Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 12 - NURSING FACILITY REGULATIONS
Section 471-12-009 - SERVICES FOR LONG TERM CARE CLIENTS WITH SPECIAL NEEDS

Universal Citation: 471 NE Admin Rules and Regs ch 12 ยง 009

Current through March 20, 2024

009.01 LONG TERM CARE CLIENTS WITH SPECIAL NEEDS. Long term care clients with special needs means those whose medical or nursing needs are complex or intensive and are above the usual level of capabilities of staff and exceed services ordinarily provided in a nursing facility.

009.01(A) VENTILATOR-DEPENDENT CLIENTS. These clients are dependent on mechanical ventilation to continue life and require intensive or complex medical services on an on-going basis. The facility shall provide 24-hour registered nurse nursing coverage.
009.01(A)(i) CRITERIA FOR CARE. The client must:
(1) Require intermittent, but not less than 10 hours in a 24-hour period, or continuous ventilator support. They are dependent on mechanical ventilation to sustain life, or is in the process of being weaned from mechanical ventilation. This does not include individuals using continuous positive airway pressure (C-PAP) or Bi-level positive airway pressure (Bi-PAP) nasally. Patients requiring use of Bi-level positive airway pressure via a tracheostomy will be considered on a case-by-case basis;

(2) Be medically stable and not require intensive acute care services;

(3) Have care needs which require multi-disciplinary care;

(4) Require daily respiratory therapy intervention or modality support; and

(5) Have needs that cannot be met at a lesser level of care.

009.01(B) CLIENTS WITH BRAIN INJURY.
009.01(B)(i) CLIENTS REQUIRING SPECIALIZED EXTENDED BRAIN INJURY REHABILITATION. These clients must require and be capable of participating in an extended rehabilitation program. Their care must be:
(1) Primarily due to a diagnosis of acute brain injury; or

(2) Primarily due to a diagnosis of chronic brain injury following demonstration of significant improvement over a period of six months while receiving rehabilitative services based on approval by Nebraska Medicaid.

009.01(B)(i)(a) CRITERIA FOR CARE. The client must:
(i) Require physician services that exceed those described in 471 NAC 12008.06;

(ii) Have needs that exceed the nursing facility level of care, that is, needs that cannot be met at a lower level of care such as a traditional nursing facility, assisted living, or a private home, as evidenced by:
(1) Complex medical needs as well as extended training or rehabilitation needs that together exceed the criteria for nursing facility level of care;

(2) Combinations of extended training or rehabilitative needs that together exceed the criteria for nursing facility level of care;

(3) Extended training or rehabilitation needs that require multi-disciplinary care; or

(4) Complex combinations of needs from various domains.

(iii) Be capable of participating in an extended training or rehabilitation program evidenced by:
(1) Ability to tolerate a full rehabilitation schedule daily;

(2) Being medically stable and free from complicating acute major medical conditions that would prohibit participation in an extended rehabilitation program;

(3) Possessing the cognitive ability to communicate some basic needs, either verbally or non-verbally;

(4) Being able to respond to simple requests with reasonable consistency, not be a danger to themselves or others, but may be confused, inappropriate, engage in non-purposeful behavior in the absence of external structure, exhibit mild agitation, or have severe attention, initiation, or memory impairment, minimum Level IV on the Rancho Los Amigos Coma Scale; or

(5) Being absent of addictive habits or behaviors that would inhibit successful participation in the training or rehabilitation program;

(iv) Have potential to benefit from an extended training or rehabilitation program resulting in reduced care needs, increased independence, and a reasonable quality of life as evidenced by:
(1) Possessing a current documented prognosis that indicates that the individual has the potential to successfully complete an extended training or rehabilitation program;

(2) Possessing the ability to learn compensatory strategies for, or to acquire skills of daily living in areas including, but not limited to transportation, money management, aide management, self medication, social skills, or other self cares which may result in requiring residency in a lower level of residential care; and

(3) Documentation supporting that they are making continuous progress in an extended training or rehabilitation program including transitional training for successful discharge or transfer.

