Chapter 514 - Nursing Facility Services - DHHR - State of West ...

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statement that the requirement was not met, and the evidence to support the determination ofnoncompliance.Denial of Payment for New Admissions (DPNA) - the denial of Medicaid payment for newadmissions when the nursing facility no longer meets the standards of facility certification.Discharge - the termination of a resident’s affiliation with the nursing facility, achieved throughthe permanent move of a resident to another facility or setting that operates independently fromthe nursing facility.Discharge Planning - the organized process of identifying the approximate length of stay andthe criteria for exit of a resident from the current service to an appropriate setting to meet theindividual’s needs. Discharge planning begins upon the day of admission to the nursing facilityand includes provision for appropriate follow-up services.Dually Certified Facility - a facility which is certified to participate in both the Medicare andMedicaid programs.Facility Certification - the official designation by BMS, based on recommendation from theOffice of Health Facility Licensure and Certification (OHFLAC), that the nursing facility meetsMedicaid standards and regulations.Governing Body - the person or group of persons with the ultimate responsibility and authorityfor the operation of the nursing facility.Health Care Authority (HCA) - an organization which administers programs that help containthe rising cost of health care and assure reasonable access to necessary health care services.HCA assures public access to the information compiled under the Rural Health SystemsProgram, the Planning Division, and Certificate of Need Program.Immediate Jeopardy (IJ) - a situation in which the nursing facility’s noncompliance with one ormore certification requirements has caused, or is likely to cause, serious injury, harm,impairment or death of a resident.Interdisciplinary Team (IDT) - a group of professionals, paraprofessionals, non-professionalsand the resident who possess the knowledge, skill, and expertise necessary to accuratelyidentify the comprehensive array of services required to meet the resident’s needs and whodesign specialized programs responsive to the needs of the resident which are to bedocumented in the care plan.Licensed Nursing Home - any institution, residence, place or any part or unit thereof, licensedin accordance with the requirements specified in W. Va. 16-5c et al, in which an accommodationof four or more beds is maintained for the purpose of providing accommodations and care for aperiod of more than twenty-four hours, to persons who are ill or otherwise incapacitated and inneed of extensive, ongoing nursing care due to physical or mental impairment, or providesservices for the rehabilitation of persons who are convalescing from illness or incapacitation.Department of Health and Human Resources Chapter 514: Nursing Facility Services Page 9January 1, 2013DISCLAIMER: This manual does not address all the complexities of Medicaid policies and procedures,and must be supplemented with all State and Federal Laws and Regulations.
Minimum Data Set (MDS) - a core set of screening, clinical, and functional status elementscompleted by an IDT of which the resident is the principal member. It also includes commondefinitions and coding categories that form the foundation of the comprehensive assessment forall residents of long-term care facilities certified to participate in Medicare and Medicaid.Misappropriation of Property - the deliberate misplacement, exploitation, or wrongful misuseof a resident’s belongings or money.Neglect - the failure to provide goods and services necessary to avoid physical harm, mentalanguish, or mental illness.Nursing Facility - defined as an institution (or a distinct part of an institution) which isprimarily engaged in providing skilled nursing care and related services for residents whorequire medical or nursing care, rehabilitation services for the rehabilitation of injured,disabled, or sick persons, or on a regular basis, health-related care and services toindividuals who because of their mental or physical condition require care and services(above the level of room and board) which can be made available to them only throughinstitutional facilities, and is not primarily for the care and treatment of mental diseases andhas in effect a transfer agreement (meeting the requirements of §1861(1)) with one or morehospitals having agreements in effect under §1866.Patient Resource (or Resident Resource) Amount - the amount calculated by the WVDHHRwhich the resident must contribute to the cost of care every month by which the monthlyMedicaid payment is reduced.Personal Needs Allowance - the amount deducted from the member’s monthly income whichallows for personal needs of the nursing facility member.Pre-Admission Screen - the preliminary screen conducted on all persons seeking admission toa nursing facility in order to identify persons with major mental illness or developmentaldisability.Representative - the spokesperson acting in the best interest of the resident. Representativesmay be designated by the residents themselves, court appointed, or physician appointed, inaccordance with state law.Resident - any individual residing in a nursing facility (NF), skilled nursing facility (SNF), ordually certified skilled nursing facility/nursing facility (SNF/NF). For the purpose of Medicaidreimbursement only, the resident may be identified as a Member of the Medicaid program.Resident Council - a group of residents residing in the nursing facility having the right to meetto express grievances in relation to the residents’ general well-being and to makerecommendations concerning nursing facility policies and procedures.Department of Health and Human Resources Chapter 514: Nursing Facility Services Page 10January 1, 2013DISCLAIMER: This manual does not address all the complexities of Medicaid policies and procedures,and must be supplemented with all State and Federal Laws and Regulations.
Page 1 and 2: CHAPTER 514 - COVERED SERVICES, LIM
Page 3 and 4: 514.4.11 Services Provided by Outsi
Page 5 and 6: 514.10.4 Podiatry Services ........
Page 7 and 8: 514.13.47 Field Audit .............
Page 9: in the balance as part of the proce
Page 13 and 14: eimbursement and annually thereafte
Page 15 and 16: A change in ownership of a nursing
Page 17 and 18: The Commissioner, in his or her dis
Page 19 and 20: 514.3.2 Civil Money Penalty (CMP)A
Page 21 and 22: Employment of an individual with on
Page 23 and 24: 514.4.7 Administrative PoliciesThe
Page 25 and 26: The agreement / contract must clear
Page 27 and 28: Where residents are in a nursing fa
Page 29 and 30: 514.5.10 Food and Dietary DirectorI
Page 31 and 32: #27: Individual has skilled needs i
Page 33 and 34: evaluator. All Level II evaluators
Page 35 and 36: It is the responsibility of the nur
Page 37 and 38: abuse and controlled drugs as ident
Page 39 and 40: 514.8.1 Nursing ServicesCovered ser
Page 41 and 42: Upon transfer to another nursing fa
Page 43 and 44: 514.9.2 Transfer and Discharge Poli
Page 45 and 46: the resident’s physical condition
Page 47 and 48: 514.9.10 Conveyance Upon DischargeU
Page 49 and 50: 514.10.6 Emergency Ambulance Transp
Page 51 and 52: 514.10.8 Documentation Requirements
Page 53 and 54: certification must include document
Page 55 and 56: It is not mandatory for providers t
Page 57 and 58: ownership and control has occurred
Page 59 and 60: The standard hours PPD, by bed grou
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The Model Nursing Facility Standard
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Starting with its total costs, incl
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eimbursable. For example: if a faci
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514.13.37 Cost AdjustmentReported f
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If it has been determined that a fa
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CHAPTER 514NURSING FACILITY SERVICE
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Changes in Ownership, either in par
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CHAPTER 514NURSING FACILITY SERVICE
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II. MEDICAL ASSESSMENTDate ________
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III. MI/MR ASSESSMENTDATE: ________
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V. ELIGIBILITY DETERMINATION DATE:
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West Virginia Department of Health
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