Current through Register Vol. 56, No. 18, September 16, 2024
(a)
Clinical eligibility for adult day health services shall be contingent upon receipt of prior authorization
from the Department on the basis of:
1. The results of an assessment of the
individual using an instrument prescribed by the Department and the eligibility criteria specified at (f)
below. The prescribed assessment instrument is designed to collect standardized information on a broad range
of domains critical to caring for individuals in the community, including items related to cognition;
communication/hearing; vision; mood and behavior; social functioning; informal support services; physical
functioning; continence; disease diagnoses; health conditions; preventive health measures;
nutrition/hydration; dental status; skin condition; environment/home safety; service utilization;
medications; and socio-demographic/background information; and
2.
The Department's evaluation and consideration of information received from either the facility RN, the
individual and/or the individual's legally authorized representative, personal physician or other healthcare
professional who has current and relevant knowledge of the individual, the individual's medical or
psychosocial needs and the individual's ADL or cognitive deficits. Such information may be considered by the
Department along with the results of the assessment performed in (a)1 above and the eligibility criteria in
(f) below as the basis for determining clinical eligibility for adult day health services.
(b) Clinical eligibility assessments shall be performed by
professional staff designated by the Department prior to the initial provision of ADHS to an individual, at
least annually after the initial authorization of services and, in accordance with (b)2 below, when a
beneficiary presents a change in status that may alter the beneficiary's eligibility to receive ADHS.
1. ADHS facilities shall retain, as part of each beneficiary's permanent
record, a signed acknowledgement of the beneficiary or the beneficiary's legally authorized representative,
as appropriate, that a determination of eligibility to receive ADHS is not permanent and that
redeterminations will be made on the basis of subsequent assessments.
2. When an adult beneficiary presents a change in status that facility
staff document in the plan of care pursuant to
N.J.A.C.
8:43F-5.4 and that may alter the beneficiary's eligibility to receive ADHS,
the facility shall:
i. Discharge the beneficiary pursuant to N.J.A.C.
8:43F; or
ii. Contact the Department to request a clinical
eligibility assessment for that beneficiary by submitting a pre-numbered prior authorization request form in
accordance with
N.J.A.C. 10:164-1.3(a)3
and providing the reason for the request.
(c) Professional staff designated by the Department may include staff of an
ADHS facility authorized by the Department to perform clinical eligibility assessments on behalf of the
Department in accordance with (d) below.
(d) The Department, for
reasons of administrative convenience, may authorize staff of an ADHS facility to perform the clinical
eligibility assessment for prior authorization on the Department's behalf.
1. If the Department expressly authorizes an ADHS facility to perform, and
if the facility agrees to perform, such clinical eligibility assessments, the facility shall satisfy each of
the conditions at (d)2 through 9 below.
2. An RN employed by the
facility shall perform the clinical eligibility assessment using the assessment instrument prescribed by the
Department.
3. The RN shall perform the clinical eligibility
assessment prior to initial provision of ADHS to the individual, at least annually thereafter, and when an
adult beneficiary presents a change in status that facility staff document in the plan of care pursuant to
N.J.A.C.
8:43F-5.4 that may alter the beneficiary's eligibility to receive
ADHS.
4. The RN shall include documentation from the assessment
and evaluation required by this section in the individual's medical record.
5. An initial assessment performed by ADHS facility staff shall include a
visit to the individual's home.
6. The RN performing the clinical
eligibility assessment may delegate the home visit component of the assessment, provided an RN who elects to
delegate the home visit component of the assessment shall make the delegation in accordance with
N.J.S.A.
45:11-26, which provides the licensure requirements of the New Jersey State
Board of Nursing, and
N.J.A.C. 13:37-6.2, and
only to a person holding New Jersey licensure or certification, as applicable, in good standing, as an
advanced practice nurse, a licensed practical nurse, a licensed social worker, a licensed clinical social
worker, or a certified social worker.
7. The home visit shall
include assessment of at least the following:
i. Living
arrangements;
ii. The individual's relationship with his or her
family;
iii. The individual's home environment;
iv. The existence of environmental barriers, such as stairs, not negotiable
by the individual;
v. Access to transportation, shopping,
religious, social, or other resources to meet the needs of the individual; and
vi. Other home care services received, including documentation of the
frequency and amount of each service received;
8. The
RN who performs the clinical eligibility assessment and the ADHS facility administrator shall sign the
assessment instrument prescribed by the Department used for an individual or beneficiary's clinical
eligibility assessment and shall submit the assessment to the following address:
Adult Day Health Services Program Office of Community Choice Options NJ
Department of Human Services PO Box 807 Trenton, NJ 08625-0807.
9. The facility administrator shall certify whether or not the individual
has been determined eligible to receive ADHS.
i. The Department shall
presume the determination of the facility to be accurate, with the understanding that the Department retains
ultimate authority with respect to determinations of eligibility and shall conduct audits of facility
determinations of eligibility through on-site visits, which may include review of facility records and
interviews with beneficiaries; and
ii. Any facility found to be
in default of this section, including, but not limited to, certifications that are intentionally misleading
or false, shall be subject to remedies that may be imposed pursuant to
N.J.A.C. 8:43F-2.8, N.J.A.C. 10:49 or
any other applicable provision of law.