009.01(B)(ii) CRITERIA FOR CARE OF CLIENTS REQUIRING LONG TERM CARE SERVICES FOR BRAIN INJURY. The client must:
(1) Have needs that exceed the nursing facility level of care as evidenced by:
(a) Combinations of medical, care or rehabilitative needs that together exceed the criteria for nursing facility level of care;

(b) Care that requires a specially trained, multi-disciplinary team;

(c) Complex care needs occurring in combinations from various domains; or

(d) Undetermined potential to benefit from extended training and rehabilitation program;

(2) Be capable of participating in clinical program as evidenced by:
(a) Being non-aggressive and non-agitated; and

(b) Being absent of addictive habits or behaviors that would inhibit participation in clinical program;

(3) Have potential to benefit from clinical program as evidenced by:
(a) Being cognitively aware of surroundings or events;

(b) Being able to tolerate open and stimulating environment;

(c) Being able to establish or tolerate routines;

(d) Being able to communicate verbally or non-verbally basic needs; and

(e) Requiring moderate to extensive assistance to preserve acquired skills.

009.01(C) OTHER SPECIAL NEEDS CLIENTS. These clients must require complex medical or rehabilitative care in combinations that exceed the requirements of the nursing facility level of care. These clients may also use excessive amounts of supplies, equipment, or therapies. The client must meet the criteria for one of the two following categories:
009.01(C)(i) CRITERIA FOR CARE OF CLIENTS WITH REHABILITATIVE SPECIAL NEEDS. The client must:
(1) Be medically stable and require physician services two to three times per week;

(2) Require multi-disciplinary care;

(3) Require care in multiple body organ systems;

(4) Require a complicated medical or treatment regimen, requiring observation and intervention by specially trained professionals, such as:
(a) Multiple stage 2, or at least one stage 3 or stage 4 decubiti with other complex needs;

(b) Multiple complex intravenous fluids, or nutrition with other complex needs;

(c) Tracheostomy within the past 30 day with other complex care needs;

(d) Intermittent ventilator use, less than ten hours in a 24-hour period, with other complex care needs;

(e) Respiratory therapy treatments or interventions more frequently than every six hours with other complex care needs;

(f) Initiation of Continuous Abdominal Peritoneal Dialysis (CAPD) or established Continuous Abdominal Peritoneal Dialysis requiring five or more exchanges per day with other complex care needs; or

(g) In room hemodialysis as required by a physician with other complex care needs;

(5) Require extensive use of supplies or equipment;

(6) Have professional documentation supporting that they are making continuous progress in the rehabilitation program beyond maintenance goals; and

(7) Have care needs that cannot be met at a lesser level of care.

009.01(C)(ii) CRITERIA FOR CARE OF PEDIATRIC CLIENTS WITH SPECIAL NEEDS. The client must:
(1) Be under age 21;

(2) Be medically stable;

(3) Require multidisciplinary care; and

(4) Require a complex medical or treatment regimen requiring observation and intervention by specially trained professionals, such as:
(a) Tracheostomy care or intervention with other complex needs;

(b) Intermittent ventilator use, less than ten hours in a 24-hour period, with other complex needs;

(c) Respiratory therapy treatments or interventions more than every six hours with other complex care needs; or

(d) Multiple complex care needs that in combination exceed care needs usually provided in a nursing facility.

009.01(D) EXCEPTION. Under extenuating circumstances, the Department may approve an exception to the criteria for care of long term care clients with special needs.

