Current through Register Vol. 54, No. 44, November 2, 2024
(a)
Recertification of continued need for care.
(1) A physician, a physician assistant under
the supervision of 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 enter into the recipient's medical record
a signed and dated statement that the recipient continues to need skilled,
heavy care/intermediate or intermediate level of care, as applicable. For a
certification for the skilled level of care to be considered valid, the
physician, physician assistant, nurse practitioner or clinical nurse specialist
shall certify that the criteria specified in Appendix E (relating to skilled
nursing care) have been met. For a certification for the heavy
care/intermediate level of care to be considered valid, the physician,
physician assistant, nurse practitioner or clinical nurse specialist shall
certify that the criteria in Appendix F (relating to heavy care/intermediate
services) have been met.
(2)
Recertification of the need for care of a recipient receiving care in an ICF/MR
shall be made at least once every 365 days after the initial certification as
specified in Appendix Q (Reserved).
(3) Recertification of the need for care of a
recipient receiving skilled nursing facility services shall be made as follows:
(i) At least 30 days after the date of the
initial certification.
(ii) At
least 60 days after the date of the initial certification.
(iii) At least 90 days after the date of the
initial certification and every 60 days thereafter.
(4) Recertification of the need for care of a
recipient receiving heavy care/intermediate or intermediate care services shall
be made as follows:
(i) At least 60 days after
the date of the initial certification.
(ii) At least 180 days after the date of the
initial certification.
(iii) At
least 12 months after the date of the initial certification.
(iv) At least 18 months after the date of the
initial certification.
(v) At least
24 months after the date of the initial certification and every 12 months
thereafter.
(b)
Continued stay reviews by the Utilization Review Committee.
(1) The Utilization Review Committee of a
facility shall document in the medical record of the recipient the continued
stay review date and need determination of the Committee.
(2) If the Utilization Review Committee
recommends that a recipient's continued stay at the skilled level of care is
needed, the Committee shall complete the Skilled Nursing Care Assessment form
substantiating that the recipient meets the minimum medical requirements for
skilled level of care specified in §
1181.53(b)(2)
(relating to payment conditions related to the recipient's initial need for
care). The Skilled Nursing Care Assessment form shall be completed each time
the Utilization Review Committee recommends that the recipient's continued stay
be at the skilled level of care. The form shall be signed by the Utilization
Review Committee chairperson and retained in the medical record of the
recipient. If the Utilization Review Committee recommends that a recipient's
level of care be changed to or from the skilled level of care, the original of
the Skilled Nursing Care Assessment form shall accompany the Committee's
notification (Utilization Review Request for Change Summary) to the Department.
Copies of the forms shall be retained in the recipient's medical
record.
(3) If the Utilization
Review Committee recommends that a recipient's level of care be changed to
intermediate care from skilled or heavy care/intermediate, the Committee shall
notify the Department of the Committee's recommendation on the Utilization
Review Request for Change Summary form. A copy of the form shall be retained in
the recipient's medical record.
(4)
If the Utilization Review Committee recommends that a recipient's level of care
be changed to heavy care/intermediate from skilled or intermediate, the
Committee shall notify the Department of the Committee's recommendation on the
Utilization Review Request for Change Summary form. A copy of the form shall be
retained in the recipient's medical record. The Committee shall also submit
documentation to the Department to substantiate that the recipient meets the
minimum medical requirements for the heavy care/intermediate level of care
specified in Appendix F (relating to heavy care/intermediate
services).
(5) If the Utilization
Review Committee recommends that a recipient not continue to receive the level
of care for which payment is authorized, the Committee shall notify the
Department of the Committee's recommendation on the Utilization Review Request
for Change Summary form. A copy of the form shall be retained in the
recipient's medical record.
(c)
Adverse decisions by the
Inspection of Care team. If the Department's Inspection of Care team
determines that a recipient no longer needs the level of care for which payment
is authorized, the Inspection of Care team shall direct the Department to take
action to authorize payment for alternate care.
(d)
Recipient notice of adverse
decisions. Upon notification of the recommended change in the level of
care, the Department will notify the recipient and facility of its decision. If
the recipient or the representative of the recipient appeals the decision
within 10 calendar days from the date the notice is mailed, payment for the
present level of care will continue pending the outcome of the hearing. If the
recipient does not respond to the notice within 10 calendar days, the
Department will deny payment in a case where care is no longer needed or
authorize payment for the appropriate level of care no earlier than 10 calendar
days from the date the notice was mailed to the recipient.
(e)
Continued review of plan of care.
