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

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individual has not been a member of Medicaid upon admission to the nursing facility, a newPAS will need to be completed before the Medicare benefit has ended and the AdvancedBeneficiary Notice of Medicare Non-Coverage has been issued. This ensures proper placementif circumstances warrant long-term placement for the individual in the nursing facility afterMedicaid becomes the primary payer.A new medical assessment must be completed for Medicaid Medical Eligibility for the nursingfacility resident for all of the following situations:Application for the Medicaid nursing facility benefit;Resident transfers from one nursing facility to another nursing facility, even if the transferis within the same corporation;Resident returns to the same nursing facility from any healthcare setting other than anacute care hospital;Resident transfers to an acute care hospital, then to a hospital-based skilled nursing unit,and then returns to the original nursing facility;Resident converts from private pay or any other payer to Medicaid; orExpiration of the Current PAS due to time limitation.514.6.4 Physician CertificationA physician who has knowledge of the individual must certify the need for nursing facility care.Medical eligibility for persons in need of nursing facility services is determined initially from theinformation supplied by the physician on the specified assessment tool. The information mustbe current as to the individual’s need for nursing facility care. With the physician’s signatureand date, this is considered the certification for nursing facility services.514.6.5 Medical Necessity (Level I)All individuals admitted or requesting admission to a Medicaid certified nursing facility must bescreened for the possible presence of a major mental illness, and/or anintellectual/developmental disability (MI/I/DD). This review is identified as the Level I evaluation.Any individual identified with the possible presence of mental health issues must be furtherevaluated.514.6.6 Pre-Admission Screening and Resident Review (PASRR) (Level II)If the Level I evaluation found the possible presence of MI and/or I/DD, further evaluation of theindividual must be completed to obtain a definitive diagnosis and the need for specializedservices for the mental health condition. This evaluation is identified as a Level II evaluationand must be completed by an individual identified by the BMS as an approved Level IIDepartment of Health and Human Resources Chapter 514: Nursing Facility Services Page 31January 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.
evaluator. All Level II evaluators are either licensed psychologists or Board certifiedpsychiatrists.It is the responsibility of the facility in which the PAS is completed, to arrange for the Level IIevaluation. This evaluation must be completed, including a report of the mental health statusand whether specialized services are needed, within (7 to 9) seven to nine days following thereferral. The Level II must be completed prior to the individual’s admission into a nursingfacility. Upon completion of the evaluation, both the referring entity and the PASARR Level IIevaluator must provide the complete mental health evaluation and the original Level I evaluationto the receiving nursing facility. Additionally, the results of the evaluation shall be sent toPsychological Consultants and Associates (PC&A) via mail to 202 Glass Drive, Cross Lanes,West Virginia 25313 or fax to (304) 776-7247 on the applicable forms.42 CFR 483.106 (ii) states “In cases of transfer of a resident with MI or IDD from a nursingfacility to a hospital or to another nursing facility , the transferring nursing facility is responsiblefor ensuring that copies of the resident’s most recent PASARR and resident assessment reportsaccompany the transferring resident”. This regulation applies to all residents of nursing facilities.Repeat Level II evaluations are necessary when there is an acute exacerbation of the mentalillness resulting in an inpatient admission to a psychiatric facility/psychiatric unit. Thedischarging facility must complete a new PAS, assuring that #31 on the PAS is completedaccurately, in which a Level II will be triggered.514.6.7 Specialized Services for I/DDSpecialized services for an individual identified as I/DD are a continuous program for anindividual requiring aggressive, consistent implementation of a program of specialized andgeneric training, treatment, health and related services developed by an IDT that is directedtowards:The acquisition of the behaviors necessary for the individual to function with as muchself-determination and independence as possible; andThe prevention or deceleration of regression or loss of their current optimal functionalstatus.These services are generally provided in an intermediate care facility for persons with I/DD or arelated condition. If the resident is presently residing in a nursing facility when the Level II iscompleted and specialized services for I/DD is indicated, and the responsible party refuses thisrecommendation, this refusal must be documented in the resident’s record and readdressedwith the responsible party on a continuing quarterly basis or until a Level II recommendsotherwise.514.6.8 Specialized Services for Mental IllnessSpecialized services for an individual with an acute exacerbation of a major mental illness arethe continuous and aggressive implementation of an individualized plan of cares that:Department of Health and Human Resources Chapter 514: Nursing Facility Services Page 32January 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 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: #27: Individual has skilled needs i
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
Page 61 and 62: The Model Nursing Facility Standard
Page 63 and 64: Starting with its total costs, incl
Page 65 and 66: eimbursable. For example: if a faci
Page 67 and 68: 514.13.37 Cost AdjustmentReported f
Page 69 and 70: If it has been determined that a fa
Page 71 and 72: CHAPTER 514NURSING FACILITY SERVICE
Page 73 and 74: Changes in Ownership, either in par
Page 75 and 76: CHAPTER 514NURSING FACILITY SERVICE
Page 77 and 78: II. MEDICAL ASSESSMENTDate ________
Page 79 and 80: III. MI/MR ASSESSMENTDATE: ________
Page 81 and 82: V. ELIGIBILITY DETERMINATION DATE:
Page 83 and 84:
West Virginia Department of Health
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