examples of services include therapy,
administration of medication and I.V. fluids, tube feeding, post surgical
convalescent care. Skilled care is also referred to as Extended Care.
3. Intermediate Care
Facility-Level I (ICF-I). An Intermediate Care Facility, Level I, provides
basic nursing services under the direction of a physician to persons who
require a lesser degree of care than skilled services, but who need care and
services beyond the level of room and board. Examples of services are
administration of injections and medication, treatment and care of persons
requiring tubes, appliances, surgical dressings, physical therapy, restraints,
and personal care.
4. Intermediate
Care Facility-Level II (ICF-II). An Intermediate Care Facility, Level II,
provides supervised personal care and health related services, under the
direction of a physician, to persons needing nursing supervision in addition to
help with personal needs. Services can usually be provided by trained aides and
orderlies. Examples of services are administration of routine oral medication,
stimulation of activities in daily living, supervision or assistance with
personal care.
5. Intermediate Care
Facility for the Mentally Retarded (ICF-MR)
a. An Intermediate Care Facility for the
Mentally Retarded provides residents with professionally developed individual
plans to cared, supervision, and therapy, to attain or maintain optimal
functioning.
b. (Refer to the
section on ICF/MR)
6.
Determination of Level of Care
a. The Office
of Family Security evaluates the necessity for Skilled and Intermediate Care
for Title XIX (Medicaid) recipients through admission review and medical
certification. Admission review is based on assurance that the recipient's
level of care is the most appropriate for his individual needs, and that there
has been a medical and social evaluation and physician certification. As
provided in the 1984 Deficit Reduction Act (P. L. 98-369), physician
recertification is required every 30, 60 and 90 days after admission to the
facility and every 60 days thereafter for recipients residing in Skilled
Nursing Facilities. Recipients residing in Intermediate Care Facilities shall
be recertified 60 and 180 days after admission, at 12, 18, and 24 months after
admission, and annually thereafter. Recertification is authorized by a
physician.
7. Payment to
Nursing Homes
a. Payment is made to nursing
homes according to the type of care provided, as described above.
b. A nursing home must be licensed by the
state in order to operate, and must be certified according to federal standards
in order to participate in the Medicare and Medicaid programs. Medicare is the
federal hospitalization and medical insurance program for the aged and
disabled, and Medicaid is the federal-state health care program for the
financially needy. Medicare applies only to Skilled Nursing Care, and pays for
up to 100 days of care in any single spell of illness, while Medicaid covers
both Skilled and Intermediate care levels without limitation on the number of
eligible days. Because of its restrictive definition and durational limits of
coverage, Medicare covers a relatively small percentage of the total number of
people currently in long term care facilities. Medicaid, the major source of
nursing home support, pays 60 percent of the nation's total nursing home
bill.
8. Alternatives
a. Alternatives to nursing home placement,
which can delay or eliminate the need for nursing home placement, include the
following: case management services, home health services, adult day medical
care, homemaker services, personal care and habilitation services, hospice
care, respite care, nutritional services (meals on wheels), volunteer services,
transportation services, semi-institutional and semi-independent living
arrangements.
b. Developing
alternatives to nursing home placement is a priority health issue for this
planning period, primarily because many of the aforementioned services are not
available currently in all areas of the state. One reason that alternatives to
nursing home care are not available to many of the state's citizens is cost.
People who may qualify for Medicaid-reimbursed nursing home care often have
sufficient income to remain in their own homes, but insufficient funds to pay
for home-based services, such as homemakers, day care, etc. Because of
eligibility criteria, many persons may not qualify for any subsidized services
other than nursing home care. For these reasons, there is nearly twice as much
utilization of nursing home services by people over 65 in the poor areas of
rural North Louisiana health system care compared to the more urban and
economically stable New Orleans/Bayou-River area.
9. Quality of Care
a. There are four quality control mechanisms
now in existence for nursing homes:
i. Title
XIX (Medicaid Program) conducts a Professional Medical Review (PMR) once
yearly. A PMR team (which includes a physician) is located in each health
planning district. Each team makes a site visit to review all medical records
and patients in each facility, to determine if patients are receiving both
quality care and appropriate care. Title XIX also conducts a Utilization
Review, simultaneous with a PMR, in which each team determines whether a
patient needs the level of care for which he is certified. Six months after the
on-site visit the team reviews the treatment plan and discharge plan of each
patient to see if the needed level of care is being provided.
