Current through September 17, 2024
007.01
STANDARDS FOR PARTICIPATION FOR NURSING FACILITIES.
The nursing facility (NF) must meet:
(A) The
Nebraska nursing home licensure, and Medicare and Medicaid certification
standards as required by state statutes and 42 CFR 483, Subpart B, or if
located outside of Nebraska, similar standards in that state;
(B) The facility type, program and
operational definitions; and
(C)
The definition of a nursing facility (NF) as defined in this chapter, and in
section 1919 of the Social Security Act.
007.02
PROVIDER
AGREEMENT. To participate as a provider the nursing facility (NF)
must meet the standards in this chapter and must complete the appropriate
provider agreement. The facility submits the completed and signed form to
Medicaid for approval and enrollment as a provider.
007.03
MINIMUM DATA SET RESIDENT
ASSESSMENT. The nursing facility (NF) must conduct an
interdisciplinary assessment of every resident's functional capacity,
regardless of payor source. This assessment must utilize the minimum data set
(MDS). The facility must submit one copy of each assessment to the Department
within 30 days of completion.
007.03(A)
REGISTERED NURSE (RN) ASSESSMENT COORDINATOR. Each
facility must designate a registered nurse (RN) assessment coordinator. The
facility must inform the Department of the name of the assessment coordinator
and must promptly inform the Department of any changes. The assessment
coordinator must coordinate each assessment with the appropriate participation
of health professionals. Each individual who completes a portion of an
assessment must sign and certify as to the accuracy of that portion of the
assessment. The assessment coordinator must sign and certify the completion of
the assessment.
007.03(B)
FREQUENCY OF ASSESSMENTS. An assessment must be
completed:
(i) Initial admission: Must be
completed by 14th day of resident's stay;
(ii) Annual reassessment: Must be completed
within 12 months of most recent full assessment;
(iii) Significant change in status
reassessment: Must be completed by the end of the 14th calendar day following
determination that a significant change has occurred; and
(iv) Quarterly assessment: Must be completed
no less frequently than once every three months.
007.03(C)
OTHER
CHANGES. The facility need not assess the resident if declines in
a resident's physical, mental, or psychosocial well-being are attributable to:
(i) Discrete and easily reversible causes
documented in the resident's record and for which facility staff can initiate
corrective action;
(ii) Short-term
acute illness, such as a mild fever secondary to a cold from which facility
staff expect full recovery of the resident's pre-morbid functional abilities
and health status; or
(iii) Well
established, predictive cyclical patterns of clinical signs and symptoms
associated with previously diagnosed conditions.
007.03(D)
USE OF INDEPENDENT
ASSESSORS. If the Department determines, under a survey by the
Department of Health and Human Services Regulation and Licensure or otherwise,
that assessments are not being completed or that there has been a knowing and
willful false certification of information under this section, the Department
may require for a period of time specified by the Department that resident
assessments under this section be conducted and certified by individuals who
are independent of the facility and who are approved by the Department. The
facility is responsible for the reasonable payment of the individuals
completing the assessment. The cost may be included in cost reports.
007.04
COMPREHENSIVE
CARE PLAN. The facility must develop a comprehensive care plan for
each client that includes measurable objectives and timetables to meet a
client's medical, nursing, and psychosocial needs that are identified in a
comprehensive assessment. The plan must be:
(A) Developed within seven days after
completion of the comprehensive assessment;
(B) Prepared by an interdisciplinary team;
and
(C) Periodically reviewed and
revised by a team of qualified persons after each assessment, or at least
quarterly. The plan must include recommendations of the Level II evaluation, if
applicable.
007.05
ANNUAL PHYSICAL EXAMINATION. The Department requires
that all nursing facility residents have an annual physical examination. The
physician, based on their authority to prescribe continued treatment,
determines the extent of the examination for clients based on medical
necessity. For the annual physical exam, a complete blood count and urinalysis
will not be considered routine and will be reimbursed based on the physician's
orders. The results of the examination must be recorded in the client's medical
record.
