Cal. Code Regs. Tit. 22, § 51343.2 - Intermediate Care Facility Services for the Developmentally Disabled-Nursing

(a) Intermediate care facility services for the developmentally disabled-nursing (ICF/DD-N) are covered subject to prior authorization by the Department for the ICF/DD-N level of care. Authorizations may be granted for up to six months. Requests for prior authorization of admission to an ICF/DD-N or for continuation of services shall be initiated by the facility on Certification for Special Treatment Program Services forms (HS 231). Certification documentation required by the Department of Developmental Services shall 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 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. When the reauthorization request is denied, or an existing authorization is cancelled, the facility shall be notified by the most expeditious means and a timely notice of action shall be sent to the beneficiary in accordance with Title 22, California Code of Regulations, Section 51014.1.

(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 shall be approved by a Department Medi-Cal consultant prior to admission except in cases of emergency as specified in Section 51056, Title 22, California Code of Regulations.

(e) The beneficiary's medical condition shall be determined on an individual basis by the Department's Medi-Cal consultant. However, in determining the need for ICF/DD-N services the following conditions shall be met:

(1) A regional center has diagnosed the beneficiary as being developmentally disabled, or has determined that the beneficiary demonstrates significant developmental delay that may lead to a developmental disability if not treated.

(2) The beneficiary's medical condition is such that 24-hour nursing supervision, in accordance with Title 22, California Code of Regulations, Section 73839(a) personal care, and developmental services are required. The stability of the beneficiary's medical condition and frequency of required skilled nursing services shall be the determining factors in evaluating whether beneficiaries are appropriate for ICF/DD-N placements.

(3) Each beneficiary shall have a physician's certification that continuous skilled nursing care is not required and that the beneficiary's medical condition is stable. Beneficiaries convalescing from surgical procedures shall be stable enough that only intermittent nursing care is needed.

(4) The beneficiary needs a level of developmental, training and habilitative program services and recurring but intermittent skilled nursing services which are not available through other small (4-15 bed) community-based health facilities.

(5) The beneficiary's condition is such that there is a need for the provision of active treatment services as described at Section 73801, thereby leading to a higher level of beneficiary functioning and a lessening dependence on others in carrying out daily living activities or in the prevention of regression or in ameliorating developmental delay.

(6) The beneficiary shall have two or more developmental deficits as measured on the Client Developmental Evaluation Report prescribed by the Department of Developmental Services in any one or combination of the following three domains:

(A) Self-help domain:

1. Eating

2. Toileting

3. Bladder control

4. Dressing

(B) Motor domain:

1. Ambulation

2. Crawling and standing

3. Wheelchair mobility

4. Rolling and sitting

(C) 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 results 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 outburst.

7. Unacceptable social behavior--positive social participation is impossible unless closely supervised or redirected.

(f) The beneficiary must have a need for active treatment, defined at Section 73801, Title 22, California Code of Regulations, and intermittent skilled nursing services such as:

(1) Apnea monitoring

(2) Colostomy care

(3) Gastrostomy feeding and care

(4) Naso-gastric feeding

(5) Tracheostomy care and suctioning

(6) Oxygen therapy

(7) Intermittent positive-pressure breathing

(8) Licensed nurse evaluation on an intermittent basis

(9) Catheterization

(10) Wound irrigation and dressing

(11) The beneficiary needs special feeding assistance.

(12) The beneficiary needs repositioning to avoid skin breakdown which would lead to decubitus ulcers and contractures.

(g) Conditions which would exclude beneficiaries from placement in an ICF/DD-N are as follows:

(1) Beneficiaries shall not have any of the following extreme developmental deficits in the social-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 treatment at least once per year.

(C) Smearing--smears at every opportunity.

(2) Beneficiaries shall not be admitted to or approved for service in an intermediate care facility for the developmentally disabled-nursing if those beneficiaries have a decubitus ulcer at the third or fourth stage of development as defined in Title 22, California Code of Regulations, Section 73811.

