RELATES TO:
42 C.F.R.
431.153,
431.154,
447.280,
482.58,
42 U.S.C.
1395tt,
1396l,
1396r
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health
and Family Services, Department for Medicaid Services, has responsibility to
administer the Medicaid Program.
KRS
205.520(3) authorizes the
cabinet, by administrative regulation, to comply with any requirement that may
be imposed or opportunity presented by federal law to qualify for federal
Medicaid funds. This administrative regulation establishes the provisions
relating to nursing facility services and services at an intermediate care
facility for individuals with an intellectual disability for which payment
shall be made by the Medicaid Program on behalf of both the categorically needy
and medically needy recipients.
Section
1. Definitions.
(1) "Department"
means the Department for Medicaid Services or its designee.
(2) "Department approved system" means a
technology system in which:
(a) Providers
electronically submit and track level of care (LOC) requests through a
self-service portal;
(b) The system
triggers LOC tasks as reminders to providers and allows them to submit
reassessments electronically; and
(c) Information is exchanged electronically
with Kentucky's:
1. Medicaid Enterprise
Management Solution (MEMS); and
2.
Integrated eligibility and enrollment system.
(3) "High-intensity nursing care services"
means care provided:
(a) To a
Medicaid-eligible individual who meets high-intensity nursing care patient
status criteria in accordance with Section 4 of this administrative regulation;
and
(b) By a nursing facility or a
nursing facility with Medicaid waiver participating in the Medicaid Program
with care provided in beds also participating in the Medicare
Program.
(4)
"High-intensity rehabilitation services" means therapy services that:
(a) Are expected to improve an individual's
condition while the individual possesses reasonable potential for improvement
in functional capability; and
(b)
Do not include restorative and maintenance nursing procedures, including
routine range of motion exercises and application of splints or braces by
nurses and staff.
(5)
"Intermediate care facility for individuals with an intellectual disability" or
"ICF-IID" means a licensed intermediate care facility for individuals with an
intellectual disability certified by the Department for Medicaid Services as
meeting all standards for an intermediate care facility for individuals with an
intellectual disability.
(6)
"Intermediate care facility for individuals with an intellectual disability
services" or "ICF-IID services" means care provided:
(a) To a Medicaid-eligible individual who
meets ICF-IID patient status criteria in accordance with Section 4 of this
administrative regulation; and
(b)
By an ICF-IID participating in the Medicaid Program.
(7) "Intermittent high-intensity nursing care
services" means services for an individual who requires high-intensity nursing
care services at regular or irregular intervals, but not on a twenty-four (24)
hour-per-day basis and not less than three (3) calendar days per
week.
(8) "Low-intensity nursing
care services" means care provided:
(a) To a
Medicaid-eligible individual who meets low-intensity nursing care patient
status criteria in accordance with Section 4 of this administrative regulation;
and
(b) By a nursing facility or a
nursing facility with Medicaid waiver participating in the Medicaid
program.
(9) "Medical
condition" means a state of health relative to a clinical diagnosis made by a
licensed physician, physician assistant, advanced practice registered nurse, or
a qualified behavioral health professional.
(10) "Nursing facility" or "NF" means:
(a) A facility:
1. To which the Cabinet for Health and Family
Services, Office of Inspector General has granted an NF license;
2. For which the Cabinet for Health and
Family Services, Office of Inspector General has recommended to the department
certification as a Medicaid provider; and
3. To which the department has granted
certification for Medicaid participation; or
(b) A hospital swing bed that provides
services in accordance with
42 U.S.C.
1395tt and
1396l,
if the swing bed is certified to the department as meeting requirements for the
provision of swing bed services in accordance with
42 U.S.C.
1396r(b), (c), (d),
42 C.F.R.
447.280 and
482.58.
(11) "Nursing facility with Medicaid waiver"
or "NF-W" means a facility:
(a) To which the
Cabinet for Health and Family Services, Office of Inspector General has granted
an NF license;
(b) For which the
Cabinet for Health and Family Services, Office of Inspector General has
recommended to the department certification as a Medicaid provider;
(c) To which the department has granted a
waiver of the nurse staffing requirement; and
(d) To which the department has granted
certification for Medicaid participation.
(12) "Patient status" means an individual's
level of care in accordance with Section 4 of this administrative regulation
for treatment in an institutional setting.
(13) "Personal care" means services to help
an individual achieve and maintain good personal hygiene, which may include
assistance with bathing, shaving, cleaning and trimming of fingernails and
toenails, cleaning of the mouth and teeth, washing, and grooming and cutting of
hair.