(a). Under state law, complaints are made to
the secretary of the Department of Health and Human Resources, who reviews such
complaints and who then may refer the matter to appropriate office or law
enforcement agency for action (R.S. 40: 2009.13 et seq.).
ii. The Ombudsman Program, in the Governor's
Office of Elderly Affairs, monitors patient care and assists residents with
resolution of problems (R. S. 40:2010.0 et seq.)
iii. The State Licensing and Certification
Office reviews each facility annually with its own team. This team has members
which the PMR team does not; i.e., dietician, pharmacist. Their concern is with
the physical plant and whether the facility is providing the care for which it
is licensed. The team monitors a 15 percent sample of patients as to level of
care needed/received. The facility is given a time limit to correct
infractions.
iv. The Louisiana
Nursing Home Association has a Peer Review Committee which conducts voluntary
evaluations of the quality of nursing home care for the purpose of "maintaining
high standards of excellence in meeting the total needs of the patients they
serve." The association surveys each nursing home prior to accepting the
facility as a member.
10. Service Area. The service area for a
proposed or existing facility is designated as the parish in which the site is
located with the following exceptions: The parishes of Ascension, Iberville,
Plaquemines and St. John shall be considered to be divided by the Mississippi
River into two separate service areas. Therefore, all east bank wards in these
parishes will be considered as separate service areas and all west bank wards
will be considered as another service area. This methodology identifies the
resources and needs of persons most likely to utilize the nursing home beds. It
allows the placement of beds in areas which are presently served only by
distant or otherwise inaccessible nursing homes.
11. Resource Goals
a. The nursing home bed supply should not be
more than 80 ICF I, II and SNF beds (combined) per 1,000 population age 65 + .
i. Beds which are counted include:
(1) licensed but not Section 1122 approved
beds,
(2) 1122 approved and
licensed beds,and
(3) 1122 approved
but not yet licensed beds. The calculation shall include licensed general acute
care hospital beds which are Medicare certified as skilled nursing facility
beds.
ii. In determining
the bed to population ratio for the proposal, Division of Policy, Planning and
Evaluation will use population projections for the anticipated opening date
(year) of the facility, which shall not exceed two years from the date the
application is declared complete.
b. The occupancy rate for the four most
recent quarters due to have been reported to Division of Licensing and
Certification in the service area should be at least 95 percent.
i. In determining this occupancy rate, beds
used in the calculations include:
(1)
licensed but not 1122 approved beds and
(2) 1122 approved and licensed beds. This
calculation shall include licensed general acute care hospital beds which are
Medicare certified as skilled nursing facility beds.
12. Adjustments to
Resource Goals
a. Circumstances may exist or
be created which cause a particular group (see Section on Health Care for
Persons with Acquired Immunodeficiency Syndrome) or area to be underserved.
When one of the following circumstances exists in a service area, an adjustment
to the above resource goals may be justified:
i. Inaccessibility to Minority Groups
(a). It is recognized that certain factors
may limit the accessibility of nursing home beds to minority groups. For this
reason, a documented claim submitted by the applicant, of inaccessibility of
nursing home beds to minority groups, may be considered a special circumstance
in the determination of need in the service area. Inaccessibility refers only
to situations where there is documented evidence of discrimination against a
particular minority in a geographic area. This requirement will be deemed met
only when the Title VI or Title VII agency has made a positive finding of
systematic discrimination against a minority group on the part of an existing
health care facility within the geographic area.
ii. Inaccessibility in High Occupancy Areas
(a). It is recognized that in certain areas
of the state nursing home care may not be available. For this reason, a
documented claim, submitted by the applicant that nursing home care is not
available may be considered a special circumstance in the determination of need
in the service area. This requirement shall be deemed met only when the
adjusted occupancy rate for all facilities in the service area exceeds 95
percent. The adjusted occupancy rate is computed for each quarter for the four
most recent quarters due to have been reported to the Division of Licensing and
Certification and is calculated from a base bed inventory which includes
licensed but not 1122 approved beds. 1122 approved but not yet licensed
beds.
