New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 164 - ADULT DAY HEALTH SERVICES
Subchapter 1 - GENERAL PROVISIONS
Section 10:164-1.3 - Program participation and evaluation

Universal Citation: NJ Admin Code 10:164-1.3

Current through Register Vol. 56, No. 18, September 16, 2024

(a) An adult day health services facility shall meet the following requirements in order to participate in the New Jersey Medicaid, HCEP or JACC programs:

1. Licensure and approval by the Department in accordance with the Standards for Licensure of Adult Day Health Services Facilities at N.J.A.C. 8:43F;

2. Completion of the New Jersey Medicaid Provider Application PE-1 (chapter Appendix A, incorporated herein by reference), the Participation Agreement PE-5 (chapter Appendix B, incorporated herein by reference) and a written narrative Statement on the Proposed Adult Day Health Services Facility (chapter Appendix C, incorporated herein by reference) and approval as a Medicaid adult day health services provider by the Department. The New Jersey Medicaid Provider Application (PE-1) and the Participation Agreement (PE-5) are also available by contacting Unisys for Medicaid participation at (800) 776-6334 and on the Worldwide Web at www.njmmis.com. Ongoing participation as a provider is contingent upon continued licensure and approval by the Department;
i. Adult day health services facilities providing services to JACC participants shall also be approved as a JACC provider/vendor by the Department.

3. For ADHS facilities, completion of a pre-numbered prior authorization request form for every individual or beneficiary to whom an ADHS facility intends to provide ADHS under the ADHS program prior to the initial provision of ADHS or the continuation of such services after an existing prior authorization term ends.
i. Pre-numbered prior authorization request forms are available upon request from UNISYS at (800) 776-6334 or on the Worldwide Web at www.njmmis.com.

ii. A facility shall contact the case or care manager for an adult individual or beneficiary who is a participant of any program listed at N.J.A.C. 10:164-1.1(b) that requires case or care management to obtain the date that the individual or adult beneficiary may begin receiving ADHS and the number of days per week he or she may receive such services as identified by his or her case or care manager pursuant to (a)3ii(1) below.
(1) The case or care manager for an individual or adult beneficiary who is a participant of any program listed at N.J.A.C. 10:164-1.1(b) that requires case or care management shall identify for an ADHS facility the number of days per week, not to exceed five days per week pursuant to N.J.A.C. 10:164-1.4(a)3, and the date the individual or adult beneficiary may begin receiving ADHS if professional staff designated by the Department determine the individual or adult beneficiary is clinically eligible and the individual or adult beneficiary is determined to have obtained prior authorization for ADHS pursuant to N.J.A.C. 10:164-1.5(f).

iii. An ADHS facility shall submit a completed pre-numbered prior authorization request form to the Department via telefacsimile at (609) 984-3897 or electronically, as specified by the Department, to the attention of the Office of Community Choice Options, Adult Day Health Services Program.

iv. An ADHS facility shall provide the following information on the pre-numbered prior authorization request form:
(1) An individual's or beneficiary's biographical and contact information, such as first and last name, address, telephone number, and social security number;

(2) The type of assistance an individual or beneficiary requires with regard to the ADLs, skilled services, or rehabilitation services, as provided at N.J.A.C. 10:164-1.5(f);

(3) The contact information for the ADHS facility completing the pre-numbered prior authorization form, including the name and telephone and telefacsimile numbers of the facility, and title of the individual completing the form; and

(4) The scope and type of ADHS the facility intends to provide to that individual or beneficiary pursuant to N.J.A.C. 10:164-1.5(f).

v. Submission of a pre-numbered prior authorization request form is the only mechanism for notifying the Department that:
(1) An ADHS facility is seeking prior authorization to provide ADHS to an individual or beneficiary who requires a clinical eligibility assessment for prior authorization pursuant to N.J.A.C. 10:164-1.5; or

(2) An ADHS facility is seeking prior authorization to provide ADHS to a beneficiary who wishes to transfer from another adult ADHS facility pursuant to N.J.A.C. 10:164-1.7.

4. Maintenance of a daily attendance record that includes the printed name and the arrival and departure times of each beneficiary attending on that day, signed by each adult beneficiary in acknowledgement of the beneficiary having been present for the time indicated and submission to the Department upon request of the Department of a completed Day Health Services Monthly Attendance Roster form CSS-11 posted at www.nj.gov/health/forms, with respect to all beneficiaries who attended at least one day that month.
i. The Day Health Services Monthly Attendance Roster form requires ADHS facilities to provide the following information: the name of the facility, the applicable month, the name of and Medicaid number for each beneficiary and each day the beneficiary attended the facility during the month of the roster.

ii. If an adult beneficiary is unable to sign the daily attendance record, the administrator of the facility or his or her designee shall attest in writing to the accuracy of the indicated arrival and departure times of the beneficiary, and the signed attestation shall be included as part of the daily attendance record maintained by the facility; and

5. Preparation of a complete financial statement and a cost report, annually detailing expenditures of the adult day health services facility. Adult day health services facility costs shall be segregated from other operational costs. (Department reimbursement rates may be based on cost report information or on a percentage of nursing facility per diem rates.) Cost reports shall be signed by the administrator or an officer of the facility. Cost reports shall include a statement that adult day health services costs have been verified as to type and amount. Financial statements shall be signed by a certified public accountant(s) licensed in accordance with N.J.A.C. 13:29. Financial statements shall include a statement that the financial statement has been prepared in accordance with generally accepted accounting principles and that all adult day health services costs have been verified as to type and amount.
i. Cost reports and financial statements shall be maintained at the facility and shall be available for review by, or submission to, the Department upon request.

(b) The Department shall conduct an ongoing evaluation of the facility's day care program by on-site visits to the adult day health services facility. The Department shall inform the adult day health services facility, in writing, of the results of the on-site evaluation.

(c) Department staff may request a plan of correction if the facility is evaluated as providing substandard services and/or inadequate documentation of these services or otherwise violates any applicable regulations. The plan of correction shall address deficiencies noted by Department staff, and shall be submitted to the Department by the facility by the requested date.

1. If a follow-up on-site visit reveals that the plan of correction is not being implemented, the Department shall take enforcement actions in accordance with N.J.A.C. 8:43E, General Licensure Procedures and Enforcement of Licensure Regulations.

(d) Non-compliance with the Department's rules at N.J.A.C. 8:43F or 10:164 may result in sanctions and remedies being imposed as provided in the Medicaid Administration Manual found at N.J.A.C. 10:49, General Licensure Procedures and Enforcement of Licensure Regulations found at N.J.A.C 8:43E or any other applicable law or regulation.

(e) Providers wishing to contest decisions made by the Department pursuant to this section may request a fair hearing pursuant to the procedures set forth below:

1. If sanctions and remedies have been imposed under the Medicaid Administration Manual, then the adult day health services facility must submit a request for a hearing pursuant to N.J.A.C. 10:49-10 and the Uniform Administrative Procedure Rules, N.J.A.C. 1:1.

2. If sanctions and remedies have been imposed pursuant to N.J.A.C. 8:43F-2.8, then the adult day health services facility must submit a request for a hearing pursuant to N.J.A.C. 8:43F-2.9, 8:43E and the Uniform Administrative Procedure Rules, N.J.A.C. 1:1.

3. The provider may request that the matter be settled in lieu of conducting an administrative hearing concerning the contested action. If the Department and the facility agree on the terms of a settlement, a written agreement specifying the terms thereof shall be executed.

(f) Caregivers of beneficiaries or the beneficiaries themselves may be contacted by Department staff to determine appropriateness of care and satisfaction with services provided.

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