Current through Register Vol. 50, No. 9, September 20, 2024
A. A facility may involuntarily or
voluntarily lose its participating status in the Medicaid Program. When a
facility loses its participating status in the Medicaid Program, a minimum of
ten percent of the final vendor payment to the facility is withheld pending the
fulfillment of the following requirements:
1.
completion of a limited scope audit of the residents' funds account and the
disposition requirements for nurse aide training funds with findings and any
recommendations of a qualified accountant of the facility's choice submitted to
the BHSF Institutional Reimbursement Section. The facility has 60 days to
submit the audit findings to the BHSF Institutional Reimbursement Section once
the section notifies the facility that a limited scope audit is required.
Failure of the facility to comply is considered a class E violation and will
result in fines as outlined in the Subchapter L entitled sanctions;
2. the facility's compliance with the
recommendations of the limited scope audit and the disposition requirements for
nurse aide training funds;
3.
submittal of an acceptable final cost report by the facility to BHSF Program
Operations Section.
B.
Once these requirements are met, the portion of the payment withheld shall be
released by BHSF Program Operations.
NOTE: If a SN-ID or SN-TDC withdraws from the Medicaid
Program, the 10 percent will not be released until the above requirements are
met and after cost settlement.
C. In situations where a facility either
voluntarily or involuntarily discontinues its operations or participation in
the Medicaid Program, residents, residents legal representative or sponsor, and
other appropriate agencies or individuals shall be notified as far in advance
of the effective date as possible to ensure an orderly transfer and continuity
of care. The owner or administrator shall submit written notice of withdrawal
to BHSF/HSS at least 30 days in advance of a voluntary withdrawal.
D. If the facility is closing its operations,
plans shall be made for transfer. If the facility is voluntarily or
involuntarily withdrawing from Medicaid Program participation, the resident has
the option of remaining in the facility on a private-pay basis.
E. Payment Limitation
1. Payments may continue for residents up to
30 days following the effective date of the facility's certification of
non-compliance.
2. The payment
limitation also applies to Medicaid applicants and recipients admitted prior to
the certification of non-compliance notice.
3. Payment is continued only if the facility
totally cooperates in the orderly transfer of applicants/recipients to other
Medicaid facilities or other placements of their choice.
NOTE: The facility shall not admit new Medicaid
applicants/recipients after receiving the certification of non-compliance
notice. There shall be no payment approved for such an admittance.
4. DHH may cancel the provider
agreement if and when it is determined that the facility is in material breach
of contract.
F. Facility
Certification of Non-Compliance
1. When the
DHH Bureau of Health Services Financing, Health Standards Section determines
that a facility no longer meets state and federal Medicaid certification
requirements, action is taken. Usually an advance certification of
non-compliance date is set unless residents are in immediate danger.
2. Certification of Non-Compliance Notice
a. On the date the facility is notified of
its certification of non-compliance, DHH shall immediately begin notifying
residents, residents legal representative or sponsor, and other appropriate
agencies or individuals of the action and of the services available to ensure
an orderly transfer and continuity of care.
b. The process of certification of
non-compliance requires concentrated and prompt coordination among the
following groups:
i. the BHSF Health Standards
regional office;
ii. the parish
office of DHH BHSF, Medicaid Program;
iii. the facility; and
iv. other offices as designated by
DHH.
c. This
coordination effort shall have the following objectives:
i. protection of residents;
ii. assistance in finding the most
appropriate placements when requested by residents and/or responsible parties;
and
iii. timely termination of
vendor payment upon the resident's discharge from the facility.
NOTE: The facility still retains its usual responsibility
during the transfer/discharge process to notify the parish office of DHH/BHSF
Medicaid Program promptly of all changes in the resident's status.