(b). This calculation shall
include licensed general acute care beds which are Medicare certified as
skilled nursing facility beds.
iii. Inaccessibility Due to Poor Quality Care
(a). It is recognized that in some areas of
the state the nursing home care being provided may not be of the quality
desired by the residents of that parish. Therefore, in these areas, a
documented claim, submitted by the applicant, that nursing home care is not
accessible due to the poor quality of care provided in the parish may be
considered a special circumstance in the determination of need in the service
area. This requirement will be deemed met only when a facility in the service
area has been disenrolled by the Office of Family Security as a Medicaid
Provider or decertified or delicensed by the Division of Licensing and
Certification and the adjusted occupancy rate for the other facilities in the
service area is greater than 95 percent. The adjusted occupancy rate is
computed for each quarter for the four most recent quarters due to have been
reported to Division of Licensing and Certification and is calculated from a
base bed inventory which includes licensed but not 1122 approved beds, 1122
approved and licensed beds and 1122 approved but not yet licensed
beds.
(b). This calculation shall
include licensed general acute care hospital beds which are Medicare certified
as skilled nursing facility beds. The beds of the facility which was
disenrolled, decertified or delicensed shall be excluded in computing the
adjusted occupancy rate and the Section 1122 approval for such facility shall
be revoked unless the facility obtains reenrollment, recertification and
relicensure within 60 days of the loss of such approvals.
13. Applications for
Proposals Based on Inaccessibility Adjustments
a. All applications for proposed or existing
facilities based on the foregoing inaccessibility adjustments will be referred
by the health planning staff to a committee of knowledgeable professionals who
will review and provide written comments to Division of Policy, Planning and
Evaluation on such applications. The following committee members are appointed
by the governor: the assistant secretary of Office of Family Security, the
administrator of Licensing and Certification, the chairman of the Statewide
Health Coordinating Council (shall always be a consumer representative), the
ombudsman coordinator of the governor's Office of Elderly Affairs, and the
director of the Bureau of Civil Rights of DHHR.
b. Division of Policy. Planning and
Evaluation shall forward copies of the applications to be reviewed to the above
noted committee members as soon as such applications are declared complete. The
transmittal will include the date of the public hearing and the decision due
date. Division of Policy, Planning and Evaluation shall also forward a summary
of the public hearing comments to the committee members.
c. Each committee members will forward
individual comments and recommendations to the Division of Policy, Planning and
Evaluation. Comments must be received by Division of Policy, Planning and
Evaluation at least five working days prior to the decision due date. If
available, such comments and recommendations will be included in the staff
analysis and considered when a decision is rendered. The number of beds which
may be approved in an area deemed inaccessible due to high occupancy shall not
exceed the lesser of (1) the average of all the facilities in the service area
or (2) 10 percent of the number of beds in the service area. For all other
resource goal adjustments based on inaccessibility, the number of beds which
may be approved shall not exceed the average of all the facilities in the
service area.
NOTE: Specific requirements for meeting these exceptions shall be further established in Section 1122 Policies and Guidelines promulgated by the Division of Policy, Planning and Evaluation.
B. Intermediate Care Facilities for the Mentally Retarded
1. Definition/Description of Services
a. An Intermediate Care Facility for the
Mentally Retarded (ICF/ MR) is one which serves individuals having disabilities
attributable to mental retardation or related conditions. The definition of
"related conditions" is hinged on legislative language contained in the
Developmental Disabilities Services and Facilities Construction Act, P. L.
91-517. This Act, as amended by P.L. 95-602, contains the following definition
of developmental disability.
i. The term
developmental disability means a severe, chronic disability of a person which:
(a). is attributable to a mental or physical
impairment or combination of mental and physical impairments;
(b). is manifested before the person attains
age 22;
(c). is likely to continue
indefinitely;
(d). results in
substantial functional limitations in three or more of the following areas of
major life activity:
(i) self-care;
(ii) receptive and expressive
language;
(iii) learning;
(iv) mobility;
(v) self-direction;
(vi) capacity for independent living;
and
(vii) economic
self-sufficiency; and
(e). reflects the person's need for a
combination and sequence of special inter-disciplinary, or generic care,
treatment, or other services which are individually planned and
coordinated.
b. The ICF/MR, referred to as an Intermediate
Care Facility-Handicapped or ICF/H by the Office of Family Security, like other
Intermediate Care Facilities, must fully meet the licensure requirements of the
State. It provides, on a regular basis, health related services to individuals
who do not require the degree of care and treatment which a hospital or skilled
nursing facility is designed to provide, but who, because of their mental or
physical condition, require care and services above the level of room and board
that can be made available only in institutional facilities. Among the
conditions that might be served in an ICF/MR are: disabilities attributable to
mental retardation, cerebral palsy, epilepsy, autism and other conditions as
defined in the paragraph above.
c.
