Cal. Code Regs. Tit. 22, § 51343.1 - Intermediate Care Facility Services for the Developmentally Disabled Habilitative
(a)
Intermediate care facility services for the developmentally disabled
habilitative (ICF-DDH) are covered subject to prior authorization by the
Department of Health Services for the ICF-DDH level of care. Authorizations may
be granted for up to six months. Requests for prior authorization of admission
to an ICF-DDH or for continuation of services shall be initiated by the
facility on forms designated by the Department. Certification documentation
required by the Department of Developmental Services must be completed by
regional center personnel and submitted with the Treatment Authorization
Request form. The attending physician shall sign the Treatment Authorization
Request form and shall certify to the Department that the beneficiary requires
this level of care.
(b) The request
for reauthorization shall be received by the appropriate Medi-Cal consultant on
or before the first working day following the expiration of a current
authorization. Certification shall be redetermined and a new certification form
shall be completed by regional center personnel and shall be attached to the
request for authorization. One day of authorization shall be denied for each
day the reauthorization request is late.
(c) The Medi-Cal consultant shall deny any
authorization request or reauthorization request, or shall cancel any
authorization in effect when services or placement are not appropriate to the
health and developmental needs of the beneficiary. Where the reauthorization
request is denied, or an existing authorization is cancelled, the facility
shall be notified by the most expeditious means. A copy of the denial letter
and the denied Treatment of Authorization Request shall serve as the official
notice of action and shall be returned to the provider. Payment will be made up
to 15 days following the postmark date of the denial letter.
(d) Prior to the transfer of a beneficiary
between facilities, the receiving facility shall originate an initial Treatment
Authorization Request signed by the attending physician. This Treatment
Authorization Request must be approved by a DHS Medi-Cal consultant prior to
admission except in cases of emergency as specified in Section
51056.
(e) Covered services shall be limited to
individuals who are defined as developmentally disabled in Welfare and
Institutions Code, Section
4512.
In determining the need for intermediate care facility services for the
developmentally disabled habilitative, the following criteria shall be
considered:
(1) The complexity of the
beneficiary's medical problems is such that skilled nursing care on an ongoing
but intermittent basis is needed. Individuals shall be placed in an ICF-DDH
only if their predominant skilled nursing needs are predictable and advance
arrangements can be made for licensed nurses to provide needed services at
prescribed intervals. Individuals who require skilled nursing procedures on an
"as needed basis" are not candidates for placement in an ICF-DDH.
(2) Medication may be mainly supportive or
stabilizing but still requires professional nurse evaluation on an intermittent
basis.
(3) The beneficiary needs
specialized developmental, training and habilitative program services which are
not available through other levels of care.
(4) The extent to which provision of
specialized developmental, training and habilitative program services can be
expected to result in a higher level of beneficiary functioning and a lessening
dependence on others in carrying out daily living activities or in the
prevention of regression.
(5) The
beneficiary must have two or more developmental deficits as measured on
standardized evaluation forms prescribed and furnished by the Department of
Developmental Services in any one of the following two domains:
(A) Self-help domain:
1. Eating
2. Toileting
3. Bladder Control
4. Dressing
(B) Social-emotional domain:
1. Aggression--has had one or more violent
episodes causing minor physical injury within the past year or has resorted to
verbal abuse and threats but has not caused physical injury within the past
year.
2. Self-injurious
behavior--behavior exists but result only in minor injuries which require first
aid.
3. Smearing feces--smears once
a week or more but less than once a day.
4. Destruction of property.
5. Running or wandering away.
6. Temper tantrums, or emotional
outbursts.
7. Unacceptable social
behavior--positive social participation is impossible unless closely supervised
or redirected.
(6) Beneficiaries shall not have any of the
following extreme developmental deficits in the socio-emotional area:
(A) Aggression--has had violent episodes
which have caused serious physical injury in the past year.
(B) Self-injurious behavior--causes severe
injury which requires physician attention at least once per year.
(C) Smearing--smears at every
opportunity.
(7)
Beneficiaries shall not be admitted to or approved for service in an
intermediate care facility for the developmentally disabled habilitative if
those beneficiaries have a decubitis ulcer.
(8) Beneficiaries shall not be admitted with
clinical evidence of an active communicable disease that is required to be
reported in accordance with Section
2500 of Title 17 of he California
Administrative Code.
(9)
Beneficiaries shall not be admitted to an ICF/DDH for purposes of respite care
with the exception of clients enrolled in a federally approved home and
community-based care program under Section
1915(c) of the
Social Security Act.
(f)
There shall be a written plan of care for each beneficiary, which shall be
established by a physician prior to the beneficiary's admission to the facility
and reviewed and evaluated at least every 90 days by all personnel involved in
the care of the individual. The plan of care shall meet the requirements of 42
Code of Federal Regulations 456.380 and shall be signed and dated by the
physician at least every 90 days.
(g) Each beneficiary shall have received a
comprehensive medical and social evaluation within 12 months prior to
admission. A psychological evaluation must have been completed within three
months prior to admission. Medical, psychological and social evaluations shall
meet the requirements of 42 Code of Federal Regulations 456.370.
(h) Each beneficiary shall receive a complete
dental examination within one month following admission unless such an
examination was done within six months prior to admission. In either case, a
comprehensive report prepared by the dentist shall be completed and entered
into the beneficiary's record. Each beneficiary shall be reexamined as needed
but at least annually.
(i) There
shall be a periodic review, no less often than annually, of all care and
services provided to beneficiaries receiving intermediate care facility
services for the developmentally disabled habilitative by the State Medical
Review Team in accordance with the requirements of 42 Code of Regulations
456.602 through 456.604.
(j) Each
beneficiary shall receive preventive health services that includes physical
examinations, immunizations and tuberculosis control in accordance with 42 Code
of Regulations 442.477.
(k)
Regardless of frequency of contact, the attending physician shall recertify, at
least every 60 days, the beneficiary's need for continued care in accordance
with the procedures specified by the Director. The facility shall attach a
physician's signed statement at the time of billing as proof of this
recertification. This statement shall be completed in the format specified by
the Department.
(l) Medi-Cal
beneficiaries in the facility shall be seen by their attending physicians no
less often than every 60 days. An alternative schedule of not more than 90 days
elapsed time may be proposed subject to approval by the Medi-Cal
consultant.
(m) Services shall be
provided at a level consistent with that described in the beneficiary's
individual service plan.
(n)
Payment for service shall be made in accordance with Section
51510.2.
(o) Leave of absence from intermediate care
facilities for developmentally disabled habilitative residents is covered up to
a maximum of 73 days in a calendar year. Payment shall be made in accordance
with Section
51535.
Notes
2. Certificate of Compliance including amendment filed by the Department of Health Services with the Secretary of State on 11-28-84. Submitted to OAL for printing only pursuant to Government Code Section 11343.8 (Register 85, No. 25).
3. Editorial correction of subsection (e)(2) (Register 95, No. 45).
Note: Authority cited: Sections 14105, 14108 and 14124.5, Welfare and Institutions Code; and Sections 208.3, 208.4 and 1267.7, Health and Safety Code. Reference: Sections 14108 and 14132, Welfare and Institutions Code; and Section 1250, Health and Safety Code.
2. Certificate of Compliance including amendment filed by the Department of Health Services with the Secretary of State on 11-28-84. Submitted to OAL for printing only pursuant to Government Code Section 11343.8 (Register 85, No. 25).
3. Editorial correction of subsection (e)(2) (Register 95, No. 45).
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