(14) "Stable medical
condition" means a medical condition that is capable of being maintained in
accordance with a planned treatment regimen requiring a minimum amount of
medical supervision without significant change or fluctuation in a patient's
condition or treatment regimen.
Section 2. Participation Requirements. A
facility desiring to participate in the Medicaid program as a nursing facility,
nursing facility with Medicaid waiver, or ICF-IID shall meet the requirements
established in this section.
(2)
(a)
Except as provided by paragraph (b) of this subsection or for a nursing
facility with Medicaid waiver, a nursing facility shall have at least twenty
(20) percent of all Medicaid certified beds, but not less than ten (10) beds,
also certified to participate in Medicare.
(b) If a nursing facility has less than ten
(10) beds certified for Medicaid, all Medicaid certified beds shall also be
certified to participate in Medicare.
(3)
(a)
Except as provided by paragraph (b) of this subsection, if a nursing facility
with Medicaid waiver chooses to participate in Medicare, the facility shall
have at least twenty (20) percent of all Medicaid certified beds, but not less
than ten (10) beds, also certified to participate in Medicare.
(b) If a nursing facility with Medicaid
waiver has less than ten (10) beds certified for Medicaid, all Medicaid beds
shall also be certified to participate in Medicare.
(4) A nursing facility or a nursing facility
with Medicaid waiver shall comply with the preadmission screening and resident
review requirements specified in
42 U.S.C.
1396r and
907 KAR 1:755. A
facility failing to comply with these requirements shall be subject to
disenrollment, with exclusion from participation to be accomplished in
accordance with
907
KAR 1:671,
42 C.F.R.
431.153, and
42 C.F.R.
431.154.
(5) A facility shall be certified by the
Cabinet for Health and Family Services, Office of Inspector General as meeting
NF, NF-W, or ICF-IID status.
(6) In
order to provide specialized rehabilitation services to an individual with a
brain injury in accordance with Section 6 of this administrative regulation, a
facility shall be accredited by:
(a) The Joint
Commission;
(b) The Commission on
Accreditation of Rehabilitation Facilities;
(c) The Council on Accreditation;
or
(d) A nationally recognized
accreditation organization.
(7) A participating nursing facility shall be
certified in accordance with standards and conditions specified in this
administrative regulation before the facility may operate a unit that provides:
(a) Preauthorized specialized rehabilitation
services for a person with a brain injury; or
(b) Care for a person who is ventilator
dependent.
(8) A
participating nursing facility, nursing facility with Medicaid waiver, or
ICF-IID shall enter a resident's discharge date into a department approved
system.
(9)
(a) A licensed swing bed facility shall
contact the department for a new level of care review prior to swinging the bed
back to nursing facility status if the bed swings to acute status for three (3)
or more consecutive calendar days.
(b) An NF shall not count the day the bed
will swing back to nursing facility status in the three (3) consecutive days
specified in paragraph (a) of this subsection.
Section 3. Payment Provisions.
(1) Payment for high-intensity nursing care,
low-intensity nursing care, or ICF-IID services shall be limited to those
services meeting the care definitions established in Section 1 of this
administrative regulation.
(2) An
NF or NF-W shall receive payment for high-intensity nursing care services
provided to a Medicaid-eligible individual meeting high-intensity nursing care
patient status criteria if the services are provided in a Medicaid
participating bed that is also participating in the Medicare Program.
(3) An NF or NF-W shall receive payment for
low-intensity nursing care services provided to a Medicaid-eligible individual
meeting low-intensity nursing care patient status criteria if the services are
provided in a Medicaid participating bed.
(4) An ICF-IID shall receive payments for
ICF-IID services only.
Section
4. Patient Status Criteria. A patient status decision shall be
based on medical diagnosis, care needs, services and health personnel required
to meet these needs, and the feasibility of meeting the needs through
alternative institutional or noninstitutional services.