009.02 FACILITY QUALIFICATIONS. To be approved as a provider of services for long term care clients with special needs, a Nebraska facility providing services to special needs clients must be licensed by the Nebraska Department of Health and Human Services Regulation and Licensure as a hospital or a nursing facility and be certified to participate in the Nebraska Medical Assistance Program. Out-of-state facilities must meet licensure and certification requirements of that state's survey agency. Out-of-state placement of clients will only be considered when their special needs services are not available within the State of Nebraska as found in 471 NAC 1. The facility must demonstrate the capacity or capability to provide highly skilled multi-disciplinary care. The facility must ensure that its professional nursing staff have received appropriate training and have experience in the area of care pertinent to the individual client's special needs. The facility must have the ability to provide the necessary professional services as the client requires. The facility must:

(A) Demonstrate the capability to provide highly skilled multidisciplinary care;

(B) Ensure that its staff have received appropriate training and are competent to care for the identified special needs population that is being served;

(C) Be able to provide the necessary professional services that the special needs clients require;

(D) Have the physical plant adaptations necessary to meet the client's special needs;

(E) Establish admission criteria and discharge plans specific to each special needs population being served;

(F) Have a separate and distinct unit for the special needs program;

(G) Establish written special program criteria with policy and procedures to meet the needs of an identified special needs group as defined in this chapter;

(H) Have written policies specific to the special needs unit regarding:
(i) Emergency resuscitation;

(ii) Fire and natural disaster procedures;

(iii) Emergency electrical back-up systems;

(iv) Equipment failure;

(v) Routine and emergency laboratory or radiology services; and

(vi) Emergency transportation.

(I) Maintain the following documentation for special needs clients:
(i) A comprehensive multidisciplinary and individualized assessment of the client's needs before admission. The client's needs dictate which disciplines are involved with the assessment process. The assessment must include written identification of the client's needs that qualify the client for the special program as defined in this chapter. The initial assessment and the team's review and decisions for care must be retained in the client's permanent record;

(ii) A copy of the admission "MDS 2.0 Basic Assessment Tracking Form" (Minimum Data Set), and Form DPI-OBRA1, "Identification Screen". These are to be maintained as part of the client's permanent record;

(iii) A minimum of daily documentation or assessment or intervention by a Registered Nurse or other professional staff as dictated by the client's needs;

(iv) A record of physician's visits; and

(v) A record of interdisciplinary team meetings to evaluate the client's response and success toward achieving the identified program goals and the team's revisions, additions, or deletions to the established program plan;

(J) Maintain financial records; and

(K) Provide support services necessary to meet the care needs of each individual client and these must be provided under existing contracts or by facility staff as required by Medicare and Medicaid for nursing facility certification.

009.03 APPROVAL PROCESS. Nebraska Medicaid pays for a special need nursing facility service when prior authorized. Each admission shall be individually prior authorized.

009.03(A) PRIOR TO ADMISSION. A written comprehensive and individualized assessment completed by the facility must be sent to the Department. The assessment and accompanying documentation must address how the client meets the criteria for special needs care as defined in this chapter. It is the facility's responsibility to assess, gather and obtain this information and submit it to the Department for prior authorization and before admission. Initial approval or denial will be given after Medicaid staff reviews the submitted information. It is the facility's responsibility to obtain and provide any missing or additional information requested by the Department. The initial approval will be delayed until all information is received by the Department. The Pre-Admission Screening Level I Screen and Level II Evaluation, when applicable, must be completed before admission and the Level II findings and reports must accompany the packet of information sent to the Department for funding authorization.
009.03(A)(i) OTHER CLIENTS. Facilities serving the needs of individuals who are ventilator-dependent and other special needs clients must include the individualized admission assessment completed by the facility and other documentation which must include:
(1) Current medical information that documents the client's current care needs;

(2) Historical information that impacts the client's care needs;

(3) Discharge summary of any facility stays within the past 6 months;

(4) Current physical, cognitive, or behavioral status;

(5) Justification for special needs level of care; and

(6) Identification of major areas of preliminary care planning and an estimate of services needed to reach the proposed goals.

