Louisiana Administrative Code › Title 50 - PUBLIC HEALTH-MEDICAL ASSISTANCE › Part II - Nursing Facilities › Subpart 3 - Standards for Payment › Chapter 103 - Standards for Payment for Intermediate Care Facilities for the Mentally Retarded (ICF/MR) › Subchapter A - Foreword, Definitions and Acronyms › Section II-10303 - Definitions and Acronyms Specific to Mental Retardation and Other Developmental Disabilities

Current through Register Vol. 50, No. 6, June 20, 2024
A.
					 Definitions regarding Mental Retardation are adopted from the American
					 Association on Mental Deficiency
Manual on Terminology and
					 Classification in Mental Retardation
, 1977 Edition.
B. Definitions for Developmental Disabilities
					 are taken from the 1983 amended R.S. 28:330-444 based on Public Law 95-602.
C. All clients must meet the criteria for
					 mental retardation and other developmental disabilities in order to qualify for
					 Title XIX reimbursement for ICF/MR services.
AAMR
-American Association of Mental
						Retardation (formerly the AAMD-American Association of Mental
						Deficiency).
Abuse
-the infliction of physical or
						mental injury to a client or causing a client's deterioration to such an extent
						that his/her health, moral or emotional well-being is endangered. Examples
						include, but are not limited to: sexual abuse, exploitation or extortion of
						funds or other things of value.
Active Treatment
-an aggressive and
						consistent program of specialized and generic training, treatment, health and
						related services directed toward the acquisition of behaviors necessary for the
						client to function with as much self determination and independence as possible
						and the prevention and deceleration of regression or loss of current optimal
						functional status.
Acuity Factor
- an adjustment factor
						which will modify the direct care portion of the Inventory for Client and
						Agency Planning (ICAP) rate based on the ICAP level for each resident.
Adaptive Behavior
-the effectiveness or
						degree with which the individual meets the standards of personal independence
						and social responsibility expected for his age and cultural group. Since these
						exceptions vary for different age groups, deficits in adaptive behavior will
						vary at different ages.
Administrative and Operating
						Costs
-include:
a. in-house and
					 contractual salaries;
b.
					 benefits;
c. taxes for
					 administration and plant operation maintenance staff;
d. utilities;
e. accounting;
f. insurances;
g. maintenance staff;
h. maintenance supplies;
i. laundry and linen;
j. housekeeping; and
k. other administrative type
					 expenditures.
A
gency-See Medicaid Agency.
Ambulatory
-an ability to walk
						about.
ANSI
-American National Standards
						Institute.
Applicant
-an individual whose written
						application for Medicaid has been submitted to the agency but whose eligibility
						has not yet been determined.
ART
-Accredited Record Technician.
Attending Physician
-a physician,
						currently licensed by the Louisiana State Board of Medical Examiners,
						designated by the client, family, agency, or responsible party as responsible
						for the direction of overall medical care of the client.
Autism
-a condition characterized by
						disturbance in the rate of appearance and sequencing of developmental
						milestones: abnormal responses to sensations, delayed or absent speech and
						language skills while specific thinking capabilities may be present, and
						abnormal ways of relating to people and things.
BHSF
-Bureau of Health Services
						Financing. See
Health Services Financing
.
Board Certified Social Worker (BCSW)
-a
						person holding a Master of Social Work (MSW) degree who is licensed by the
						Louisiana State Board of Certified Social Work Examiners.
Capacity for Independent Living
-the
						ability to maintain a full and varied life in one's own home and
						community.
Capital Costs
-include:
a. depreciation;
b. interest expense on capital
					 assets;
c. leasing
					 expenses;
d. property taxes;
					 and
e. other expenses related to
					 capital assets.
Care Related Costs
- include in-house and
						contractual salaries, benefits, taxes, and supplies that help support direct
						care but do not directly involve caring for the patient and ensuring their well
						being (e.g., dietary and educational). Care related costs would also include
						personal items, such as clothing, personal hygiene items (soap, toothpaste,
						etc.), hair grooming, etc.
Cerebral Palsy
-a permanently disabling
						condition resulting from damage to the developing brain, which may occur
						before, during or after birth and results in loss or impairment of control over
						voluntary muscles.
Certification
-a determination made by
						the Department of Health and Hospitals (DHH) that an ICF/MR meets the necessary
						requirements to participate in Louisiana as a provider of Title XIX (Medicaid)
						Services.