(1) For an admission and continued stay, an
individual shall qualify under the preadmission screening and resident review
criteria specified in
42 U.S.C.
1396r and
907 KAR 1:755.
(2) An individual shall be considered to meet
the level of care criteria for high-intensity nursing care if:
(a) On a daily basis:
1. The individual's needs mandate:
a. High-intensity nursing care services; or
b. High-intensity rehabilitation
services; and
2. The care
can only be provided on an inpatient basis;
(b) The inherent complexity of a service
prescribed for an individual exists to the extent that it can be safely or
effectively performed only by or under the supervision of technical or
professional personnel; or
(c) The
individual has an unstable medical condition manifesting a combination of at
least two (2) or more care needs in the following areas:
1. Intravenous, intramuscular, or
subcutaneous injections and hypodermoclysis or intravenous feeding;
2. Nasogastric or gastrostomy tube
feedings;
3. Nasopharyngeal and
tracheotomy aspiration;
4. Recent
or complicated ostomy requiring extensive care and self-help
training;
5. In-dwelling catheter
for therapeutic management of a urinary tract condition;
6. Bladder irrigations in relation to
previously indicated stipulation;
7. Special vital signs evaluation necessary
in the management of related conditions;
8. Sterile dressings;
9. Changes in bed position to maintain proper
body alignment;
10. Treatment of
extensive decubitus ulcers or other widespread skin disorders;
11. Receiving medication recently initiated,
which requires high-intensity observation to determine desired or adverse
effects or frequent adjustment of dosage;
12. Initial phases of a regimen involving
administration of medical gases; or
13. Receiving services that would qualify as
high-intensity rehabilitation services if provided by or under the supervision
of a qualified therapist, for example:
a.
Ongoing assessment of rehabilitation needs and potential;
b. Therapeutic exercises;
c. Gait evaluation and training performed by
or under the supervision of a qualified physical therapist;
d. Range of motion exercises that are part of
the active treatment of a specific disease state that has resulted in a loss
of, or restriction of, mobility;
e.
Maintenance therapy if the specialized knowledge and judgment of a qualified
therapist is required to design and establish a maintenance program based on an
initial evaluation and periodic reassessment of the patient's needs and
consistent with the patient's capacity and tolerance;
f. Ultrasound, short wave, and microwave
therapy treatments;
g. Hot pack,
hydrocollator infrared treatments, paraffin baths, and whirlpool (if the
patient's condition is complicated by circulatory deficiency, areas of
desensitization, open wounds, fractures, or other complications, and the
skills, knowledge, and judgment of a qualified therapist are required); or
h. Services by or under the
supervision of a speech-language pathologist or audiologist if necessary for
the restoration of function in speech or hearing.
(3)
(a) An individual shall be considered to meet
the level of care criteria for low-intensity patient status if, unrelated to
age appropriate dependencies with respect to a minor, the individual meets the
requirements of this paragraph:
1. An
individual with a stable medical condition requiring intermittent
high-intensity nursing care services not provided in a personal care home shall
be considered to meet low-intensity patient status;
2. An individual with a stable medical
condition, who has a complicating problem that prevents the individual from
caring for himself or herself in an ordinary manner outside the institution,
shall be considered to meet low-intensity patient status. For example, an
ambulatory cardiac patient with hypertension may be reasonably stable on
appropriate medication, but have intellectual deficiencies preventing safe use
of self-medication, or other problems requiring frequent nursing appraisal, and
thus be considered to meet low-intensity patient status; or
3. An individual with a stable medical
condition manifesting a significant combination of at least two (2) or more of
the following care needs shall be determined to meet low-intensity patient
status:
a. Assistance with personal
care;
b. Medication administration
via a medication planner filled by a registered nurse or licensed practical
nurse;
c. Assistance with
transferring to or propelling a wheelchair;
d. Physical or environmental management for
confusion and mild agitation;
e.
Must have assistance and be present during the entire meal time;
f. Physical assistance with going to the
bathroom or using a bedpan for elimination;
g. Existing colostomy care;
h. Indwelling catheter for dry
care;
i. Changes in bed
position;
j. Administration of
stabilized dosages of medication;
k. Restorative and supportive nursing care to
maintain the individual and prevent deterioration of the individual's
condition;
l. Administration of
injections during time licensed personnel is available; or
m. Routine administration of oxygen after a
regimen of therapy has been established.
(b) An individual shall not be considered to
meet low-intensity patient status criteria if care needs are limited to the
following:
1. Verbal or gestural assistance
with activities of daily living;
2.
Independent use of mechanical devices, for example, assistance in mobility by
means of a wheelchair, walker, crutch, or cane;
3. A limited diet such as low salt, low
residue, reducing or another minor restrictive diet; or
4. Medications that can be self-administered
or the individual requires minimal assistance such as set up of medications or
simple cuing.
(4) An individual who meets patient status
criteria shall be specifically excluded from coverage if the department
determines that in the individual case the combination of care needs are beyond
the capability of the facility and that placement in the facility is
inappropriate due to potential danger to the health and welfare of the
individual, other patients in the facility, or staff of the facility.