009.03(A)(ii) BRAIN INJURIES. Facilities serving the needs of clients with brain injuries shall submit the individualized admission assessment completed by the facility and the following documentation which must include:
(1) Current medical information that documents the client's current care needs, including a letter from the client's primary care physician indicating the potential for successful rehabilitation;

(2) Historical information that impacts the client's care needs;

(3) Discharge summaries of any facility stays within the past year;

(4) All discharge or service summaries of any rehabilitative services received since the qualifying injury;

(5) An Individualized Educational Plan (IEP) of any client under age 21 if one exists;

(6) An Individual Program Plan (IPP) and discharge statement or meeting for any client receiving or who has received services from the Developmental Disabilities System since the qualifying injury;

(7) The written plan from Vocational Rehabilitative services if the client is receiving or has received since the qualifying injury;

(8) Current physical, cognitive, or behavior status; and

(9) Identification of major areas of preliminary care planning and an estimate of services needed to reach the proposed goals.

009.03(B) INITIAL APPROVAL. Based on the pre-admission assessment, initial approval or denial will be given by the Department for a 90-day admission, for assessment and development of a special needs plan of care. During this 90-day period, the individual will be receiving special needs care for the purposes of determining the potential for benefit from longer-term participation in the special needs program. At the end of 30 days, the Department will be provided a special needs formal plan of care, developed by the full interdisciplinary team. By the end of the 60th day, a report will be provided to the Department establishing demonstrated potential to benefit from the additional special needs programming, and estimating the time needed to complete the special needs plan of care, or recommendations to a lesser level of care.
009.03(B)(i) IN-STATE FACILITY PLACEMENT. Within 15 days of the date of admission to the nursing facility or the date Medicaid eligibility is determined facility staff shall:
(1) Complete an admission Form MC-9-NF or submit electronically the standard Health Care Services Review Request for Review and Response transaction (ASC X12N 278);

(2) Attach a copy of Form DM-5 or physician's history and physical;

(3) Attach a copy of Form DPI-OBRA1; and

(4) Submit all information to the Department.

009.03(B)(i)(a) ASSESSMENT. Facility staff must make a comprehensive assessment of the resident's needs within 14 days of admission, using the Minimum Data Set (MDS), and transmit it electronically to the Department.

009.03(B)(i)(b) APPROVAL. The Department shall determine final approval for the level of care and return the forms to the local office and the facility. Approval of payment may be time-limited.

009.03(B)(ii) OUT-OF-STATE FACILITY PLACEMENT. Within 15 days of the date of admission to the nursing facility or the date Medicaid eligibility is determined, facility staff shall:
(1) Complete an admission Form MC-9-NF or submit electronically the standard Health Care Services Review Request for Review and Response transaction (ASC X12N 278);

(2) Attach a copy of Form DM-5 or physician's history and physical;

(3) Attach a copy of Form DPI-OBRA1 where applicable;

(4) Attach a copy of their state-approved Minimum Data Set; and

(5) Submit all information to the Department.

009.03(B)(ii)(a) APPROVAL. The Department shall determine final approval for the level of care and return the forms to the local office and the facility. Approval of payment may be time-limited.

009.04 UTILIZATION REVIEW. The Department will review records and programs established for authorized Medicaid client stays in a Special Needs program on a quarterly basis. These reviews can be conducted on-site or by submitting requested documentation to the Department. Upon completion of a review, Department staff may determine that a client no longer meets the criteria as established in this chapter. The Department will notify the facility in writing of this finding.

009.04(A) COMPREHENSIVE PLAN OF CARE. The facility must submit copies of the initial comprehensive plan of care and subsequent interdisciplinary team meetings that document the client's progress or lack of progress toward the client's established program outcomes or goals to the Department quarterly.
009.04(A)(i) MONTHLY REVIEWS. Nebraska Medicaid requires monthly reviews for extended brain injury rehabilitation stays beyond two years.

009.04(A)(ii) RIGHT TO CONTEST A DECISION. See 471 NAC 2.

009.05 PAYMENT FOR SERVICES FOR LONG TERM CARE CLIENTS WITH SPECIAL NEEDS. Payment for services to all special needs clients must be prior authorized by the Department.

009.05(A) OUT-OF-STATE FACILITIES. The Department pays out-of-state facilities participating in Medicaid at a rate established by that state's Medicaid program at the time of the establishment of the Nebraska Medicaid provider agreement. The payment is not subject to any type of adjustment.

