Current through Register Vol. 54, No. 44, November 2, 2024
(a)
Inspection team. The Department's Inspection of Care team will
inspect the care and services provided to each recipient in a participating
nursing facility at least annually. The Department will not give the facility
more than 48 hours notice of the time and date of the scheduled arrival of the
team. The facility shall make readily available to the team the patient's
complete medical records for the year since the last review of the team. The
team's inspection will include:
(1) Personal
contact with and observation of each recipient in a skilled nursing facility,
intermediate care facility, or intermediate care facility for the mentally
retarded.
(2) Review of each
recipient's medical record. The record must include timely certification and
recertifications by the physician that the services are needed and a written
individual plan of care developed either by an interdisciplinary team or the
attending or staff physician, whichever is applicable. The plan of care must
indicate time limits and measurable care objectives and goals to be
accomplished and who is to give each element of care.
(b)
Determination of
inspection. The team will determine in its inspection whether:
(1) The services are available and adequate
to meet the recipient's health needs.
(2) It is medically necessary and desirable
for the recipient to remain in the facility.
(3) Recipients receiving skilled care meet
the minimum medical requirements for skilled nursing care specified in §
1181.53(b)(2)
(relating to payment conditions related to the recipient's initial need for
care).
(4) It is feasible for the
facility to meet the recipient's health needs and, in an ICF, the recipient's
rehabilitative needs or whether the recipient's needs could be met through
alternative institutional or noninstitutional services.
(5) Each recipient in an intermediate care
facility for the mentally retarded is receiving active treatment.
(6) The medical evaluation including any
required psychological or social evaluations and the plan of care are complete
and current, are followed, and all ordered services are provided and recorded.
(7) The recipient receives
adequate services based on personal observations, that is, the recipient is
clean, bedsores are absent, there is absence of signs of malnutrition or
dehydration and there is apparent maintenance of maximum physical, mental and
psychosocial function.
(8) In an
ICF, there is evidence of a planned activities program to prevent regression
and there is progress toward meeting goals of the plan of care.
(9) Service needs are met by the facility or
by outside arrangements.
(10)
Recipient needs continued placement in the facility or there is an appropriate
plan to transfer to an alternate level of care.
(c)
Reports on inspections of
care.
(1) The Inspection of Care
team will develop a summary report at the conclusion of its inspection of each
facility. The report will include:
(i) The
alternate care determinations.
(ii)
Findings of the adequacy and quality of care rendered by the facility. The
findings will specify that the care rendered is acceptable or in need of
improvement.
(2) Within
45 days following the conclusion of the inspection, two copies of the summary
report will be forwarded to the administrator of the facility. The
administrator shall forward one copy of the summary report to the Utilization
Review Committee chairperson. On the second copy of the summary report, the
administrator will give written responses to each area identified as deficient
and all narrative recommendations.
(3) In advance of forwarding the summary
report to the facility, the Inspection of Care team will notify the County
Assistance Office and the facility of any alternate care determinations made by
the team.
(d)
Recipient right of appeal of alternate care determinations.
The recipient or the person or the nursing facility acting on the behalf of the
recipient, in accordance with Chapter 275 (relating to appeal and fair hearing
and administrative disqualification hearings), has 30 days in which to appeal
the Inspection of Care team's alternate care determination. Neither the
facility, the facility's Utilization Review Committee, nor the recipient's
attending physician has the right to appeal the alternate care determination on
their own behalf. If the recipient or the person or the facility acting on
behalf of the recipient appeals the decision within 10 calendar days from the
date the County Assistance Office issues the advance notice, payment for the
present level of care will continue pending the outcome of the hearing subject
to the provisions of §
1181.54(g)
(relating to payment conditions related to the recipient's continued need for
care).
The provisions of this §1181.83 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 Chapter 1181 Appendix
O (relating to OBRA sanctions).