New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 60A - PEDIATRIC MEDICAL DAY CARE › Subchapter 3 - PROCEDURES FOR DETERMINING CLINICAL ELIGIBILITY FOR PMDC SERVICES › Section 10:60A-3.1 - Functional assessment of Medicaid/NJ FamilyCare beneficiaries

Current through Register Vol. 56, No. 14, July 15, 2024
(a) PMDC admission and Medicaid/NJ FamilyCare reimbursement for PMDC shall be contingent upon a Medicaid/NJ FamilyCare beneficiary's receipt of authorization from the Department pursuant to N.J.A.C. 10:60A-3.4 and the performance of an initial functional assessment of the Medicaid/NJ FamilyCare beneficiary by professional staff designated by the Department that results in a determination that the Medicaid/NJ FamilyCare beneficiary is a medically complex and/or technology-dependent child who requires PMDC facility services pursuant to N.J.A.C. 10:60A-5.
(b) The initial functional assessment shall consist of:
1. An interview with the Medicaid/NJ FamilyCare beneficiary's parent(s);
2. Observation of the Medicaid/NJ FamilyCare beneficiary;
3. A review of the Medicaid/NJ FamilyCare beneficiary's medical status in the past six months with attention to changes in symptoms, feeding, medications, or activity and intervening events, such as hospitalization or acute illness;
4. A detailed review of the skilled nursing needs of the Medicaid/NJ FamilyCare beneficiary during a typical 24-hour period, including, but not limited to:
i. Dependence on mechanical ventilation;
ii. The presence of a tracheostomy requiring frequent suctioning;
iii. The presence of pulmonary insufficiency requiring positioning, suctioning and/or chest physical therapy;
iv. The need for enteric feeding complicated by either gastroesophageal reflux and risk of aspiration or by a need for frequent venting of the tube, or both;
v. The presence of diabetes requiring frequent blood sugar testing and medication adjustment;
vi. The presence of a seizure disorder manifested by frequent and prolonged seizures requiring emergency medication administration;
vii. The presence of moderate persistent or severe persistent asthma requiring nebulizer treatments more than twice a day and frequent medication adjustment in accordance with the Asthma Guidelines; and/or
viii. The need for intermittent bladder catheterization;
5. A detailed review of all other elements of the Medicaid/NJ FamilyCare beneficiary's care needs during a typical 24-hour period, including a review of:
i. Who provides care to the beneficiary;
ii. The types of care the beneficiary receives;
iii. The locations at which the beneficiary receives each type of care; and
iv. If the beneficiary receives private-duty nursing, the quantity of time (that is, the number of hours) during which, and the times and locations at which, the beneficiary receives private-duty nursing;
6. An evaluation and consideration of information about the Medicaid/NJ FamilyCare beneficiary's medical, rehabilitative, developmental, and psychosocial needs received from the nursing director, the child's primary health care provider, and/or other healthcare professionals who have current and relevant knowledge of the Medicaid/NJ FamilyCare beneficiary; and
7. A review of the family composition, ages of any siblings residing with the Medicaid/NJ FamilyCare beneficiary, and the available community support.