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

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CHAPTER 514 – COVERED SERVICES, LIMITATIONS, AND EXCLUSIONS FORNURSING FACILITY SERVICESTABLE OF CONTENTSTOPICPAGE NO.Introduction ................................................................................................................................. 7514.1 Definitions .................................................................................................................. 7514.2 Provider Participation Requirements ........................................................................ 11514.2.1 State Licensure ........................................................................................................ 11514.2.2 Provider Enrollment ................................................................................................. 11514.2.3 Nursing Facility Provider Agreement ........................................................................ 11514.2.4 Enforcement ............................................................................................................ 12514.2.5 Ownership ............................................................................................................... 12514.2.6 Change of Ownership .............................................................................................. 13514.2.7 Bed Configuration .................................................................................................... 15514.2.8 Noncompliance of Nursing Facilities ........................................................................ 16514.3 Provider Certification ............................................................................................... 17514.3.1 Denial of Payment for New Admission (DPNA)........................................................ 17514.3.2 Civil Money Penalty (CMP) ...................................................................................... 18514.3.3 Temporary Management/Administrator .................................................................... 18514.4 Standards for Nursing Facilities ............................................................................... 18514.4.1 Employment Restrictions ......................................................................................... 19514.4.2 Staffing Requirements ............................................................................................. 20514.4.3 General Staffing Information .................................................................................... 20514.4.4 General Administration ............................................................................................ 21514.4.5 Governing Body and Management .......................................................................... 21514.4.6 Physical Environment Requirements ....................................................................... 21514.4.7 Administrative Policies ............................................................................................. 22514.4.8 Emergency/Disaster Preparedness Procedure ........................................................ 22514.4.9 Resident Rights ....................................................................................................... 23514.4.10 Hospital Transfer Agreement ................................................................................... 23Department of Health and Human Resources Chapter 514: Nursing Facility Services Page 1January 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.
514.4.11 Services Provided by Outside Sources .................................................................... 23514.5 Qualified Staff .......................................................................................................... 24514.5.1 Administrator ........................................................................................................... 24514.5.2 Medical Director ....................................................................................................... 24514.5.3 Physician Services ................................................................................................... 25514.5.4 Nursing Services ..................................................................................................... 25514.5.5 Director of Nursing (DON) ........................................................................................ 26514.5.6 Licensed Nurse ........................................................................................................ 26514.5.7 Certified Nurse Aide (CNA) ...................................................................................... 26514.5.8 Social Services ........................................................................................................ 26514.5.9 Activities Director ..................................................................................................... 27514.5.10 Food and Dietary Director ........................................................................................ 28514.6 Eligibility Requirements ........................................................................................... 28514.6.1 Application Procedure .............................................................................................. 28514.6.2 Pre Admission Screening and Resident Review (PAS) ............................................ 29514.6.3 Medical Eligibility Regarding the Pre-Admission Screening ..................................... 29514.6.4 Physician Certification ............................................................................................. 31514.6.5 Medical Necessity (Level I) ...................................................................................... 31514.6.6 Pre Admission Screening and Resident Review (PASRR) (Level II) ........................ 31514.6.7 Specialized Services for I/DD .................................................................................. 32514.6.8 Specialized Services for Mental Illness .................................................................... 32514.6.9 Fair Hearing Process ............................................................................................... 33514.6.10 Contribution to the Cost of Care............................................................................... 33514.6.11 Admission Policies ................................................................................................... 34514.6.12 Physician Recertification of Continued Stay ............................................................. 34514.7 Mandatory Services ................................................................................................. 34514.7.1 In-Service Education Program ................................................................................. 34514.7.2 Pharmacy Services .................................................................................................. 35514.7.3 Rehabilitative Services ............................................................................................ 36514.7.4 Minimum Data Set (MDS) ........................................................................................ 36Department of Health and Human Resources Chapter 514: Nursing Facility Services Page 2January 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: CHAPTER 514 - COVERED SERVICES, LIM
Page 5 and 6: 514.10.4 Podiatry Services ........
Page 7 and 8: 514.13.47 Field Audit .............
Page 9 and 10: in the balance as part of the proce
Page 11 and 12: Minimum Data Set (MDS) - a core set
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
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certification must include document
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It is not mandatory for providers t
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ownership and control has occurred
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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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