Change in Ownership (CHOW)
-any change in
						the legal entity responsible for the operation of an ICF/MR.
Chief Executive Officer (CEO)
-an
						individual licensed, currently registered, and engaged in the day to day
						administration/management of an ICF/MR.
Client
-an applicant for or recipient of
						Title XIX (Medicaid) ICF/MR services.
Code of Federal Regulations (CFR)
-the
						regulations published by the federal government. Section 42 includes
						regulations for ICF/MRs.
Comprehensive Functional
						Assessment
-identifies the client's need for services and provides
						specific information about the client's ability to function in different
						environments, specific skills or lack of skills, and how function can be
						improved, either through training, environmental adaptations, or provision of
						adaptive, assistive, supportive, orthotic, or prosthetic equipment.
Developmental Disabilities (DD)
-severe,
						chronic disabilities which are attributable to mental retardation, cerebral
						palsy, autism, epilepsy or any other condition, other than mental illness,
						found to be closely related to mental retardation. This condition results in an
						impairment of general intellectual functioning or adaptive behavior similar to
						that of mental retardation, and requires treatment or services similar to those
						required for MR/DD are manifested before the person reaches age 22 and are
						likely to continue indefinitely.
Developmental Period
-a period from birth
						to before a person reaches age 22.
DHH
- Department of Health and Hospitals
						or its designee.
DHHS
-the federal Department of Health
						and Human Services in Washington, D.C.
Direct Care Costs
-consist of all costs
						related to the direct care interaction with the patient.
Direct care
						costs
include:
a. in-house
					 and contractual salaries;
b.
					 benefits; and
c. taxes for all
					 positions directly related to patient care, including:
i. medical;
ii. nursing;
iii. therapeutic and training;
iv. ancillary in-house services;
					 and
v. recreational.
Dual Diagnosis
-clients who carry
						diagnoses of both mental retardation and mental illness.
Enrollment
-process of executing a
						contract with a licensed and certified ICF/MR provider for participation in the
						Medical Assistance Program. Enrollment includes the execution of the provider
						agreement and assignment of the provider number used for payment.
Epilepsy
-disorder of the central nervous
						system which is characterized by repeated seizures which are produced by
						uncontrolled electrical discharges in the brain.
Facility
-an Intermediate Care Facility
						for the Mentally Retarded and Developmentally Disabled.
Fiscal Intermediary
-the private fiscal
						agent with which DHH contracts to operate the Medicaid Management Information
						System. It processes the Title XIX (Medicaid) claims for services provided
						under the Medical Assistance Program and issues appropriate payment(s).
General Intellectual Functioning
-results
						obtained by assessment with one or more of the individually administered
						general intelligence tests developed for that purpose.
HCFA
-Health Care Financing
						Administration.
Health Services Financing, Bureau of
						(BHSF)
-a division of DHH responsible for administering, overseeing,
						and monitoring the state's Medicaid Program.
HSS
-Health Standards Section within
						BHSF, the section responsible for licensing, certifying and enrolling
						ICFs/MR.
ICAP-Inventory for Client and Agency
						Planning.
A standardized instrument for assessing adaptive and
						maladaptive behavior and includes an overall service score. This ICAP service
						score combines adaptive and maladaptive behavior scores to indicate the overall
						level of care, supervision or training required.
ICAP Service Level
- ranges from 1 to 9
						and indicates the service need intensity. The lower the score the greater is
						the client need.
ICAP Service Score
-indicates the level
						of service intensity required by an individual, considering both adaptive and
						maladaptive behavior.
NOTE: The relationship between the service level and
						service score for ICAP support levels is as follows.
ICAP Relationship Graph
ICAP Service Level
ICAP Service Score
ICAP Support Levels
Pervasive +
1
1-19
Pervasive
2
20-29
Extensive
3
30-39
4
40-49
Limited
5
50-59
6
60-69
7
70-79
Intermittent
8
80-89
9
90+
Index Factor
-this factor will be based
						on the
Skilled Nursing Home without Capital Market Basket
						Index
published by Data Resources Incorporated or a comparable index
						if this index ceases to be published.
I.Q
.-Intelligence Quotient.
Individual Habilitation Plan (IHP)
-the
						written ongoing program of services developed for each client by an
						interdisciplinary team in order for that client to achieve or maintain his/her
						potential. The plan contains specific, measurable goals, objectives and
						provides for data collection.