3. Transfer
Team. DHH shall designate certain staff members as a transfer team when a mass
transfer is necessary. Their responsibilities shall include supervising
transfer activities in the event of a proposed facility certification of
non-compliance with Medicaid participation. The following procedures shall be
taken by or under the supervision of this team.
a. Supervision and Assistance. When payments
are continued for up to 30 days following certification of non-compliance, the
transfer team shall take the following actions:
i. supervise the facility certification of
non-compliance and transfer of its Medicaid residents;
ii. determine the last date for which vendor
payment for resident care can be made; and
iii. assist in making the most appropriate
arrangements for the residents, providing the team members' names as contact
persons if such help is needed.
b. Effecting the Transfer. To ensure an
orderly transfer or discharge, the transfer team shall also be responsible for
performing the following tasks:
i. they shall
meet with appropriate facility administrative staff and other personnel as soon
as possible after termination of a provider agreement to discuss the transfer
planning process;
ii. they shall
identify any potential problems;
iii. they shall monitor the facility's
compliance with transfer procedures;
iv. they shall resolve disputes in the
resident's best interest; and
v.
they shall ensure that the facility takes an active role in the transfer
planning.
vi. the local ombudsman
and advocacy agencies shall be notified.
Note: The facility's failure to comply with the transfer
team's requests may result in denial of reimbursement during the extension
period.
c.
Provisions for Resident Services During Transfer or Discharge. DHH has the
following responsibilities:
i. to provide
social services necessary in the transfer or discharge plan or otherwise
necessary to ensure an orderly transfer or discharge in accordance with the
State Plan of the Medicaid Program; and
ii. to obtain other services available under
Medicaid.
d. Parish
DHH/BHSF Medicaid Program Responsibilities: Applicant/Recipient Status Listing.
The parish office of DHH/BHSF Medicaid Program shall maintain a listing of each
applicant/recipient's status as authorization forms are submitted regarding
transfer or discharge. At the conclusion of the 30 day period referred to
above, the transfer team shall submit a report to the office of DHH/BHSF
Medicaid Program, outlining arrangements made for all Medicaid
applicants/recipients.
e. Resident
Rights. Nothing in the transfer or discharge plan shall interfere with the
existing bill of rights.
G. Recertification of an Involuntary
Withdrawal. After involuntary certification of non-compliance, a facility
cannot participate as a provider of Medicaid services unless the following
conditions are met:
1. the reasons for the
certification of non-compliance of the contract no longer exist;
2. reasonable assurance exists that the
factors causing the certification of non-compliance will not recur;
3. the facility demonstrates compliance with
the required standards for a 60 day period prior to reinstatement in a
participating status; and
4. the
initial survey verifies that residents are receiving proper care and
services;
5. certification
requirements for swing bed hospitals. Small rural hospitals may certified to
provide Medicaid nursing facility services if all of the following conditions
are met:
a. the hospital has a valid agreement
as a title XVIII (Medicare) provider of swing bed services;
b. the hospital has fifty hospital beds or
fewer, excluding beds for newborns and beds in intensive care type in residents
units;
c. the hospital is located
in an area not designated as "urban" in the most recent census;
d. a facility need review approval has been
granted;
e. the hospital is not
operating under a waiver of the hospital requirements for 24 hour nursing
services;
f. the hospital has a
valid title XIX (Medicaid) agreement as a provider of acute care hospital
services;
g. the hospital has not
had a swing bed title XVIII (Medicare) or Title XIX (Medicaid) approval
terminated within two years previous to application;
h. a provider of swing bed services shall
comply with conditions for title XIX (Medicaid) participation as both acute
care hospital and Medicaid nursing facility; however, a lack of compliance with
nursing facility requirements does not affect participation as a provider of
acute care hospital services;
i.
hospitals seeking to enroll as swing bed facilities on or after July 9, 1987
shall also meet the following criteria:
i.
possess a current nursing home license;
ii. be administered by a licensed Nursing
Home Administrator;
iii. meet the
need and resource goals as established in facility need review regulations;
and
iv. list enrollment to ten
percent of bed capacity.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
46:153.