There is a wide range in the types of facilities which may meet licensing and
Title XIX regulatory standards as ICF/MRs. At one end of this range are those
facilities that provide domiciliary care. These facilities have a bed capacity
of sixteen or more beds. Thus, they constitute the largest ICF/MR facilities
and may be referred to as large residential facilities. These facilities exist
in a network of publically owned State schools as well as in privately owned
arrangements. Group homes and community homes comprise the community based
services. The former consists of facilities with a bed capacity between seven
and 15 beds while facilities in the latter category have between one and six
beds. Elderly persons suffering from mental retardation or related conditions
and unable to benefit from active treatment are provided care in nursing homes
(SNF, ICF I and ICF II). As of January, 1986 there were 5,104 large residential
facility beds, 183 group home beds, and 669 community home beds approved and
licensed to serve those with mental retardation and related conditions. In
addition, 125 community home beds and 48 residential facility beds were Section
1122 approved but not yet licensed.
2. Issues
a. There has been an ongoing commitment for
over 10 years within the Office of Mental Retardation/Developmental
Disabilities to reduce the populations of the large state institutions for the
mentally retarded. There exists additional impetus at the national level to
encourage the development of community-based ICF/MRs with a corresponding
reduction in the population of large residential facilities.
b. Successful development of a variety of
community-based programs for the developmentally disabled depends heavily on
the existence of a stabilizing center for the coordination of activities and
provisions of support and consultation services. The State School with its
cadre of professional services provides the most efficient and economical base
for a regional system of support services for the developmentally
disabled.
3. Bed Need
a. According to 1980 census data, Louisiana
had a population of 4,206,313. Projections for 1990 indicate a population of
over 4,849,038. A three percent prevalence rate has generally been accepted to
estimate the number of individuals with mental retardation existing in the
general population. However, recent studies and experiences in Louisiana
indicate that a one percent prevalence rate is more realistic. Therefore, a one
percent prevalence rate was used to project the number of individuals with
mental retardation in Louisiana. Hence, in 1980 it was estimated that there
were 42,063 individuals with mental retardation, with a projection of 48,490
mentally retarded individuals in 1990. According to many experts, 70 percent of
the mentally retarded individuals fall into the category of mild retardation.
Fifteen percent are considered moderately retarded and 15 percent are
considered severely and profoundly retarded.
b. The emphasis in bed need has shifted from
traditionally large domiciliary care facilities to alternative living
arrangements. The 1983-85 Developmental Disabilities State Plan delineated four
priority areas to meet needs of developmentally disabled individuals, one of
which is the development of alternatives to the large domiciliary care
facility. Such alternative living arrangements include adoption homes,
substitute family care homes, supervised apartments, and independent living
services as well as such residential alternatives as community homes and group
homes.
c. Under the subcategory of
living arrangements outside of the family home, adoptive homes are needed by
some developmentally disabled children whose families cannot or will not care
for them any longer. Some who are returning from more restrictive placements
and need a family-like living environment can benefit most from such
arrangements. These specialized adoptive homes must have professional backup
and support, and the adoptive parents should be well trained and able to carry
out any in-home training specified in the child's individual habilitation plan
(IHP).
d. Substitute family care
homes are required for a number of disabled children and some adults who need a
stable family-like environment when the natural family can no longer care for
them or when the individual is returning from a more restrictive placement.
Foster care is preferable when there is a chance that the natural family may
accept the child back or permanent placement with a family is not feasible. The
foster parents should be trained and under contract to provide any in-home
training prescribed in the individual's IHP.
e. A larger proportion of developmentally
disabled children and adults require temporary or permanent community home, or
group home, living arrangements because they need round-the-clock supervision
and intensive programming. These persons may be in need of this alternative if
they are removed from the natural family for periods of time, are returning
from an institution or are exhibiting severe behavioral problems. This
alternative calls for a staff that has been trained in administering intensive
programming, and for the availability of professional back-up
support.
f. A number of
developmentally disabled adults need supervised apartment or independent living
alternatives, which usually entail obtaining necessary support services, such
as training in independent living, attendant care, homemaker services, and
supervision or assistance in locating accessible housing. These community
supports are the key to successful independent living for the otherwise
self-sufficient developmentally disabled individuals. The staff providing the
supervision must have skills in understanding and meeting these service
needs.
