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

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WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCESAGREEMENTFORNURSING FACILITY PARTICIPATION IN THE TITLE XIX MEDICAID PROGRAMNursing Home Name: __________________________________________________________Address: ____________________________________________________________________Type of State License: ______Nursing Facility _______ NPI#___________________________Title XIX Medicaid Provider Number: ______________________________________________This Agreement, made and entered into on this day of _____ (mo./yr.) by andbetween the West Virginia Department of Health and Human Resources Bureau for MedicalServices, hereinafter designated as the Bureau, and the_________________________________________________(name of Nursing Home), aProvider of Service hereinafter designated as the Nursing Home. This agreement is for thepurpose of defining the responsibilities of the parties hereto in providing needed medical care inthe form of medical services to eligible members under the Medical Assistance Program, TitleXIX (Medicaid) of the Social Security Act and for payment of such services.To participate in the West Virginia Medicaid Title XIX Program, the Nursing Home must:be licensed as a nursing home under the applicable State Laws of West Virginia andLocal Law;meet and maintain the standards for licensure, on a continuing basis;be administered by a licensed nursing home administrator who is legally responsible forestablishing and implementing policies regarding the management and operation of thehome and who holds an approved, current license, as required by State law;meet all Federal and State standards for participation in the Title XIX Medicaid Program;and,remain in substantial compliance with all other applicable Federal, State, and Local laws,rules, and regulations affecting the health and safety of all residents.I. THE NURSING HOME AGREES TO FOLLOW THE FEDERAL REGULATIONS 42 PART483, AS UPDATED AND REQUIREMENTS FOR STATES AND LONG TERM CAREFACILITIES OF THE FEDERAL REGULATIONS.The Nursing Home agrees to complete and sign this Nursing Home Agreement toparticipate in the Title XIX Medicaid Program and to keep the information in the agreementcurrent. Any/all succeeding change(s) in this agreement require(s) notification to the Bureauwithin five (5) working days and will constitute an amendment to this Agreement. Failure tokeep the information current constitutes a breach of this Agreement. The Nursing Home willunderstand that any breach or violation of any of these provisions shall make this entireAgreement, at the Bureau’s discretion, subject to immediate cancellation. This includes all
Changes in Ownership, either in part or whole, of the Nursing Home includingadministration/management changes and stock or asset transfers for Ownership. This alsoincludes Ownership transfers, either through sale or otherwise; the Nursing Home’s providernumber may not be transferred or used by another entity, and payments under this scenarioare not reimbursable.The Nursing Home agrees to accept the Bureau’s payment, in full, for services renderedaccording to 42 CFR Part 483. The payment will be accepted as payment in full for the careof the resident and no additional charge will be made to the resident, any member of thefamily, estate or any other payer source for any supplementation of payment for services.The Nursing Home agrees to provide the Bureau with full and complete information on allpersons having an ownership, managerial or controlling interest in the nursing home and topromptly report any changes which would affect the current accuracy of the informationrequired to be supplied. This includes continuance with the provider enrollment applicationinformation submitted to the Bureau. The Nursing Home agrees to supply the Bureau or itsdesignee with any / all changes in the current enrollment application within five (5) businessworking days of a change. The Nursing Home agrees to notify the Bureau of all structuralchanges proposed in the physical environment prior to implementation and inform theBureau when the proposed structural changes to the facility are completed.The nursing home will keep current with Federal Laws, State Laws, Medicaid State PlanChanges, and Medicaid Policy services.II.THE BUREAU AGREES:A. To pay for such nursing services in amounts and under conditions determined by theBureau, for persons receiving nursing care, who have been determined by theDepartment to be eligible for such assistance under the Title XIX Medicaid Program;B. To make such payments in accordance with the applicable laws and after a properclaim is submitted and approved;C. To withhold payments, if necessary, due to irregularity from whatever cause, untilsuch irregularity or difference can be adjusted with the view toward providingexcellence in nursing care within the limitations of the law;D. To provide the Nursing Home reasonable notice of any impending change in itsstatus as a participating Nursing Home with the Bureau for Medical Services;E. To provide an administrative review procedure for the Nursing Home, in the eventthe Bureau suspends or cancels the Nursing Home's participation in the Title XIXMedicaid Program or denies payment;F. To provide methods and procedures for establishing medical review of care andservices in accordance with the Title XIX Medicaid Program.III.THE BUREAU AND THE NURSING HOME MUTUALLY AGREE:A. That, in the event the Federal and/or State laws should be amended or judiciallyinterpreted so as to render the fulfillment of this Agreement on the part of either party
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CHAPTER 514 - COVERED SERVICES, LIM
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514.4.11 Services Provided by Outsi
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514.10.4 Podiatry Services ........
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514.13.47 Field Audit .............
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in the balance as part of the proce
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Minimum Data Set (MDS) - a core set
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eimbursement and annually thereafte
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A change in ownership of a nursing
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The Commissioner, in his or her dis
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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
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: CHAPTER 514NURSING FACILITY SERVICE
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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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