007.05(A)
BILLING FOR THE
ANNUAL PHYSICAL EXAMINATION. If the annual physical examination is
performed solely to meet the Medicaid requirement, the physician must submit
the appropriate professional claim to the Department. If the physical
examination is performed for diagnosis or treatment of a specific symptom,
illness, or injury and the client has Medicare or other third party coverage,
the physician must submit the claim through the usual Medicare or other third
party process.
007.06
PHYSICIAN SERVICES. The physician must see the client
whenever necessary, but at least once every 30 days for the first 90 days
following admission, and at least once every 60 days thereafter. At the time of
each visit, the physician must:
(1) Review
the client's total program of care, including medications and
treatments;
(2) Write, sign, and
date progress notes at each visit; and
(3) Sign all orders.
007.06(A)
PHYSICIAN
TASKS. In accordance with
42 CFR
483.40(f), the Department
will allow all but the following required physician tasks in a nursing facility
to be satisfied when performed by a nurse practitioner or physician's assistant
who is not an employee of the facility but who is working in collaboration with
a physician according to Nebraska statute and designation of duties:
(i) Initial certification;
(ii) Admission orders; and
(iii) Admission plan of care.
007.07
MEDICAL CARE AND SERVICES. The facility must ensure
that admitted Medicaid clients receive appropriate medical care and services.
If the appropriate medical care or service cannot be provided using facility
staff, the facility must arrange for the care or service to be
provided.
007.08
DENTAL
CARE. Facilities must make arrangements for dental examinations as
needed.
007.09
FREEDOM
OF CHOICE. Each facility must ensure that any client may exercise
their freedom of choice in obtaining covered services from any provider
qualified to perform the services. Clients participating in Medicaid managed
care must comply with the conditions of their managed care plan.
007.10
ROOM AND BED
ASSIGNMENTS. Facility staff must maintain a permanent record of
the client's room and bed assignments. This record must show the dates and
reasons for all changes and be maintained in the nurses' notes in the health
chart or medical record.
007.11
RESIDENTS' RIGHTS. The facility must protect and
promote the rights of each resident as defined in
42 CFR 483.10.
When the resident is unable to manage their own personal funds, and there is
not a guardian or responsible family member, the facility must arrange for, or
manage, the personal funds as specified in
42 CFR
483.10(c)(1) thru
(8).
007.12
BED-HOLDING
POLICIES FOR HOSPITAL AND THERAPEUTIC LEAVE. The facility must
develop policies as defined in
42 CFR
483.15(d).
007.13
INITIAL NOTICE OF
BED-HOLDING POLICIES. The facility must provide written
information to the client and a family member or legal representative that
specifies:
(A) The duration of the bed-hold
policy during which the client is permitted to return and resume residence in
the facility; and
(B) The
facility's policies regarding bed-hold periods which must be consistent with
42 CFR
483.15(d).
007.14
NOTICE UPON
TRANSFER. At the time of transfer, the facility must provide
written notice to the client and a family member or legal representative which
specifies the duration of the bed-hold policy.
007.15
PERMITTING THE CLIENT TO
RETURN TO THE FACILITY. The facility must establish and follow a
written policy under which a client whose leave exceeds the bed-hold period is
re-admitted to the facility immediately upon availability of a bed if the
client:
(A) Requires the services provided by
the facility; and
(B) Is eligible
for Medicaid nursing facility services.
007.16
FACILITY-TO-FACILITY
TRANSFER. To transfer any Medicaid client from one facility to
another, the transferring facility must:
(A)
Obtain physician's written order for transfer;
(B) Obtain written consent from the client,
his or her family, or guardian;
(C)
Notify the Department that handles the client's case in writing, stating:
(i) The reason for transfer;
(ii) The name of facility to which the client
is being transferred; and
(iii) The
date of transfer;
(D)
Transfer the following to the receiving facility:
(i) Necessary medical, social, and
Preadmission Screening and Resident Review (PASRR) information;
(ii) Any non-standard wheelchair and
wheelchair accessories, options, or components, including power operated
vehicles;
(iii) Any augmentative
communication devices with related equipment and software;
(iv) Supports; and
(v) Custom fitted or custom fabricated items;
and
(E) Document
transfer information in the client's record and discharge summary.
007.17
DISCHARGES. At the time of or no later than 48 hours
after a client is discharged or expires, the facility must notify the
Department that handles the client's case of:
(A) Date of discharge and the place to which
the client was discharged; or
(B)
Date of death.