4. Types of
Facilities Needed. In planning for the expansion of ICF/MR services for the
mentally retarded and developmentally disabled, the emphasis will be on
smaller, community-based facilities distributed throughout the state. In
addition, there is a need for special units or facilities for certain segments
of the developmentally disabled population who have special needs because of
adaptive difficulties, such as the mentally retarded/emotionally disturbed and
the mentally retarded delinquent. In all cases, the facility should be the
least restrictive setting for the clients it is designed to serve.
5. Elements of an ICF/MR
a. The following characteristics are required
in ICF/MRs. The Office of Mental Retardation/Developmental Disabilities will
evaluate proposed new or expanded programs based on these characteristics. In
accordance with L. R. S. 28:420, OMR/DD shall approve the program model for the
population to be served. Criteria for judging the program model will be based
on Title XIX regulations, state licensing requirements and the OMR/DD law.
i. Program Characteristics
(a). Normalization-Care for the
developmentally disabled in intermediate care facilities should be provided in
a manner which facilitates the individual's training in developmental skills
for restoring lost function, acquisition of new skills, or the maintenance of
present skills. Therefore, proposals should delineate the manner in which
residents will participate in such services as may be specified in their
individual habilitation plans. Services must be designed to approximate as
nearly as possible the normal patterns of life and conditions of those not
developmentally disabled. Through normalization, individuals with disabilities
should have available to them the options of everyday life which closely
parallel the norms and patterns of the mainstream of society.
(b). Developmental Approach-It has been
demonstrated that persons who are developmentally disabled are capable of
change and can increase their self-sufficiency when provided with appropriate
learning and experimental opportunities. Therefore, services should be offered
which are designed to increase the person's ability to cope progressively with
more complex situations, increase his/her control over these situations, and
help the person live a normal life in the community. Care in such residential
settings should be focused through developmental programming.
(c). Least Restrictive Setting-Individuals
shall be provided services in ways and settings that are suitable and
appropriate to their abilities while least restrictive to their liberties.
Generic community resources can be used by most developmentally disabled
persons. Specialized services shall be used by the developmentally disabled
only when general service programs fail to meet needs appropriately.
(d). Individual Program Planning-Since
developmentally disabled persons often have multiple disabilities in a variety
of combinations and so are especially vulnerable to neglect, state and federal
mandates require that individual program planning be made for each disabled
person. The plan shall include: goals toward which a person should be directed;
specific activities and services needed to achieve those goals; and evaluation
measures to determine and adjust for goal achievement. The plan should cover
all services needed by the client/family whether one or several agencies are
required to provide all of those services.
(e). Interdisciplinary Program
Planning-Diagnosis, evaluation, and individual program planning are best
accomplished through a team effort of client, family or significant others, and
professionals representing a variety of perspectives and disciplines. The
clients and family members are included in the team as active participants in
both the planning and decision-making process. The client's individual
habilitation plan shall be implemented, followed up, monitored and revised
periodically to ensure provision of appropriate quality services.
ii. Facility Characteristics
(a). Facility Types-there are two types of
community residential facilities, the group home and the community home. The
community home has a bed capacity of six or fewer beds while a group home has a
capacity of 15 or fewer beds. ICF/MRs should be as small as possible to provide
a home-like environment. Individuals who are severely retarded may be served
appropriately in an ICF/MR. Moderately retarded persons with a secondary
disability or extreme deficits in adaptive behavior may also be placed in an
ICF/MR. In large residential facilities (16 beds and over), individuals of
substantially different ages or developmental levels or having special needs,
should be housed in small, separate physical units within the facility.
Although persons should be provided with ICF/MR placements, services and
programs in the region where their families or advocates reside, the
individual's habilitative needs should be given priority in considering
placement recommendations. Characteristics to be considered in making an ICF/MR
placement are adaptive behavior, mobility, physical disability, behavior,
medical needs, age range, and level of retardation.
(b). Facility Design-the physical environment
should be home-like in terms of furnishings, equipment and availability of
privacy. In a large residential facility (16 beds and over) the physical
arrangement of the living environment should permit its occupants to be divided
into smaller groups (up to 8 persons) in separate living units (apartments,
cottages, etc.)
(c). Facility
Location-the location of ICF /MRs is important. In order to assure that the
location provides maximum support to the facility the following conditions
should be present:
(i). the location should
be in communities of sufficient size to permit integration of the clients into
the community and there should be opportunities for the residents to establish
patterns of normal everyday activities;
(ii). the location should provide access to
recreational activities, shopping, public education programs, and sheltered
workshops;
(iii). the location
should be in an area capable of providing the required support services through
a qualified and experienced labor force and in settings outside of the
residence to ensure separation of life functions;
(iv). in accordance with L.