(5) An individual shall be considered to meet
the level of care criteria for ICF-IID if the individual meets criteria for a
diagnosis of an intellectual disability as defined by the current Diagnostic
and Statistical Manual of Mental Diseases (DSM) with onset of condition prior
to age eighteen (18) or meets criteria for a person with a related condition as
defined by
42 C.F.R.
435.1010 with onset of condition prior to age
twenty-two (22) and meets the following criteria:
(a) Requires physical or environmental
management or habilitation;
(b)
Requires a planned program of active treatment;
(c) Requires a protected environment;
and
(d) Unrelated to age
appropriate dependencies with respect to a minor, has substantial deficits in
adaptive functioning that, without ongoing support, limit functioning in one
(1) or more activities of daily life such as communication, social
participation, and independent living across multiple environments, such as
home, school, work, and community.
(6) An individual who does not require a
planned program of active treatment to attain or maintain the individual's
optimal level of functioning shall not meet ICF-IID patient status.
(7) An individual shall not be denied for
ICF-IID services solely due to advanced age, length of stay in an institution,
or history of previous institutionalization, if the individual qualifies for
ICF-IID services on the basis of all other factors.
(8) Transfer trauma criteria. A Medicaid
recipient in an NF who does not meet the low-intensity or high-intensity
nursing care patient status criteria established in this section shall not be
discharged from an NF if:
(a) The recipient
has resided in an NF for at least eighteen (18) consecutive months;
(b) The recipient's attending physician
determines that the recipient would suffer transfer trauma in that the
individual's physical, emotional, or mental well-being would be compromised by
a discharge action as a result of not meeting patient status criteria;
and
(c) The department confirms the
recipient's attending physician's assessment regarding the trauma caused by
possible discharge from the NF.
(9) A Medicaid recipient who meets transfer
trauma criteria in accordance with subsection (8) of this section shall:
(a) Remain in an NF and continue to be
covered by the department for provider reimbursement at least until the
individual's subsequent transfer trauma assessment; and
(b) Be reassessed for transfer trauma every
180 calendar days.
(10)
The recipient transfer trauma criteria established in subsection (8) of this
section shall not apply to an individual who resides in a facility that
experiences closure or a license or certificate revocation.
Section 5. Reevaluation of Need
for Service.
(1) Nursing facility, nursing
facility with Medicaid waiver, or ICF-IID services shall continue to be
provided to an individual if the individual's health status and care needs are
within the scope of program benefits as described in Sections 3 and 4 of this
administrative regulation.
(2) An
individual's patient status shall be reevaluated at least once every twelve
(12) months.
(3) Except as provided
in Section 4(8) and (9) of this administrative regulation, if a reevaluation of
care needs reveals that an individual no longer requires high-intensity nursing
care, low-intensity nursing care, or intermediate care for an individual with
an intellectual or a developmental disability:
(a) Payment shall continue for ten (10)
calendar days to permit orderly discharge or transfer to an appropriate level
of care; and
(b) Ten (10) calendar
days from the date the reevaluation is finalized, payment shall no longer be
appropriate to the facility.
Section 6. Requirements, Standards, and
Preauthorization of Specialized Rehabilitation Services for Individuals with
Brain Injuries. An individual who has a brain injury and meets the
high-intensity nursing care patient status criteria established in Section 4 of
this administrative regulation or is qualified under subsection (5) of this
section shall be provided care in a certified unit providing specialized
rehabilitation services for persons with brain injuries (i.e., brain injury
unit) if the care is preauthorized by the department using criteria specified
in this section. For coverage to occur, authorization of coverage shall be
granted prior to admission of the individual with the brain injury into the
certified brain injury unit, or if previously admitted to the unit with other
third party coverage, authorization shall be granted prior to exhaustion of
those benefits.
(1) Injuries within the scope
of benefits shall be:
(a) Central nervous
system injury from physical trauma;
(b) Central nervous system damage from anoxia
or hypoxic episodes; or
(c) Central
nervous system damage from an allergic condition, toxic substance, or another
acute medical or clinical incident.
(2) The following items shall be indicators
for admission and continued stay:
(a) The
individual sustained a traumatic brain injury with structural, nondegenerative
brain damage and is medically stable;
(b) The individual shall not be in a
persistent vegetative state;
(c)
The individual demonstrates physical, behavioral, and cognitive rehabilitation
potential;
(d) The individual
requires coma management; or
(e)
The individual has sustained diffuse brain damage caused by anoxia, toxic
poisoning, or encephalitis.
