Cal. Code Regs. Tit. 22, § 51124.6 - Pediatric Subacute Care Services

(a) Pediatric subacute care services are the health care services needed by a person under 21 years of age who uses a medical technology that compensates for the loss of a vital bodily function.

(b) Medical necessity for pediatric subacute care services shall be substantiated by any one of the following items in (1) through (4) below:

(1) A tracheostomy with dependence on mechanical ventilation for a minimum of six hours each day;

(2) Dependence on tracheostomy care requiring suctioning at least every six hours, and room air mist or oxygen as needed, and dependence on one of the four treatment procedures listed in (B) through (E) below:

(A) Dependence on intermittent suctioning at least every eight hours, and room air mist or oxygen as needed;

(B) Dependence on continuous intravenous therapy including administration of therapeutic agents necessary for hydration or of intravenous pharmaceuticals; or intravenous pharmaceutical administration of more than one agent, via a peripheral or central line, without continuous infusion;

(C) Dependence on peritoneal dialysis treatments requiring at least four exchanges every 24 hours;

(D) Dependence on tube feeding, naso-gastric or gastrostomy tube;

(E) Dependence on other medical technologies required continuously, which in the opinion of the attending physician and the Medi-Cal consultant require the services of a professional nurse.

(3) Dependence on total parenteral nutrition or other intravenous nutritional support, and dependence on one of the five treatment procedures listed in (b)(2)(A) through (E) above;

(4) Dependence on skilled nursing care in the administration of any three of the five treatment procedures listed in (b)(2)(A) through (E) above.

(c) Medical necessity for pediatric subacute skilled nursing care shall be further substantiated by all of the following conditions:

(1) The intensity of medical/skilled nursing care required by the patient shall be such that the continuous availability of a registered nurse in the pediatric subacute unit is medically necessary to meet the patient's healthcare needs, and not be any less than the nursing staff ratios specified in Section 51215.8(g) and (i);

(2) The patient's medical condition has stabilized such that the immediate availability of the services of an acute care hospital, including daily physician visits, are not medically necessary;

(3) The intensity of medical/skilled nursing care required by the patient is such that, in the absence of a facility providing pediatric subacute care services, the only other medically necessary inpatient care appropriate to meet the patient's health care needs under the Medi-Cal program is in an acute care licensed hospital bed.

Notes

Cal. Code Regs. Tit. 22, § 51124.6

1. New section filed 4-13-94 as an emergency; operative 4-1-94. Emergency adoption submitted to OAL for printing only pursuant to section 4, AB 36 (chapter 1030, Statutes of 1993) (Register 94, No. 15).
2. Certificate of Compliance as to 4-13-94 order including amendment of section transmitted to OAL 9-26-94 and filed 10-20-94 (Register 94, No. 42).
3. Editorial correction of HISTORY 1 and 2 (Register 95, No. 14).

Note: Authority cited: Sections 10725 and 14124.5, Welfare and Institutions Code. Reference: Sections 14114 and 14132.25, Welfare and Institutions Code.

1. New section filed 4-13-94 as an emergency; operative 4-1-94. Emergency adoption submitted to OAL for printing only pursuant to section 4, AB 36 (chapter 1030, Statutes of 1993) (Register 94, No. 15).
2. Certificate of Compliance as to 4-13-94 order including amendment of section transmitted to OAL 9-26-94 and filed 10-20-94 (Register 94, No. 42).
3. Editorial correction of History 1 and 2 (Register 95, No. 14).