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

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IV. PHYSICIAN RECOMMENDATIONDATE: ___________________________________NAME: ________________________________35. Prognosis - Check one only: a Stable b Improving c Deteriorating d TerminalOther _________________________________________________________________________36. Rehabilitative Potential (Check one only) a ___ Good b ___ Limited c___ Poor37. Diagnosis:a. Primary ______________________________________________________________________________b. Secondary_____________________________________________________________________________c. Other medical conditions requiring services_________________________________________________38. Physician RecommendationsA. FOR NURSING FACILITY PLACEMENT ONLYOn the basis of present medical findings, theindividual may eventually be able to returnhome or be discharged.a ___ Yesb___ NoIf yes, check one of the following:B. I recommend that the services and care to meet theseneeds can be provided at the level of care indicated.a. Nursing Homeb. Nursing Home waiting A/D Waiverc. A/D Waiverd. Personal Carea. Less than 3 monthsb. 3-6 monthsc. Over 6 monthsd. Terminal illness39. To the best of my knowledge, the patient’s medical and related needs are essentially as indicated above (Mustbe signed by M.D. or D.O.)____________________________________________Physicians SignatureMD/DO____________________________________________Date This Assessment Completed:TYPE OR PRINT Physicians name/address below:________________________________________________________________________________________________________________________________________________________________________________________________________DISCLAIMER: Approval of this form does not guarantee eligibility for payment under the State Medicaid Plan.NOTE: Information gathered from this form may be utilized for statistical/data collection.PAS-2000 Page 5 of 6 Effective 11-1-01Revised: 11/2001
V. ELIGIBILITY DETERMINATION DATE: ____________________________NAME: ____________________________DEPARTMENT USE ONLYLEVEL I (Medical Screen)Medical and other professional personnel of the Medicaid Agency or its designees MUST evaluate eachindividuals need for admission by reviewing and assessing the evaluations required by regulation.Exemptions from requirements for Level II Assessment40. Does the individual have or require:a. Diagnosis of dementia (Alzheimer’s or related disorder)? Yes Nob. Thirty days of respite care? Yes Noc. Serious Medical Condition? Yes No41. Medical Eligibility Determination:a. Nursing Facility Services/Aged/Disabled Waiver b. Personal Care Servicesc. No Services Needed d. Optional Services42. PASARR Determination:a. Level II required b. Level II not required___________________________________________________________ ___________________Nurse Reviewers Signature - Title Date Control NumberPrinted Name_______________________________________________________________________WAIVER ONLY: Level of Care:_____________ Number of Hours:______________________DEPARTMENTAL USE ONLYLEVEL II (MI/MR Screen)(Completed by PASARR Provider)43. DETERMINATION:a. Nursing facility services needed - Specialized services not needed.b. Nursing facility services needed - Specialized services needed.c. Alzheimer’s or related disorder identified.d. Thirty day Respite care needed.e. Terminal illness identified.f. Serious illness identified.g. Nursing facility services not needed.44. RECOMMENDED PLACEMENT:a. Nursing Facility Services/Aged/Disabled Wavierb. Psychiatric Hospital (21 years or under)c. ICF/MR or I/DD Waiverd. Other-Identify:___________________________________________________________________________________________ _____________________________________________PASARR Reviewers Signature Title Printed Name__________________________________________ _________________________________________Agency NameDateA COPY OF THIS FORM MUST BE IN THE INDIVIDUAL’S MEDICAL RECORDSPAS-2000 Page 6 of 6 Effective: 11-1-01
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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
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Employment of an individual with on
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514.4.7 Administrative PoliciesThe
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The agreement / contract must clear
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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 and 72: CHAPTER 514NURSING FACILITY SERVICE
Page 73 and 74: Changes in Ownership, either in par
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Page 77 and 78: II. MEDICAL ASSESSMENTDate ________
Page 79: III. MI/MR ASSESSMENTDATE: ________
Page 83 and 84: West Virginia Department of Health
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