R.S.
28:478 B, there shall be no community home
placed within one thousand foot radius of another community home;
(v). the location of the ICF/MR site must be
specific and must either be owned by or under an option to be bought, leased,
or rented by the provider;
(vi).
the capability of the receiving community to support the proposed ICF/MR should
be evaluated by the State Office of Mental Retardation/Developmental
Disabilities and a written assessment from this office shall be provided to the
State Health Planning and Development Agency during project reviews.
iii. Community Support.
Providers are encouraged to work with the Office of Mental
Retardation/Developmental Disabilities to develop and implement strategies that
will foster community acceptance. Prior to the development of a community home,
a legal notice shall be published in the local newspaper of the community where
the project is to be developed. The notice shall give the proposed site to be
used.
iv. Staffing
(a). The following kinds of staff are
considered appropriate to various types of ICF/MR programs. A qualified mental
retardation professional (QMRP) is a person who has specialized training or one
year of experience in treating or working with the developmentally disabled and
is one of the following:
(i).
Psychologist-Master's degree from an accredited program in psychology. Must
have specialized training or one year of experience in treating the
developmentally disabled and receive in-service training during the first year
of employment in various specialty areas related to the needs of the clients in
the facility.
(ii).
Educator-Bachelor's degree in education with a minimum of one year of teaching
preferred. Must have specialized training or one year of experience in
educating the developmentally disabled and receive in-service training during
the first year of employment in various specialty areas related to the needs of
the clients in the facility.
(iii).
Social Worker-Bachelor's or master's degree in social work from an accredited
program and one year of experience in direct service with developmental
disabilities. A QMRP in social work can also be an individual with a bachelor's
degree in a field other than social work with at least three years of social
work experience under the supervision of a qualified social worker. Must
receive in-service training during the first year of employment in various
specialty areas related to the needs of the clients in the facility.
(iv). Physical or Occupational
Therapist-Appropriate degree from an accredited program. One year of experience
in direct service with developmental disabilities. Must receive in-service
training during first year of employment in various specialty areas related to
the needs of the clients in the facility.
(v). Speech Pathologist or Audiologist-Degree
with license and certification of clinical competence and one year of
experience as speech pathologist. Must receive in-service training the first
year of employment in various specialty areas related to the needs of the
clients in the facility.
(vi).
Rehabilitation Counselor-B.S. degree in counseling with one year of experience
in counseling and must be certified by the Committee of Rehabilitation
Counselor Certification. Must receive in-service training during first year of
employment in various specialty areas related to the needs of the clients in
the facility.
(vii). Registered
Nurse-Licensed with a minimum of one year of experience in nursing. Experience
in restorative or rehabilitative nursing preferred. Must receive in-service
training during first year of employment in various specialty areas related to
the needs of the clients in the facility.
(viii). Therapeutic Recreation
Specialist-graduate of accredited program in recreation therapy. One year of
experience in therapeutic training required. Must receive in-service training
during the first year of employment in various specialty areas related to the
needs of the clients in the facility.
[a].
While the administrator of an ICF/MR does not have to be a qualified mental
retardation professional, he or she should be qualified in management.
|
Type of Facility |
Staff |
|
Developmental/Medical |
Administrator/Program Director (QMRP) |
|
Registered nurse |
|
|
Paraprofessionals |
|
|
Developmental/Family-Living |
Administrator/Program Director (QMRP) |
|
Trained house-parents or shift staff serving as parent or peer models |
|
|
Social/Vocational Programs |
Administrator/Program Director (QMRP) |
|
Trained houseparents/shift staff serving as parent or peer models |
|
|
Developmental/Behavioral Training |
Administrator/Program Director (QMRP) |
|
Psychologist or educator (QMRP) with expertise in behavior modification training |
|
|
Houseparents or shift staff with behavior modification experience. |
6. Distribution of
ICF/MR Beds
a. The incidence of mental
retardation does not occur uniformly throughout the population. Causes for mild
and moderate retardation (nearly 85 percent of the mentally retarded
population) often have socioeconomic implications. Because of the desirability
of making client placements which will permit the return of mentally retarded
clients to the community where their families or advocates reside, ICF/MR beds
should be distributed in a manner which parallels somewhat the distribution of
the mentally retarded population.
b. At present, there is no data available to
be used in sketching the actual geographic distribution of persons who are
mentally retarded. Until such data is available, bed need projections will be
based on prevalence rates and occupancy rates at existing facilities in the
region.