Individual Plan of Care
(IPC)-same as
						Individual Habilitation Plan.
Individual Program Plan
(IPP)-same as
						Individual Habilitation Plan.
Individual Service Plan
(ISP)-same as
						Individual Habilitation Plan.
Interdisciplinary Team (IDT)
-a group of
						individuals representing the different disciplines in the formulation of a
						client's Individual Habilitation Plan. That team meets at least annually to
						develop and review the plans, more frequently if necessary.
Intermediate Care Facility for the Mentally Retarded and
						Developmentally Disabled (ICF/MR)-same as Facility for the Mentally Retarded or
						Persons with Related Conditions.
Learning
-general cognitive competence.
						The ability to acquire new behaviors, perceptions, and information and to apply
						previous experiences in new situations.
Legal Status
-a designation indicative of
						an individual's competency to manage their affairs.
Level of Care (LOC)
-service needs of the
						client based upon his/her comprehensive functional status.
Licensed
-a determination by the
						Louisiana Department of Health and Hospitals, Bureau of Health Service
						Financing, that an ICF/MR meets the state requirements to participate in
						Louisiana as a provider of ICF/MR services.
Living Unit
-a place where a client lives
						including sleeping, training, dining and activity areas.
LPN
-Licensed Practical Nurse.
LSC
-Life Safety Code.
LTC
-Long Term Care.
Major Life Activities
-any one of the
						following activities or abilities:
a.
					 self-care;
b. understanding and use
					 of language;
c. learning;
d. mobility;
e. self-direction;
f. capacity for independent living.
Measurable Outcomes
-a standard or goal
						by which performance is measured and evaluated.
Mechanical Support
-a device used to
						achieve proper body position or balance.
Medicaid
-medical assistance provided
						according to the State Plan approved under Title XIX of the Social Security
						Act.
Medicaid Agency
-the single state agency
						responsible for the administration of the Medical Assistance Program (Title
						XIX). In Louisiana, the Department of Health and Hospitals is the single state
						agency.
Medicaid Management Information System
						(MMIS)
-the computerized claims processing and information retrieval
						system which includes all ICF/MR providers eligible for participation in the
						Medical Assistance Program. This system is an organized method for payment for
						claims for all Title XIX Services.
Medical Assistance Program (MAP)
-another
						name for the Medicaid Program.
Medicare
-the federally administered
						Health Insurance program for the aged, blind and disabled under the Title XVIII
						of the Social Security Act.
Medicare Part A
-the Hospital Insurance
						program authorized under Part A of Title XVIII of the Social Security
						Act.
Medicare Part B
-the Supplementary
						Medical Insurance program authorized under Part B of Title XVIII of the Social
						Security Act.
Mental Retardation (MR)
-significantly
						sub-average general intellectual functioning existing concurrently with
						deficits in adaptive behavior, and manifested during the developmental
						period.
NOTE: It shall be emphasized that a finding of low I.Q.
						is never by itself sufficient to make the diagnosis of mental retardation or in
						evaluating its severity. A low I.Q. shall serve only to help in making a
						clinical judgement regarding the client's adaptive behavioral capacity. This
						judgement also includes present functioning including academic and vocational
						achievement, motor skills, and social and emotional maturity.
Mobility
-motor development and ability
						to use fine and gross motor skills; the ability to move the extremities at
						will.
Mobil Nonambulatory
-the inability to
						walk without assistance, but the ability to move from place to place with the
						use of a device such as a walker, crutches, wheelchair or wheeled
						platform.
Neglect
-the failure to provide proper or
						necessary medical care, nutrition or other care necessary for a client's well
						being.
New Facility
-an ICF/MR newly opened or
						recently began participating in the Medical Assistance Program.
Nonambulatory
-the inability to walk
						without assistance.
Nursing Facility or Facility
-health care
						facilities such as a private home, institution, building, residence, or other
						place which provides maintenance, personal care, or nursing services for
						persons who are unable to properly care for themselves because of illness,
						physical infirmity or age. These facilities serve two or more persons who are
						not related by blood or marriage to the operator and may be operated for profit
						or nonprofit.
Office for Citizens with Developmental
						Disabilities (OCDD)
-the office within DHH responsible for programs
						serving the MR/DD population.