10.
Departmental authorization for facility staff to perform eligibility assessments shall not preclude the
Department from withdrawing such authorization if the facility is found in default as provided in (d)9 above
or at such time as the Department, with due notice to the affected facility, decides that the Department will
resume performing prior authorization by Department staff.
11.
When an ADHS facility determines after its performance of a clinical assessment that an individual is
ineligible to receive ADHS, the individual may advise the facility that he or she believes that the
facility's performance of the eligibility assessment prescribed by the Department has resulted in an inequity
or erroneous determination.
i. Upon the facility's receipt of this advice,
the facility shall submit to the completed assessment, any documents that the individual wants the Department
to consider, and documentation identifying the individual's issues, signed by the individual, to the
Department for review;
ii. The facility shall request Department
review of the clinical eligibility assessment the facility performed on behalf of the individual within five
business days of notification of ineligibility by the facility to the Regional Office of Community Choice
Options, Department of Human Services, Division of Aging Services, serving the beneficiary's county of
residence;
iii. Appropriate professional staff of the Department
shall conduct a review of the assessment and the supporting documentation;
iv. Both the individual and the facility should be prepared to provide such
substantiating information as may be required for an informal discussion of the issues; and
v. Department staff shall make a determination to uphold or overturn the
facility's assessment and shall notify both the individual and the facility within 15 business days of
receipt of the requested documentation.
(e) An individual shall have an opportunity for a fair hearing if he or she
is not satisfied with the determination made by professional staff designated by the Department, in
accordance with (b) and (d)11 above; or if the services provided to the individual in an adult day health
services facility have been terminated, reduced or suspended.
1. Subject to
(e)2 below, an individual must submit a request for an administrative hearing pursuant to N.J.A.C. 10:49-10
and the Uniform Administrative Procedure Rules, N.J.A.C. 1:1.
2.
Individuals enrolled in HCEP or JACC must submit a request for an administrative hearing pursuant to the
Uniform Administrative Procedure Rules, N.J.A.C. 1:1.
3. A
request for an administrative hearing shall be considered timely filed if it is submitted within 20 days:
i. From the date of notification of the Departmental determination based on
a review of the facility's assessment;
ii. From the date of
notification of the direct determination of ineligibility by professional staff designated by the Department;
or
iii. From the date that the individual receives notice that
his or her services in an adult day health services facility have been terminated, reduced or
suspended.
4. At the administrative hearing, the
burden is upon the individual to demonstrate eligibility for ADHS under the eligibility criteria at (f)
below.
5. The individual may request that the matter be settled
in lieu of conducting an administrative hearing concerning the contested action. If the Department and the
individual agree on the terms of a settlement, a written agreement specifying the terms thereof shall be
executed.
(f) An adult shall be eligible for ADHS and
the Department shall approve the request for prior authorization referenced in
N.J.A.C. 10:164-1.3(a)3
if the adult shall have been determined eligible for or enrolled in one of
the programs specified at
N.J.A.C.
10:164-1.1(b), shall not have been determined ineligible
to receive ADHS pursuant to N.J.A.C. 10:164-1.5(g), and shall have been determined clinically eligible for
ADHS by professional staff designated by the Department, on the basis of having been assessed as requiring at
least one of the following:
1. At least limited assistance in a minimum of
two ADLs and the facility will provide all of the assistance for the claimed ADLs on-site in the
facility;
2. At least one skilled service provided daily on-site
in the facility;
3. Rehabilitation services to attain a
particular treatment goal(s) for a specified time-limited period as ordered by the individual's attending
physician, physician assistant, or advanced practice nurse; or
4. Supervision/cueing in at least three ADLs and the facility will provide
all of the supervision/cueing for the claimed ADLs on-site in the facility; and, as identified by the
assessment instrument prescribed by the Department, the individual:
i.
Exhibits problems with short-term memory following multitask sequences, and in daily decision-making in new
situations.
(g) An individual shall be
ineligible for ADHS if (g)1, 2, or 3 below applies to the individual:
1.
Admission of the individual to an ADHS facility would result in the individual receiving a service(s) that is
duplicative or redundant of any other Medicaid-funded service(s) that the individual has chosen;
i. Examples of services, programs and ambulatory care settings that may
constitute duplicative or redundant services include, but are not limited to, services provided in an
individual's home, by a personal care attendant, in the office of a physician, in a hospital outpatient
department, at a partial care/partial hospitalization program, and/or in an adult day training
program;
2. The individual resides at a residential
health care facility; or
3. The individual requires and is
receiving care 24 hours per day on an inpatient basis in a hospital or nursing home.
(h) In order to be eligible for services in an HIV adult day health
services facility, an individual shall be at least 18 years of age with HIV infection, eligible for adult day
health services in accordance with
N.J.A.C.
10:164-1.1(b), and require outpatient drug abuse
treatment.