(3) Beneficiaries shall not be admitted with clinical evidence of an active communicable disease that is required to be reported in accordance with Section 2500, Title 17, California Code of Regulations.

(h) There shall be a written individual program 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 members of the interdisciplinary staff/team involved in the care of the individual. The plan of care shall include the following:

(1) Diagnoses, symptoms, complaints, and complications indicating the need for admission;

(2) A description of the functional level of the individual;

(3) Objectives;

(4) Any orders for:

(A) Medications;

(B) Treatments;

(C) Restorative and rehabilitative services;

(D) Activities;

(E) Therapies;

(F) Social services;

(G) Diet; and

(H) Special procedures designed to meet the objectives of the plan of care;

(5) Plans for continuing care, including review and modification of the plan of care;

(6) Plans for discharge.

(i) Each beneficiary shall have received a comprehensive medical evaluation within three months and a comprehensive social evaluation within six months prior to admission. A psychological evaluation (developmental evaluation for clients under 18 months of age) must have been completed within three months prior to admission. Subsequent medical, psychological and social evaluations shall be completed at least annually by staff involved in carrying out the beneficiary's plan of care. Each evaluation must include:

(1) Diagnoses;

(2) Summary of present medical, social, and where appropriate, developmental findings;

(3) Medical and social family history;

(4) Mental and physical functional capacity;

(5) Prognoses;

(6) Kinds of services needed;

(7) Evaluation by placement worker of the resources available to the beneficiary in the home, family and community; and

(8) A recommendation concerning:

(A) Admission to the ICF/DD-N, or

(B) Continued care in the ICF/DD-N for individuals who apply for Medi-Cal while in the ICF/DD-N.

(j) 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.

(k) 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-nursing by the State Medi-Cal Utilization Review Team in accordance with the requirements of Title 42, Code of Federal Regulations, Sections 456.602 through 456.604.

(l) Each beneficiary shall receive preventive health services as follows:

(1) Annual physical examinations that include examination of vision and hearing, routine screening laboratory examinations as determined necessary by the physician, and special studies when needed.

(2) Immunizations, using as a guide the most current recommendations of the Public Health Service Advisory Committee on Immunization Practices or the Committee on the Control of Infectious Diseases of the American Academy of Pediatrics.

(3) Tuberculosis control, appropriate to the ICF/DD-N population, in accordance with the most current recommendations of the American College of Chest Physicians or the section on diseases of the chest of the American Academy of Pediatrics or both.

(m) Regardless of frequency of contact, the attending physician shall recertify in writing, at least every 60 days, the beneficiary's need for continued care in the ICF/DD-N.

(n) Medi-Cal beneficiaries in the facility shall be seen by their attending physicians no less often than every 60 days.

(o) Services shall be provided at a level consistent with that described in the beneficiary's individual service plan.

Notes

Cal. Code Regs. Tit. 22, § 51343.2

1. New section refiled by the Department of Health Services with the Secretary of State on 5-30-89 as an emergency pursuant to Healthand Safety Code Section 1275.3; operative 5-30-89. Submitted to OAL for printing only pursuant to Government Code Section 11343.8 (Register 89, No. 23). For prior history, see Register 89, No. 1.
2. Certificate of Compliance as to 5-30-89 order including amendment transmitted to OAL 9-27-89 and filed 10-26-89 (Register 89, No. 44).

Note: Authority cited: Sections 14105 and 14124.5, Welfare and Institutions Code; and Sections 208 and 1275.3, Health and Safety Code. Reference: Sections 1250.1 and 1275.3, Health and Safety Code.

1. New section refiled by the Department of Health Services with the Secretary of State on 5-30-89 as an emergency pursuant to Healthand Safety Code Section 1275.3; operative 5-30-89. Submitted to OAL for printing only pursuant to Government Code Section 11343.8 (Register 89, No. 23). For prior history, see Register 89, No. 1.
2. Certificate of Compliance as to 5-30-89 order including amendment transmitted to OAL 9-27-89 and filed 10-26-89 (Register 89, No. 44).