007.18
DISCHARGE PLANNING. Before a client's discharge or
deinstitutionalization, the facility staff must document in the medical record
the actual implementation date of the discharge plan. Each nursing facility
must maintain written discharge planning procedures for all Medicaid clients
that describe:
(A) Which staff member of the
facility has operational responsibility for discharge planning;
(B) The manner in, and methods by, which the
staff member will function, including authority and relationship with the
facility's staff;
(C) The time
period in which each client's need for discharge planning will be determined,
which period may not be later than seven days after the day of
admission;
(D) The maximum time
period after which the interdisciplinary team reevaluates each client's
discharge plan;
(E) The resources
available to the facility, the client, and the attending physician to assist in
developing and implementing individual discharge plans; and
(F) The provisions for periodic review and
reevaluation of the facility's discharge planning program.
007.19
INAPPROPRIATE LEVEL OF
CARE (LOC). If it is determined that the client's present level of
care is inappropriate:
(A) The present
facility must provide services to meet the needs of the client and must refer
to appropriate agencies for services until an appropriate living situation is
available;
(B) The facility must
document that other alternatives were explored and the responses;
(C) The facility must make documentation of
active exploration for appropriate living situations available to the
Department or their agent;
(D) The
facility must work cooperatively with the preadmission screening and resident
review referral (PASRR) process.
007.20
AT THE TIME OF
DISCHARGE. At the time of the client's discharge, the facility
must:
(A) Provide any information about the
discharged client that will ensure the optimal continuity of care to those
persons responsible for the individual's post-discharge care.
(B) Include current information on diagnosis,
prior treatment, rehabilitation potential, physician advice concerning
immediate care, and pertinent social information.
(C) Discharge the following items
specifically purchased for and used by the client with the client:
(i) Any non-standard wheelchair and
wheelchair accessories, options, and components, including power operated
vehicles;
(ii) Any augmentative
communication devices with related equipment and software;
(iii) Supports; and
(iv) Custom fitted or custom fabricated
items.
007.21
APPEALS OF DISCHARGES, TRANSFERS, AND PREADMISSION SCREENING AND
RESIDENT REVIEW (PASRR) DETERMINATIONS. A resident of a skilled
nursing facility (SNF) or a nursing facility (NF) who receives a notice from
the skilled nursing facility (SNF) or nursing facility (NF) of the intent to
discharge or transfer the resident may appeal to the Department of Health and
Human Services for a hearing on this notice. The appeal and hearing must be
conducted under 465 NAC 2 and 6. An individual who is adversely affected by any
Preadmission Screening and Resident Review (PASRR) determination may appeal to
the Department of Health and Human Services for a hearing on the decision. The
individual or legal representative will be instructed to contact the Department
or contractor for information on appeals and to forward a written request for
an appeal to the Department within 90 days of the date of the Preadmission
Screening and Resident Review (PASRR) determination notice. The appeal and
hearing must be conducted under 465 NAC 2.
007.22
PRIOR
AUTHORIZATION. Medicaid requires authorization for the following
services:
(A) Nursing facility services for
clients under the age of 18;
(B)
Special needs nursing facility (NF) services;
(C) Out-of-state nursing
facilities;
(D) Room and board
services for clients receiving hospice in a special needs nursing facility
(NF);
(E) Swing bed services;
and
(F) Specialized add-on services
for clients with intellectual disabilities or related conditions residing in
nursing facilities.
007.23
PHYSICIAN'S INITIAL
CERTIFICATION. The physician must certify the medical necessity
for nursing facility level of care (NF LOC) for all admissions. Documentation
indicating certification must be maintained in the medical record. The
physician must also certify the medical necessity for nursing facility level of
care (NF LOC):
(A) For clients who became
eligible after admission, the physician must certify medical necessity prior to
requesting prior authorization for nursing facility level of care (NF LOC);
and
(B) Proof of prior
authorization must be maintained in the client's medical record in the facility
or building where the client resides or in the client account file.
007.24
ADMISSION
HISTORY AND PHYSICAL. The client must have a physical examination
within 48 hours after admission unless an examination was performed within five
days before admission.
