Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1181 - NURSING FACILITY CARE
Subchapter A - NURSING FACILITY CARE
PAYMENT FOR NURSING FACILITY CARE
Section 1181.53 - Payment conditions related to the recipient's initial need for care

Universal Citation: 55 PA Code ยง 1181.53

Current through Register Vol. 54, No. 44, November 2, 2024

(a) Certification of need for care. For skilled, heavy care/intermediate, intermediate and intermediate care for the mentally retarded levels of care, a physician, or a nurse practitioner or clinical nurse specialist who is not an employe of the facility but is working in collaboration with a physician, shall certify in writing on the medical record that the applicant or recipient needs skilled, heavy care/intermediate, intermediate care or intermediate care for the mentally retarded as applicable. The certification shall be signed and dated by a physician, or a nurse practitioner or clinical nurse specialist who is not an employe of the facility but is working in collaboration with a physician, not more than 30 days prior to the admission of an applicant or recipient to a facility, or, if an individual applies for assistance while in a facility before the Department authorizes payment for nursing facility care or intermediate care for the mentally retarded.

(b) Medical evaluation. The medical evaluation shall consist of the following:

(1) Before admission to a facility for skilled nursing care or before authorization of payment, the attending physician shall make a medical evaluation of the applicant's or recipient's need for skilled nursing care.

(2) Before the latter of the admission of an applicant or recipient to a skilled nursing facility or the Department's authorization of payment for skilled nursing care, an applicant or recipient shall be determined to be medically eligible for skilled nursing care in accordance with the criteria specified in Appendix E (relating to skilled nursing care). Skilled Nursing Care Assessment forms which are designed to enable the Department to determine whether the criteria specified in Appendix E are met by a recipient, will be supplied by the Department. The form shall be completed by a physician.

(3) Before admission to a facility for heavy care/intermediate, intermediate care or intermediate care for the mentally retarded, or before authorization for payment, an interdisciplinary team of health professionals shall make a comprehensive medical and social evaluation and, when appropriate, a psychological evaluation of each applicant's or recipient's need for heavy care/intermediate, intermediate care or intermediate care for the mentally retarded. In an intermediate care facility for the mentally retarded, the team shall also make a psychological evaluation of need for care.

(4) The following criteria shall be met before a person qualifies for an intermediate care facility for the mentally retarded level (ICF/MR) of care:
(i) The applicant or recipient has a diagnosis of mental retardation.

(ii) The applicant or recipient requires active treatment.

(iii) The applicant or recipient is recommended for an ICF/MR level of care based on medical evaluation as specified in Appendix Q (Reserved).

(5) The evaluations required in this subsection shall be recorded on the patient's medical record and on forms issued by the Department and forwarded to the Department for review and assessment. The Department's Review Team will evaluate the need for admission and authorize payment for the appropriate level of care.

(6) The Department will send a written notice of the authorization or denial of payment to the nursing facility and the patient.

(7) The notice will indicate the effective date of coverage and the amount of money the patient has available to contribute toward the interim per diem rate. Obtaining the patient's share of the interim per diem rate is the responsibility of the nursing facility.

(c) Plan of care. Before admission to a skilled nursing facility, intermediate care facility or intermediate care facility for the mentally retarded, or before authorization for payment, the attending physician shall establish a written plan of care for each applicant or recipient. The plan of care shall indicate time-limited and measurable care objectives and goals to be accomplished and who is to give each element of care.

The provisions of this §1181.53 amended under sections 403(a) and (b), 443.1(2) and (3) and 443.6 of the act of June 13, 1967 (P. L. 31, No. 21) (62 P. S. §§ 403(a) and (b), and 443.1(2) and (3) and 443.6).

This section cited in 55 Pa. Code § 1181.52 (relating to payment conditions); 55 Pa. Code § 1181.54 (relating to payment conditions related to the recipient's continued need for care); 55 Pa. Code § 1181.83 (relating to inspections of care); 55 Pa. Code § 1181.94 (relating to failure to adhere to certification requirements); and 55 Pa. Code § 1181.95 (relating to failure to adhere to medical evaluation requirements).

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