(3) The determination as to whether
preauthorization is appropriate shall be made taking into consideration the
following:
(a) The presenting
problem;
(b) The goals and expected
benefits of the admission;
(c) The
initial estimated time frames for goal accomplishment; and
(d) The services needed.
(4) The following list of conditions shall
not be considered brain injuries requiring specialized rehabilitation under
this section:
(a) A stroke treatable in a
nursing facility providing routine rehabilitation services;
(b) A spinal cord injury in which there is no
known or obvious injury to the intercranial central nervous system;
(c) Progressive dementia or other mentally
impairing condition;
(d) Depression
or psychiatric disorder in which there is no known or obvious central nervous
system damage;
(e) An intellectual
disability or birth defect related disorder of long standing; or
(f) Neurological degenerative, metabolic or
other medical condition of a chronic, degenerative nature.
(5) An individual may qualify for coverage
under the brain injury program if:
(a) The
individual has a stable medical condition with complicating care needs that
prevent the individual from caring for himself or herself in an ordinary manner
outside an institution;
(b) The
individual has sufficient neurobehavioral sequelae resulting from the brain
injury that, when taken in combination, require specialized rehabilitation
services; and
(c) The following
criteria are met:
1. The individual shall not
have previously received specialized rehabilitation services (an individual
discharged for the purpose of transfer to another brain injury facility shall
not be considered to have "previously received specialized rehabilitation
services") as established in this section;
2. The individual shall have the potential
for rehabilitation;
3. The care
shall be prior authorized on an individual basis by the department;
and
4. No more than 180 calendar
days shall be approved per authorization.
Section 7. Requirements,
Standards, and Preauthorization of Certified Distinct-part Nursing Facility
Ventilator Services. An individual who is ventilator dependent and meets the
high-intensity nursing care patient status criteria established in Section 4(2)
of this administrative regulation shall be provided care in a certified
distinct-part ventilator nursing facility unit providing specialized ventilator
services if the care is preauthorized using criteria specified in this section.
(1) To participate in the Medicaid Program as
a distinct-part nursing facility ventilator service provider:
(a) A nursing facility shall operate a
program of ventilator care within a certified distinct-part nursing facility
unit that meets the needs of all ventilator patients admitted to the unit;
and
(b) A certified distinct-part
nursing facility unit shall:
1. Not have less
than twenty (20) beds certified for the provision of ventilator care;
2. Have had an average patient census of not
less than fifteen (15) patients during the calendar quarter preceding the
beginning of the facility's rate year or the quarter for which certification is
being granted in order to qualify as a distinct-part ventilator nursing
facility unit;
3. Have a ventilator
machine owned by the facility for each certified bed with an additional backup
ventilator machine required for every ten (10) beds; and
4. Have a program for discharge planning and
weaning from the ventilator.
(2) This subsection shall constitute the
patient criteria and treatment characteristics for a distinct-part ventilator
nursing facility.
(a) An individual shall be
considered ventilator dependent if the individual:
1. Requires:
a. This mechanical support for twelve (12) or
more hours per day; and
b.
Twenty-four (24) hours per day high-intensity nursing care services;
or
2. Is in an active
weaning program ordered by and under the management of a physician and reviewed
and approved by the department; and
a. The
goal of the active weaning program is to attain the least mechanical support in
the least invasive manner that is consistent with the maximal function of the
individual and ultimately no mechanical respiratory support;
b. The individual demonstrates steady
progress in decreasing the number of hours and dependence upon the ventilator
as documented in the individual's physician and nursing progress notes;
and
c. The individual requires
twenty-four (24) hours per day high-intensity nursing care
services.
(b)
An individual shall not be considered ventilator dependent due to being in an
active weaning program if:
1. The individual
is no longer demonstrating steady progress in decreasing the number of hours
and dependence upon the ventilator; or
2. The individual has been off the ventilator
for seventy-two (72) consecutive hours.
(c) An admission from hospitalization or
other location shall demonstrate two (2) weeks clinical and physiologic
stability including applicable weaning attempts prior to transfer from the
hospital or other location.
(d) A
physician's order shall specify that the services shall not be provided in an
alternative setting due to the medical stability and safety needs of the
individual.