007.25
SPECIFIC PAYMENTS.
007.25(A)
MEDICAID PAYMENT
RESTRICTIONS FOR NURSING FACILITIES. The Department must pay for a
nursing facility service only when prior authorized, when prior authorization
is required.
007.25(B)
INITIAL CERTIFICATION. The Department must approve
payment to a facility for services rendered to an eligible client beginning on
the latest date:
(i) The client is admitted
to the facility;
(ii) The client's
eligibility is effective, if later than the admission date; or
(iii) Of the intellectual disability
screen.
007.25(C)
DEATH ON DAY OF ADMISSION. If a client is admitted to
a facility and dies before midnight on the same day, the Department allows
payment for one day of care.
007.25(D)
INAPPROPRIATE FOR
NURSING FACILITY CARE. For those clients who, at the time of
medical review determination, no longer meet nursing facility (NF) criteria for
nursing facility (NF) services, the medical review must limit Medicaid payment
for up to a maximum of 30 days, beginning with the date the medical review
determines that nursing facility (NF) care is inappropriate. Time-limited
authorizations exceeding 30 days may be made based on the client's potential
for discharge as determined by the medical review.
007.25(E)
EFFECT OF PREADMISSION
SCREENING AND RESIDENT REVIEW (PASSR). Medicaid payment is
available for nursing facility services provided to Medicaid-eligible clients
who, as a result of Preadmission Screening and Resident Review (PASRR):
(1) Were found to require the nursing
facility level of care (NF LOC); or
(2) Were found inappropriate for nursing
facility care but through the 30-month choice have elected to remain in a
nursing facility (NF).
007.25(E)(i)
PREADMISSION
SCREENING NOT PERFORMED. When a preadmission screening and
resident review (PASRR) is not performed before admission, Medicaid payment for
nursing facility services is available only for services provided after the
preadmission screening and resident review (PASRR) is
completed.
007.25(F)
ITEMS INCLUDED IN PER DIEM RATES. The following items
are included in the per diem rate:
(i)
Routine services: Routine nursing facility (NF)
services include regular room, dietary, and nursing services; social services
and activity program as required by certification standards; minor medical
supplies; oxygen and oxygen equipment; the use of equipment and facilities; and
other routine services;
(ii)
Injections: The patient's physician must prescribe all
injections. Payment is not authorized for the administration of injections,
since giving injections is considered a part of routine nursing care and
covered by the long term care facility's reimbursement. Payment is authorized
to the drug provider for drugs used in approved injections. Syringes and
needles are necessary medical supplies and are included in the per diem
rate;
(iii)
Transportation: The facility is responsible for
ensuring that all clients receive appropriate medical care. The facility must
provide transportation to client services that are reimbursed by Medicaid. The
reasonable cost of maintaining and operating a vehicle for patient
transportation is an allowable cost and is reimbursable under the long term
care reimbursement plan;
(iv)
Contracted services: The nursing facility must
contract for services not readily available in the facility:
(1) If the service is provided by an
independent licensed provider who is enrolled in Medicaid the provider must
submit a separate claim for each person served; and
(2) If the service is provided by a certified
provider of medical care the nursing facility is responsible for payment to the
provider. This expense is an allowable cost;
(v)
Single room
accommodations: Medicaid residents should be afforded equal
opportunity to remain in or utilize single-room accommodations. Any facility
that prohibits or requires an additional charge for Medicaid utilization of
single-room accommodations must make an appropriate adjustment on its cost
report to remove the additional cost of single-room accommodations. The
facility must not make an additional charge for a therapeutically required
single room nor is the facility required to make a cost report adjustment for
this type of room. Each facility must have a written policy on single-room
accommodations for all payers.
007.25(G)
ITEMS NOT INCLUDED IN
PER DIEM RATES. Items for which payment may be made to nursing
facility (NF) providers and are not considered part of the facility's Medicaid
per diem are listed below. To be covered, the client's condition must meet the
criteria for coverage for the item as outlined in the appropriate Medicaid
provider chapter:
(i) Any non-standard
wheelchairs and wheelchair accessories, options, and components, including
power-operated vehicles needed for the client's permanent and full time use.