7. Quality of
Care
a. The following quality control
mechanisms are in existence for ICF/MRs.
i.
All Section 1122 applications for new or expanded ICF/MR projects are reviewed
by the Office of Family Security (OFS) to determine if the proposed developer
has had prior experience in the operation of an ICF/MR and, if so, has
demonstrated an ability to provide quality care. The applications are reviewed
by the Division of Licensing and Certification (DLC) to determine if the
project appears in conformity with Title XIX regulations and state licensing
laws. The application is reviewed by the Office of Mental
Retardation/Developmental Disabilities (OMR/DD) to determine if the most
appropriate program components are in place.
ii. All projects are monitored at least twice
yearly by Department of Health and Human Resources review teams.
iii. The following Inter-Agency Agreement on
Procedures Relative to Quality Assurance in ICF/MRs is to be followed.
(a). The Office of Family Security and
Division of Licensing and Certification will forward to Office of Mental
Retardation/Developmental Disabilities regional offices a copy of the
monitoring reports on each provider, within 30 days.
(b). If deficiencies are identified, OMR/DD
will meet with the provider to discuss their corrective action plan. OMR/DD
regional offices will follow-up to the providers in writing with an offer of
specific technical assistance with a carbon copy to OFS and DLC. OMR/DD
regional offices will advise the central office of any technical assistance
needs which exceed the resources of the region.
(c). OMR/DD regional offices will keep a
record on each provider reflecting deficiencies noted in each monitoring
report. The provider's record will also contain references to all technical
assistance offered to the provider. Also noted in the record will be the
provider's willingness to work with OMR/DD in correcting deficiencies. OFS and
DLC will receive carbon copies of all relevant OMR/DD correspondence with
providers.
(d). OFS and DLC will
reflect in their subsequent monitoring reports the extent to which deficiencies
were corrected and the extent to which OMR/DD was contacted for technical
assistance. OFS will take appropriate action including sanctions if
indicated.
8. Service Area. The service area for a
proposed or existing facility is designated as the one of 8 OMR/DD planning
regions in which the facility or proposed facility is or will be
located.
9. Resource Goals
a. In accordance with the department's policy
of least restrictive environment, there is no currently identified need for
additional facilities with 16 or more beds. Beds may be transferred from one
existing residential facility to another.
b. The bed to population ratio for community
and group homes may at no time exceed .36 per 1000 population in each service
area. In determining the bed to population ratio for a proposal, Division of
Policy, Planning and Evaluation will use population projections for the
anticipated opening date (year) of the facility which in no case shall exceed
two years from the date the application is declared complete.
c. The occupancy rate for community homes in
the service area must be 80 percent or greater in order for another community
home to be approved.
d. The
occupancy rate for group homes in the service area must be 85 percent or
greater in order for another group home to be approved.
e. In determining the occupancy rate, beds
used in the calculations are 1122 approved and licensed beds.
f. Community or group homes will be
determined to meet the above resource goals where mandated by courts.
g. A distinct part of a publicly supported
facility other than an intermediate care facility will be determined to meet
the above resource goals provided that the distinct part:
i. meets all requirements for an intermediate
care facility;
ii. is an
identifiable unit, such as an entire ward or contiguous ward, a wing, floor, or
building;
iii. consists of all beds
and related facilities in the unit;
iv. houses all recipients for whom Title XIX
payments are being claimed; and
v.
is clearly identified.
h. Capital costs must not exceed the amount
that a cost-conscious buyer would pay.
i.
Authorization. Subchapter I, Part 100 of P. L. 98-21 provides a mandate for
cost containment pursuant to Section 1122 of the Social Security Act. Utilizing
the wording of the Provider's Reimbursement Manual, there is an expectation
that the provider seeks to minimize costs and that its actual costs do not
exceed what a cost-conscious buyer pays for a given item or service. If costs
are determined to exceed the level that such buyers incur, in the absence of
clear evidence that the higher costs were unavoidable, the excess costs are not
reimbursable.
ii. In an effort to
contain capital costs involved in operating ICF/ MR facilities to reasonable
levels the following procedure has been designed to establish the maximum
amount that a cost conscious buyer would be expected to pay in capital costs.
