Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1181 - NURSING FACILITY CARE
Subchapter D - NURSING HOME REFORM-STATEMENT OF POLICY
APPEALS OF ADVERSE DETERMINATIONS
Appendix F - HEAVY CARE/INTERMEDIATE SERVICES
I. Introduction.
The Department has developed criteria to be used in determining whether an applicant or recipient is medically eligible for the heavy care/intermediate level of care. To be determined medically eligible for the heavy care/intermediate level of care, a recipient shall meet the requirements in Section II. If any one of the requirements specified in Section II are not met, the recipient cannot be determined to be medically eligible for the heavy care/intermediate level of care.
II. Heavy care/intermediate services.
(a) Heavy care/intermediate services shall be provided in a dually certified skilled bed and are subject to the same limits on nursing hours as skilled care services.
(b) Heavy care/intermediate services are services provided to patients who are functionally impaired to the following extent with respect to the following activities of daily living:
(1)Eating-requires total care. Requires total care means that the individual must be hand fed by another person, is tube fed, or is in a feeding retraining program. Functional impairment shall be at level 3 or 4.
(2)Dressing-requires total care. Requires total care means that the individual must be dressed by another person. Functional impairment shall be at level 3.
(3)Continence of urine-is incontinent or has an indwelling bladder catheter. Incontinent means incontinent more than 50% of the time. Functional impairment shall be at level 3 or 4.
(4)Mental status-confused or speech-aphasic with behavioral problems. Confused means confused most of the time, semi-comatose or comatose. Functional impairment shall be at level 3, 4 or 5. Speech-aphasic with behavioral problems means unable to communicate for whatever reason. Functional impairment shall be at level 3 and there shall be behavioral problems.
(5)Mobility-wheelchair/mobile. Mobility includes those categories of mobility status which are wheelchair/mobile, cane/walker, chairbound or bedfast. Functional impairment shall be at level 2, 3, 4 or 5.
| ITEM | LEVEL 1 | LEVEL 2 | LEVEL 3 | LEVEL 4 | LEVEL 5 |
| [][]Eating | Self | With Assistance | Total Care | Tube Fed | |
| [][]Bathing | Self | With Assistance | Total Care | ||
| [][]Dressing | Self | With Assistance | Total Care | ||
| [][]Continence of Urine | Continent | Occas. Incontinent | Incontinent | Catheter | |
| [][]Continence of Bowel | Continent | Occas. Incontinent | Incontinent | Colostomy | |
| [][]Mental Status | Clear | Occas. Confused | Confused | Semi Comatose | Comatose |
| [][]Noisy | Never | Occasionally | Most of the Time | ||
| [][]Combative | Never | Occasionally | Most of the Time | ||
| [][]Withdrawn | Never | Occasionally | Most of the Time | ||
| [][]Wanders | Never | Occasionally | Most of the Time | ||
| [][]Suicidal | Never | Occasionally | Most of the Time | ||
| [][]Mobility | Ambulatory | Wheelchair/Mobile | Cane/Walker/Asst. | Chairbound | Bedfast |
| [][]Sight | Not Impaired | Impaired | Blind | ||
| [][]Hearing | Not Impaired | Impaired | Deaf | ||
| [][]Speech | Not Impaired | Impaired | Aphasic |
(c) Documentation justifying the need for heavy care/intermediate services on an inpatient basis shall be recorded in the patient's medical record at least monthly.
This section cited in 55 Pa. Code § 1181.2 (relating to definitions); and 55 Pa. Code § 1181.54 (relating to payment conditions related to the recipient's continued need for care).