The plan of care shall comply with the following:
(1) For recipients receiving skilled nursing
care, the attending or staff physician and other personnel involved in the care
of the recipient shall review each plan of care at least every 60 days and
document the date of the review in the record of the patient.
(2) For recipients receiving intermediate,
heavy care/intermediate or intermediate care for the mentally retarded, the
interdisciplinary team shall review each plan of care at least every 90 days
and document the date of the review in the record of the
recipient.
(f)
Attending physician decision on level of care.
(1) In response to changes in the recipient's
medical condition, the attending physician may order a change in the
recipient's level of care which is different from the level of care for which
payment is authorized.
(2) If the
attending physician recommends a change in the recipient's level of care to or
from the skilled level of care, the attending physician shall document the
change in the recipient's medical record and sign a completed Skilled Nursing
Care Assessment form which substantiates that the recipient meets or does not
meet the minimum medical criteria for skilled level of care specified in §
1181.53(b)(2).
The attending physician shall sign and date the entry in the medical record.
The original of the Skilled Nursing Care Assessment form shall accompany the
Attending Physician Request for Change Summary form to the Department. Copies
of the forms shall be retained in the recipient's medical record. The facility
shall make the change immediately and notify the Department of the change. The
Department will issue a Confirming Notice to the recipient or the person acting
on behalf of the recipient and to the nursing facility.
(3) If the attending physician recommends a
change in the recipient's level of care to the intermediate level of care, the
attending physician shall document the change in the recipient's medical record
and notify the Department of the level of care change on the Attending
Physician Request for Change Summary form. A copy of the form shall be retained
in the recipient's medical record.
(4) If the attending physician recommends a
change in the recipient's level of care to the heavy care/intermediate level of
care, the attending physician shall document the change in the recipient's
medical record. The facility shall notify the Department of the level of care
change on the Attending Physician Request for Change Summary form. A copy of
the form shall be retained in the recipient's medical record. The facility
shall also submit documentation to the Department to substantiate that the
recipient meets the minimum medical requirements for the heavy
care/intermediate level of care in Appendix F.
(5) If the recipient's level of care is
changed as a result of a determination by the Department's Inspection of Care
team as described in subsection (c), the attending physician may order a change
in the recipient's level of care only if the recipient's medical condition
changes subsequent to the date of the Inspection of Care team's determination
and the change in the recipient's medical condition warrants another level of
care. The physician shall date and sign the documentation of the change in the
medical condition and state the alternate care recommendation in the
recipient's record.
(i) If ordering the
skilled level of care, the attending physician shall sign and date a completed
Skilled Nursing Care Assessment form substantiating that the recipient meets
the minimum medical requirements for skilled level of care specified in §
1181.53(b)(2).
The original of the Skilled Nursing Care Assessment form substantiating the
recipient's medical eligibility shall accompany the Attending Physician Request
for Change Summary form to the Department. Copies of the forms shall be
retained in the recipient's medical record.
(ii) If ordering the intermediate level of
care, the attending physician shall complete an Attending Physician Request for
Change Summary form, and the original copy shall be sent to the Department. A
copy of the form shall be retained in the recipient's medical record.
(iii) If ordering the heavy care/intermediate
level of care, the attending physician shall complete an Attending Physician
Request for Change Summary form. The original of the Attending Physician
Request for Change Summary form and documentation to substantiate that the
recipient meets the minimum medical requirements for the heavy
care/intermediate level of care in Appendix F, shall be sent to the Department.
A copy of the form shall be retained in the recipient's medical
record.
(g)
Payment pending appeal. If the recipient or the person or the
nursing facility acting on behalf of the recipient appeals an action of the
Department to change the level of care for which payment is authorized within
the time period specified on the advance notice issued by the Department, the
Department will make payment to the facility for the level of care the
recipient is presently receiving pending the outcome of the hearing under
§
275.4(a)(3)(iii)
(relating to procedures). If the Department is sustained in its action, the
Department will recover from the facility payments in excess of the amount that
would have been made if the action of the Department had not been appealed. The
period for which the Department will recover excess payment runs from the
effective date specified on the advance notice to the date that the appropriate
change in the level of care for which payment is authorized is made.
The provisions of this §1181.54 amended under sections
403(a) and (b) and 443.1(2) and (3) of the Public Welfare Code (62 P. S.
§§
403(a) and (b)
and 443.1(2) and
(3)).
This section cited in 55 Pa. Code §
1181.52 (relating to payment
conditions); 55 Pa. Code §
1181.83 (relating to inspections
of care); and 55 Pa. Code §
1181.94 (relating to failure to
adhere to certification
requirements).