Operational
-admission of at least one
						client, completion of functional assessments(s) and development of individual
						program plan(s) for the client(s); and implementation of the program plan(s) in
						order that the facility actually demonstrate the ability, knowledge, and
						competence to provide active treatment.
Overall Plan of Care (OPC)-
see
						Individual Habilitation Plan.
Pass through Cost Component
-includes the
						provider fee.
Peer Group
-t he administrative and
						operating per diem rate and the capital per diem rate are tiered based on peer
						group size. Peer groups are as follows:
a. 1-8 beds;
b. 9-15 beds;
c. 16-32 beds;
d. 33 or more beds.
Provider
-any individual or entity
						enrolled to furnish Medicaid Services under a provider agreement with the
						Medicaid Agency.
Qualified Mental Retardation Professional
						(QMRP)
-a person who has specialized training and at least one year or
						more of experience in treating and/or working directly with and in direct
						contact with the Mentally Retarded clients. To qualify as a QMRP a person must
						meet the requirements of
						42CFR
						483.430.
Rate Year
- a one-year period
						corresponding to the state fiscal year from July 1 through June 30.
Rebasing
-r ecalculation of the per diem
						rate components using the latest available audited or desk reviewed cost
						reports.
Recipient
-an individual who has been
						determined eligible for Medicaid.
Registered Nurse (RN)
-a nurse currently
						registered and licensed by the Louisiana State Board of Nursing.
Representative Payee
-a person designated
						by the Social Security Administration to receive and disburse benefits in the
						best interest of and according to the needs of the beneficiary.
Responsible Party
-a person authorized by
						the client, agency or sponsor to act as an official delegate or agent in
						dealing with the Department of Health and Hospitals and/or the ICF/MR.
Self-Care
-daily activities which enable
						a person to meet basic life needs for food, hygiene, appearance and
						health.
Self-Direction
-management and control
						over one's social and personal life and the ability to make decisions that
						affect and protect one's own interests. A substantial functional limitation in
						self-direction would require a person to need assistance in making independent
						decisions concerning social and individual activities and/or in handling
						personal finances and/or in protecting his own self-interest.
Significant Assistance
-help needed at
						least one-half of the time for one activity or a need for some help in more
						than one-half of all activities normally required for self-care.
Significantly Sub-Average
-for purposes
						of certification for ICF/MR an I.Q. score of below 70 on the Wechsler,
						Standford-Binet, Cattell, or comparable test will be considered to establish
						significantly sub-average intellectual functioning.
SNF
-Skilled Nursing Facility.
Sponsor
-an adult relative, friend, or
						guardian of the client who has a legitimate interest in or responsibility for
						the client's welfare. Preferably, this person is designated on the admission
						forms as "responsible party."
Substantial Functional Limitation
-a
						condition that limits a person from performing normal life activities or makes
						it unsafe for a person to live alone to such an extent that assistance,
						supervision, or presence of a second person is required more than half of the
						time.
Support Levels
-describe the levels of
						support needed by individuals with mental retardation and other developmental
						disabilities. The five descriptive levels of service intensity using the ICAP
						assessment are summarized in Subparagraphs a-e below.
a. Intermittent -supports on an as needed
					 basis. Characterized as episodic in nature, the person does not always need the
					 support(s), or short-term supports needed during life-span transition (e.g.,
					 job loss or an acute medical crisis). Intermittent supports may be high or low
					 intensity when provided.
b. Limited
					 -supports characterized by consistency over time, time-limited but not of an
					 intermittent nature, may require fewer staff members and less costs than more
					 intense levels of support (e.g., time-limited employment training or
					 transitional supports during the school to adult provided period).
c. Extensive- supports characterized by
					 regular involvement (e.g., daily) in at least some environment (such as work or
					 home) and not time-limited (e.g., long term support and long-term home living
					 support).
d. Pervasive- supports
					 characterized by their constancy, high intensity; provided across environments;
					 potential life-sustaining nature. Pervasive supports typically involve more
					 staff members and intrusiveness than do extensive or time-limited
					 supports.
e. Pervasive Plus-a
					 time-limited specific assignment to supplement required Level of Need services
					 or staff to provide life sustaining complex medical care or to supplement
					 required direct care staff due to dangerous life threatening behavior so
					 serious that it could cause serious physical injury to self or others and
					 requires additional trained support staff to be at "arms length" during waking
					 hours.