(3) A patient
status determination shall be made taking into consideration the following
factors:
(a) Alternative care
possibilities;
(b) Goals for
patient care;
(c) Primary
hypoventilation, restrictive lung, ventilatory muscular dysfunction, or
obstructive airway disorders needs that may necessitate mechanical ventilator
and related care;
(d) Patient
treatment characteristics;
(e) Home
care potential;
(f) Suitability of
transfer to the ventilator care unit; and
(g) Provision of an appropriate place of
care.
Section
8. Denial of Patient Status. If an individual does not meet
Medicaid criteria for admission or continued stay in a nursing facility,
nursing facility with Medicaid waiver, or ICF-IID, the individual may appeal
the denial in accordance with
907
KAR 1:563.
Section
9. Reserved Bed Days. The department shall cover and reimburse for
reserved bed days as established in this section.
(1) In accordance with subsection (3) of this
section, reserved bed days, per resident, for an NF or an NF-W shall be:
(a) Covered for a maximum of fourteen (14)
days per calendar year due to hospitalization. Accumulated bed reserve days
shall follow a resident if the resident relocates to another facility within a
calendar year rather than starting over at zero due to the
relocation;
(b) Covered for a
maximum of ten (10) days per calendar year for leaves of absence other than
hospitalization. Accumulated bed reserve days shall follow a resident if the
resident relocates to another facility within a calendar year rather than
starting over at zero due to the relocation;
(c) Reimbursed at seventy-five (75) percent
of a facility's rate if the facility's occupancy percentage is ninety-five (95)
percent or greater; and
(d)
Reimbursed at fifty (50) percent of a facility's rate if the facility's
occupancy percentage is less than ninety-five (95) percent.
(2) In accordance with subsection
(3) of this section, for an ICF-IID:
(a)
Reserved bed days, per resident, for an ICF-IID shall:
1. Be covered for a maximum of forty-five
(45) days within a calendar quarter; and
2. Not exceed fifteen (15) calendar days per
stay due to hospitalization; and
(b) More than thirty (30) consecutive
reserved bed days due to hospitalization plus leave of absence or due to leave
of absence shall not be approved for coverage.
(3) Coverage during an individual's absence
due to hospitalization or due to leave of absence shall be contingent upon the
following conditions being met:
(a) The
individual shall:
1. Be in Medicaid payment
status in the level of care the individual is authorized to receive;
and
2. Have been a resident of the
facility at least overnight;
(b) An individual for whom Medicaid is making
Medicare coinsurance payments shall not be considered to be in Medicaid payment
status for purposes of this policy;
(c) The individual shall be reasonably
expected to return to the same level of care;
(d) Due to demand at the facility for beds at
that level, there shall be a likelihood that the bed would be occupied by
another patient were it not reserved;
(e) The hospitalization shall be for
treatment of an acute condition, and not for testing, brace-fitting, or another
noncovered service;
(f) For a leave
of absence other than for hospitalization, the individual's plan of care shall
include a physician's order providing for leave; and
(g) A leave of absence shall include a visit
with a relative or friend, or a leave to participate in a state-approved
therapeutic or rehabilitative program.
(4) Bed reservation days shall not be
available for an individual admitted to a psychiatric hospital or
ICF-IID.
(5) An NF shall advise a
resident prior to the resident's departure from the facility if the NF chooses
not to reserve a bed for the resident.
Section 10. Determination of Patient Care
Status.
(1) Prior to or on the date of
admission of an individual, an NF shall complete a level of care application in
a department approved system, which consists of a:
(a) Level I PASRR in accordance with
907 KAR
1:755, Section 4; and
(b) A level of care request for admission in
a department approved system, except for an individual requesting
institutionalized hospice.
(2) Compliance with
907 KAR
1:755 shall be required in order for an individual to
be admitted to an NF.
(3)
(a) The department shall:
1. Approve the level of care
application;
2. Deny the level of
care application; or
3. Request
more information from the facility if all required information was not
previously provided.
(b)
Notification of denial shall be sent to the:
1. Patient or their responsible party;
and
2. NF.
(c) If the admission is approved, the
department shall:
1. Except as provided by
paragraph (d) of this subsection, perform an onsite continuing stay review
within thirty (30) calendar days of the admission to ensure the resident
continues to meet the nursing facility level of care criteria in accordance
with this administrative regulation; and
2. Re-certify the resident every 180 calendar
days.
(d) There shall not
be a review pursuant to paragraph (c)1. of this subsection for an individual
who has a Level II PASRR.
(4) Prior to or on the date of admission of
an individual to an ICF-IID, the facility shall complete a level of care
request for admission in a department approved system.