009.06 ALL REQUIREMENTS APPLY. The requirements of 471 NAC 12 apply to services provided under 471 NAC 12.010 unless otherwise specified in 471 NAC 12.010.

009.07 IN-HOME SERVICES FOR CERTAIN DISABLED CHILDREN. This section applies to children age 18 or younger with severe disabilities living in their parents' home, also referred to as the "Katie Beckett" program. Services for special needs children are a skilled level of care provided by a certified Home Health agency, licensed registered nurses or licensed practical nurses. These providers must have necessary training and experience in the care of ventilator-dependent, pulmonary, or other special needs clients. This level of care is highly skilled, provided by professionals in amounts not normally available in a skilled nursing facility, but available in the hospital. Lack of these services would normally result in continued hospitalization or institutionalization of these children. The cost of in-home services must be less than the cost of hospitalization. The child must meet one of the following definitions to qualify for the Katie Beckett program:

(1) Ventilator-Dependent Clients: These clients are ventilator-dependent and require intensive medical services or continual observation on an on-going basis;

(2) Pulmonary Clients: These clients must require complex respiratory or medical care, in combinations which exceed the needs of the skilled nursing client. These clients may also use excessive amounts of supplies and equipment; or

(3) Other Special Needs Clients: The clients must require complex medical or rehabilitative care in combinations, which exceed the requirements of the skilled nursing client. These clients may also use excessive amounts of supplies, equipment, or therapies.

009.07(A) APPROVAL. Department approval for this level of care is required.

009.08 INTERMEDIATE SPECIALIZED SERVICES FOR PERSONS WITH SERIOUS MENTAL ILLNESS. Nebraska Medicaid covers intermediate specialized services (ISS) for persons with serious mental illness. Intermediate Specialized Services (ISS) are covered for those individuals who have been identified by the Level II Preadmission Screening and Resident Review (PASRR) evaluation and through the Intermediate Specialized Services (ISS) evaluation process as needing services to maintain or improve their behavioral or functional levels above and beyond services that nursing facilities normally provide, but who do not require the continuous and aggressive implementation of an individualized plan of care, as "specialized add-on services" is defined by Preadmission Screening and Resident Review (PASRR) regulations in this chapter. These individuals need more support than nursing facilities would normally provide, but not at a "specialized services" level.

009.08(A) ALL REQUIREMENTS APPLY. The requirements of 471 NAC 12 apply to Intermediate Specialized Services (ISS) providers unless otherwise specified.

009.08(B) INTERMEDIATE SPECIALIZED SERVICES (ISS) FOR INDIVIDUALS WITH SERIOUS MENTAL ILLNESS. Intermediate Intensive Treatment Services (ISS) for Individuals with Serious Mental Illness means services necessary to prevent avoidable physical and mental deterioration and to assist clients in obtaining or maintaining their highest practicable level of functional and psycho-social well being. Services are characterized by:
(i) The client's regular participation, in accordance with their comprehensive care plan, in professionally developed and supervised activities, experiences, and therapies; and

(ii) Activities, experiences, and therapies that reduce the client's psychiatric and behavioral symptoms, improve the level of independent functioning, and achieve a functional level that permits reduction in the need for intensive mental health services.

009.08(C) PROGRAM COMPONENTS. Intermediate Specialized Services (ISS) is designed to:
(i) Provide and develop the necessary services and supports to enable clients to reside successfully in a nursing facility without the need of more intensive services;

(ii) Maximize the client's participation in community activity opportunities, and improve or maintain daily living skills and quality of life;

(iii) Facilitate communication and coordination between any providers that serve the same client;

(iv) Decrease the frequency and duration of hospitalization and inpatient mental health (MH) services;

(v) Provide client advocacy, ensure continuity of care, support clients in time of crisis, provide and procure skill training, ensure the acquisition of necessary resources, and assist the client in achieving social integration;

(vi) Expand the individual's comprehensive care plan to assure that it includes interventions to address: community living skills, daily living skills, interpersonal skills, psychiatric emergency and relapse, medication management including recognition of signs of relapse and control of symptoms, mental health services, substance abuse services, and other related areas necessary for successful living in the community;