(a). The Division of Policy, Planning and
Evaluation shall, at the beginning of each fiscal year, obtain from the
Division of Rate Administration, Office of Management and Finance, statistics
on budgeted annual capital costs of newly approved facilities over the previous
three year period grouped by urban/rural setting, facility type, facility size,
and ownership arrangement.
(b).
Reasonable Capital Cost will be computed by generating categories of facilities
based on setting, facility type, facility size, and ownership arrangement;
computing the mean budgeted capital cost for each category; and adding the
value of one standard deviation.
(c). There are two adjustments which are made
in the procedure described above for computing reasonable capital cost when
warranted by circumstances.
(d).
Whenever a category of facilities contains a Department of Housing and Urban
Development sponsored facility, the capital cost of that facility will not be
considered in computing the mean value for the category.
(e). On those infrequent occasions when an
application is received for a facility in a category containing fewer than
three values, reasonable capital costs cannot validly be based on the mean and
standard deviation. In this circumstance allowable capital costs will be
determined in one of two ways, depending on whether the facility and equipment
are owned or leased.
(f). In the
case of owned property and building, allowable capital costs shall be based on
fair market value, including conversion costs and development costs, provided
that the nature and size of the building and property are consistent with the
nature of the programs to be provided. In the event that the fair market value
is not known, it shall be established as the competitive market value. In the
event that neither of these values can be determined, fair market value shall
be estimated in consultation with an appropriate vendor other than one utilized
by the applicant. These three values will be applied in the same sequence to
establish the allowable cost of equipment.
(g). In the case of leased facilities and
equipment in a category containing fewer than three values, reasonable cost
shall be established as 16 percent of the fair market value plus an inflation
factor (see definitions). When the lease is for land and/or buildings, an
additional 11% of annual rent shall be added to cover vacancy time and property
management and an amount equal to conversion costs amortized over the term of
the lease shall be added. In the event that there is a lease for furnishings,
equipment or chattel properly considered a capital expense item, the amount of
the lease shall be averaged over its term to arrive at the amount to be
budgeted as a capital cost.
iii.Section 1122 certification shall be for
actual capital costs only up to the reasonable cost limit unless the provider
can provide clear evidence that higher costs cannot be avoided.
iv. An applicant whose capital costs exceed
the reasonable capital cost limit is not limited in the kinds and amounts of
evidence which he may present to prove the higher costs cannot be avoided.
However, the following types of evidence shall be considered clear evidence"
when they support the applicant's claim.
(a).
Documentation of special or unique program features that demand costly
equipment, specially designed features of physical plant, expanded grounds, or
other requirements that will drive capital costs up.
(b). Construction industry recognition that
construction costs in the geographic location of the applicant facility are
significantly higher than in other areas of the state, such as the
Locality Adjustments of the Dodge Construction Systems
Costs.
v. In
carrying out the above procedure, the following definitions shall apply:
(a).
Appropriate Vendor-is a
vendor who sells property or equipment similar to that for which fair market
value is being determined.
(b).
Capital Cost-for the purpose of generating the annual mean, is
that portion of the basic support component comprised of costs associated with
buildings, land and equipment. More specifically it includes:
(i). in the case of proprietor owned
facilities and equipment: depreciation, debt service, and property tax plus any
amount of these cost elements associated with a central office that has been
allocated to the facility's budget; and
(ii). in the case of leased facilities and
equipment: lease amount plus any amount of capital cost elements associated
with a central office that has been allocated to the facility's
budget.
(c).
Facility Size-is determined by the number of beds and consists
of two categories, those with six beds or less and those with more than six
beds.
(d).
Facility
Type-consists of two classifications, those that accommodate
nonambulatory residents and those limited to ambulatory residents.
(e).
Inflation
Factor-applies in lease arrangements only and consists of a 5 percent
annual increase in rental rate averaged over the lease term. Thus, for a three
year lease it would amount to 10 percent/3 years 3.33 percent.
(f).
Ownership
Arrangement-consists of three categories, owned, leased and mixed. The
mixed category consists of those facilities in which some of the property and
equipment is leased and some is owned, provided that neither owned nor leased
amounts of annual capital costs shall be in an amount less than $100.
(g).
Urban/Rural-an urban
location is any location within one of Louisiana's Metropolitan Statistical
Areas. Any other location shall be considered rural.
AUTHORITY NOTE: Promulgated in accordance with P. L. 93-641 as amended by P. L. 96-79, and R.S. 36:256(b).
Disclaimer: These regulations may not be the most recent version. Louisiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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