Standard wheelchairs are considered necessary equipment in a nursing facility
to provide care and part of the per diem;
(ii) Air fluidized bed units and low air loss
bed units; and
(iii) Negative
pressure wound therapy.
007.25(H)
PAYMENTS TO OTHER
PROVIDERS. Items for which payment may be authorized to
non-nursing facility (NF) providers and are not considered part of the
facility's Medicaid per diem are listed below. To be covered, the client's
condition must meet the criteria for coverage for the item as outlined in the
appropriate Medicaid provider chapter. The provider of the service may be
required to request prior authorization of payment for the service:
(i) Legend drugs, over-the-counter (OTC)
drugs, and compounded prescriptions, including intravenous solutions and
dilutants;
(ii) Personal appliances
and devices, if recommended in writing by a physician, such as eye glasses and
hearing aids;
(iii)
Orthoses;
(iv) Prostheses;
and
(v) Ambulance
service.
007.25(I)
MAY BE CHARGED TO RESIDENT'S FUNDS. Items that may be
charged to residents' funds and are not considered as part of the facility's
Medicaid per diem are:
(i)
Telephone;
(ii) Television and
radio for personal use, except cable service;
(iii) Personal comfort items, including
smoking materials, notions, and novelties, and confections;
(iv) Cosmetic and grooming items and services
that are specifically requested by the client and are in excess of the basic
grooming items provided by the facility;
(v) Personal clothing;
(vi) Personal reading matter;
(vii) Gifts purchased on behalf of the
client;
(viii) Flowers and
plants;
(ix) Social events and
entertainment offered outside the scope of the activities program required by
certification;
(x) Non-covered
special care services such as privately hired nurses or aides specifically
requested by the client or family;
(xi) Specially prepared or alternative food
requested instead of the food generally prepared by the facility, as required
by certification; or
(xii) Single
room, except when therapeutically required.
007.25(J)
OTHER. The
facility must meet the following requirements:
(i) The facility must not charge a client for
any item or service not requested by the resident.
(ii) The facility must not require a resident
to request any item or service as a condition of admission or continued
stay.
(iii) The facility must
inform the client requesting an item or service for which a charge will be made
that there will be a charge for the item or service and what the charge will
be.
007.25(K)
PAYMENT FOR BED-HOLDING. The Department makes payments
to reserve a bed in a nursing facility (NF) during a client's absence due to
hospitalization for an acute condition and for therapeutically-indicated home
visits. Therapeutically-indicated home visits are overnight visits with
relatives and friends or visits to participate in therapeutic or rehabilitative
programs. Payment for bed-holding is subject to the following conditions:
(1) A held bed must be vacant and counted in
the census. The census must not exceed licensed capacity;
(2) Hospital bed-holding is limited to
reimbursement for 15 days per hospitalization. Hospital bed-holding does not
apply if the transfer is to the following: nursing facility, hospital nursing
facility, swing-bed, a Medicare-covered special needs facility stay, or to
hospitalization following a Medicare-covered special needs facility
stay;
(3) Therapeutic leave
bed-holding is limited to reimbursement for 18 days per calendar year.
Bed-holding days are prorated when a client is a resident for a partial
year;
(4) A transfer from one
facility to another does not begin a new 18-day period;
(5) The client's comprehensive care plan must
provide for therapeutic leave;
(6)
Facility staff must work with the client, the client's family, or guardian to
plan the use of the allowed 18 days of therapeutic leave for the calendar year;
and
(7) Qualifying hospital and
therapeutic leave days will be reimbursed at the facility's bed-hold rate.
007.25(K)(i)
SPECIAL
LIMITS. When the limitation for therapeutic leave interferes with
an approved therapeutic or rehabilitation program, the facility may submit a
request for special limits of up to an additional six days per calendar year to
Medicaid. Requests for special limits must include:
(1) The number of leave days
requested;
(2) The need for
additional therapeutic bed-holding days;
(3) The physician's orders;
(4) The comprehensive plan of care;
and
(5) The discharge
potential.
007.25(K)(ii)
REPORTING. It is mandatory that the nursing facility
(NF) report all bedholding days monthly. Facilities must report bedholding
days. The nursing home days are adjusted to the actual number of days the
client was present in the facility at 12:00 midnight.