(vii) Provide the individualized support and rehabilitative interventions as identified through the comprehensive care planning process to address client needs in the areas of: community living skills, daily living skills, interpersonal skills, psychiatric emergency and relapse, medication management including recognition of signs of relapse and control of symptoms, mental health services, substance abuse services, and other related services necessary for successful living in the community;

(viii) Monitor client progress in the services being received and facilitate revision to the comprehensive care plan as needed;

(ix) Provide therapeutic support and intervention to the client in time of crisis and, if hospitalization is necessary, facilitate, in cooperation with the inpatient treatment provider, the client's transition back into the client's place of residence upon discharge;

(x) Establish hours of service delivery that ensure program staff are accessible and responsive to the needs of the client, including scheduled services that include evening and weekend hours; and

(xi) Provide or otherwise demonstrate that each client has on call access to a mental health provider on a 24 hour, 7 days per week basis.

009.08(D) CRITERIA FOR ISS. For Intermediate Specialized Services (ISS), the client must have been evaluated through the Preadmission Screening and Resident Review (PASRR) process and the Intermediate Specialized Services (ISS) evaluation process, and been determined to not need intensive treatment services based on the outcomes of the Level II evaluation and the Intermediate Specialized (ISS) Services Evaluation Process. The Intermediate Specialized Services (ISS) Evaluation Process must include evaluation by a team which must consider an individual's long term residence in a mental health facility, higher levels of aggression, and higher levels of medical need. The client must be currently diagnosed with a mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within the current version of DSM or ICD-9-CM equivalent except DSM "V" codes, substance use disorders, developmental disorders, and dementia which are excluded, unless they co-occur with another diagnosable serious mental illness.

009.08(E) COMPREHENSIVE CARE PLAN DEVELOPMENT. The Department or its designee will refer clients authorized for Intermediate Specialized Services (ISS) to the most appropriate providers, consistent with client choice. The Intermediate Specialized Services (ISS) provider must work with the client to complete a comprehensive care plan that includes:
(i) An assessment of the client's strengths and needs in that service domain according to the requirements of the Level II evaluation and the Intermediate Specialized Services evaluation process; and

(ii) The Resident Assessment.

009.08(F) MOVEMENT BETWEEN INTENSIVE TREATMENT SERVICES, INTERMEDIATE SPECIALIZED SERVICES (ISS), AND REGULAR NURSING FACILITY SERVICES. Individuals' needs change over time and level of service intensity must change to appropriately meet those needs. Nursing facility staff and other service providers must identify changes in level of need as they occur. Such changes would include a decline in psychiatric stability that requires intensive treatment services or marked decrease in the need for Intermediate Specialized Services (ISS).
009.08(F)(i) INCREASE IN SERVICE NEEDS. Nursing facility staff must request review by the consulting psychiatrist when Intermediate Specialized Services (ISS) are not sufficient to meet a client's needs. Based on the findings of the consulting psychiatrist, the client may be moved to an inpatient facility for receipt of intensive treatment services.
009.08(F)(i)(1) RETURNING FROM RECEIVING INTENSIVE TREATMENT SERVICES FOR MENTAL ILLNESS. For Intermediate Specialized Services (ISS) clients, this process must follow procedures at 471 NAC 12-007.09(A) and 12-010.08(D).

009.08(F)(ii) DECREASE IN SERVICE NEEDS. When the need for Intermediate Specialized Services (ISS) decreases, regular services that the nursing facility would normally provide may be sufficient. In addition to the normal discharge planning process, Intermediate Specialized Services (ISS) facility staff must request review by the Intermediate Specialized Services (ISS) evaluation team. With the team's approval, the client may be transferred to regular nursing facility services.

009.08(G) TRANSFERS. For Intermediate Specialized Services (ISS) clients, transfers between nursing facilities will not require a Level I screen or Level II Preadmission Screening and Resident Review (PASRR) evaluation. A Tracking Form must be completed and faxed to the Department for clients with a Preadmission Screening and Resident Review (PASRR) determination.

009.08(H) STANDARDS FOR PROVIDER PARTICIPATION. Intermediate Specialized Services (ISS) providers may be any nursing facility certified to participate in Medicaid and Medicare. If the Intermediate Specialized Services (ISS) provider subcontracts with service providers, they must be Medicaid enrolled providers. All providers of Intermediate Specialized Services (ISS) must be approved and meet all applicable requirements under Title 471 NAC 2, Provider Participation and other applicable sections of the NAC. However, for the purposes of effectiveness and efficiency in delivering these services, the Department approves Intermediate Specialized Services (ISS) providers through a proposal process, and certifies all or part of a facility to provide Intermediate Specialized Services (ISS). The Department will announce, through public notice, when it will entertain facility proposals. These announcements will detail to potential Intermediate Specialized Services (ISS) providers the primary locations, number of beds, architectural standards, staffing requirements, and any other information to assist facilities with their proposals.

009.08(I) STAFF REQUIREMENTS. The facility must maintain a sufficient number of staff with the required training, competencies, and skills necessary to meet the client's needs. Training must be approved by the Department and specific to the delivery of Intermediate Specialized Services (ISS) and related mental health services. At a minimum, the Intermediate Specialized Services (ISS) facility must have a consulting psychiatrist. It must develop and implement a comprehensive care plan for each Intermediate Specialized Services (ISS) client, ensure necessary monitoring and evaluation and must modify the care plan when appropriate. Staff must have the skills to care for the clients, know how to respond to emergency and crisis situations and fully understand client rights. The facility must provide care and treatment to clients in a safe and timely manner and maintain a safe and secure environment for all residents.
009.08(I)(i) STAFF CREDENTIALING. The facility must ensure that:
(1) Any staff person providing a service for which a license, certification, registration, or credential is required holds the license, certification, registration, or credential in accordance with applicable state laws;

(2) The staff have the appropriate license, certification, registration, or credential before providing a service to clients including training specific to the delivery of Intermediate Specialized Services and related mental health services; and

(3) It maintains evidence of the staff having appropriate license, certification, registration, or credential.

009.08(I)(ii) INITIAL ORIENTATION. The facility must provide staff with orientation before the staff person having direct responsibility for care and treatment of clients receiving Intermediate Specialized Services (ISS) provides services to clients. The training must include:
(1) Client rights;

(2) Job responsibilities relating to care and treatment programs and client interactions;

(3) Emergency procedures including information regarding availability and notification;

(4) Information on any physical and mental special needs of the clients of the facility;

(5) Information on abuse, neglect, and misappropriation of money or property of a client and the reporting procedures;

(6) De-escalation techniques;

(7) Crisis intervention strategies;

(8) Behavior management planning and techniques;

(9) The role of medication in psychiatric treatment;

(10) Cardiopulmonary resuscitation and medical first aid; and

(11) Strength-based services and the recovery model.

009.08(I)(iii) DOCUMENTATION. The facility must maintain documentation of staff initial orientation and training.

009.08(I)(iv) ONGOING TRAINING. The facility must provide each staff person ongoing training in topics appropriate to the staff person's job duties, including meeting the needs, preferences, and protecting the rights of the clients in the facility.

009.08(J) CLIENT RIGHTS. The facility must ensure that clients rights are ensured in accordance with 42 CFR 483.10 and 175 NAC 12.

009.08(K) UTILIZATION REVIEW. The Department or its designee will provide utilization review for Intermediate Specialized Services (ISS). This includes assessing the appropriateness of the intensity of services and providing ongoing utilization review of the client's progress in relation to the comprehensive care plan. At least annually, the Department or its designee will reassess clients receiving Intermediate Specialized Services (ISS), and will review and approve new service recommendations and continued eligibility for Intermediate Specialized Services (ISS).

009.08(L) PAYMENT. The Department pays for Intermediate Specialized Services (ISS) as specified in this chapter.

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