reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.60 - Utilizing Medicare as a resource

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An eligible recipient who is a Medicare
					 beneficiary, is receiving care in a Medicare certified facility and is
					 authorized by the Medicare Program to receive skilled nursing care benefits
					 shall utilize these benefits before payment will be made by the MA Program. For
					 each benefit period, the Medicare Program makes full payment for the first 20
					 days of skilled nursing care and pays all but a specified coinsurance amount
					 for days 21 through 100. If the Medicare payment for days 21 through 100 is
					 less than the facility's MA interim per diem rate for skilled nursing care, the
					 Department will participate in payment of the coinsurance charge to the extent
					 that the total of the Medicare payment and the Department's coinsurance payment
					 does not exceed the MA skilled interim per diem rate for the facility. The
					 Department will not pay more than the maximum coinsurance amount.
(b) The facility may not seek or accept
					 payment from a source other than Medicare for any portion of the Medicare
					 coinsurance amount that is not paid by the Department on behalf of an eligible
					 recipient because of the limit of the facility's MA skilled interim per diem
					 rate.
(c) The Medicare payment will
					 be recognized as payment in full for each day that a Medicare payment is made
					 during the first 20 days of a benefit period.
(d) If a recipient either has purchased
					 Medicare Part B coverage or the coverage has been purchased for the recipient,
					 the facility shall use available Medicare Part B resources for Medicare Part B
					 services.
(e) The amendments to
					 this section as published in Annex A at 20 Pa.B. 6175 (December 15, 1990), and
					 corrected at 21 Pa.B. 228 (January 19, 1991), required by the Medicare
					 Catastrophic Coverage Act of 1988 (Pub. L. No. 100-360 (Repealed)) are in
					 effect for the period from January 1, 1989 to December 31, 1989.
This section cited in 55 Pa. Code §
													1181.52 (relating to payment
						  conditions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.61 - Services included in the interim per diem rate

Current through Register Vol. 54, No. 28, July 13, 2024
The Department's interim per diem rate of reimbursement
						for long term care provided eligible recipients in participating facilities
						includes allowable costs for routine services. Services include but are not
						limited to:
(1) Regular room, dietary
					 and nursing services, social services and other services required to meet
					 certification standards, medical and surgical supplies, and the use of
					 equipment and facilities.
(2)
					 General nursing services, including but not limited to administration of oxygen
					 and related medications, handfeeding, incontinency care, tray service and
					 enemas.
(3) Items furnished
					 routinely and relatively uniformly to all patients, such as patient gowns,
					 water pitchers, basins and bedpans.
(4) Items furnished, distributed or used
					 individually in small quantities such as alcohol, applicators, cotton balls,
					 bandaids, antacids, aspirin (and other nonlegend drugs ordinarily kept on
					 hand), suppositories and tongue depressors.
(5) Items used by individual patients but
					 which are reusable and expected to be available, such as ice bags, bedrails,
					 canes, crutches, walkers, wheelchairs, traction equipment and other durable
					 medical equipment.
(6) Special
					 dietary supplements used for tube feeding or oral feeding, such as elemental
					 high nitrogen diet, even if written as a prescription item by a
					 physician.
(7) Laundry services
					 other than for personal clothing, except for intermediate care facilities for
					 the mentally retarded in which laundry services including the laundering of
					 resident's personal clothing are allowable.
(8) Other special medical services of a
					 rehabilitative, restorative or maintenance nature, designed to restore or
					 sustain the patient's physical and social capacities.
This section cited in 55 Pa. Code §
													1181.52 (relating to payment
						  conditions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.61a - Nurse-aide programs-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
As a result of provisions contained in the Federal
						Omnibus Budget Reconciliation Act of 1987 (42 U.S.C.A. §
												1396r(b)(5)) regarding nurse
						aide training and testing fees, the Department will reimburse nursing
						facilities the reasonable and appropriate costs for State-approved nurse aide
						training programs that meet Federal requirements and are completed by
						individuals employed or offered employment within 12 months of completing the
						Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency
						Evaluation Program (CEP).
This section cited in 55 Pa. Code §
													1181.52 (relating to payment
						  conditions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.62 - Noncompensable services

Current through Register Vol. 54, No. 28, July 13, 2024
Payment will not be made to a nursing facility for:
(1) Services provided to a recipient
					 who no longer requires the level of care for which payment is authorized by the
					 County Assistance Office.
(2)
					 Reserved bed days that exceed the limits set for the different levels of care
					 in §
											1181.56 (relating to limitations
					 on payment for reserved beds).
(3)
					 Services provided to a recipient occupying a bed which is not certified for the
					 level of care for which payment is authorized by the County Assistance
					 Office.
(4) Services covered but
					 disallowed by Medicare.
(5)
					 Services rendered by a provider that do not meet the conditions for payment
					 established by this chapter and Chapter 1101 (relating to general
					 provisions).
This section cited in 55 Pa. Code §
													1181.52 (relating to payment
						  conditions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.63 - Method of payment

Current through Register Vol. 54, No. 28, July 13, 2024
Payment for nursing facility care is made in accordance
						with the provisions of the Medicaid State Plan and this chapter.
This section cited in 55 Pa. Code §
													1181.52 (relating to payment
						  conditions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.64 - Cost reporting

Current through Register Vol. 54, No. 28, July 13, 2024
Each facility shall submit a cost report to the
						Department within 90 days following the close of each fiscal year as designated
						by the facility in accordance with §
											1181.71 (relating to annual
						reporting). The report shall be prepared using the accrual basis of accounting
						and must cover a fiscal period of 12 consecutive months. Facilities beginning
						operations during a fiscal period will prepare a report from the date of
						approval for participation to the end of the facility's fiscal year. The cost
						report shall identify costs of services, facilities and supplies furnished by
						organizations related to the provider by common ownership or
						control.
This section cited in 55 Pa. Code §
													1181.45 (relating to ongoing
						  responsibilities of providers); 55 Pa. Code §
													1181.52 (relating to payment
						  conditions); and 55 Pa. Code §
													1181.91 (relating to failure to
						  file a cost report).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.65 - Cost-finding

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A nursing
					 facility shall use the direct allocation method of cost-finding. The costs of
					 ancillary and administrative services shall be apportioned directly to the
					 appropriate level of care based on appropriate statistical data.
(b) A facility's direct or indirect allowable
					 costs related to patient care will be considered in the finding and allocation
					 of costs to the MA Program for its eligible recipients. Total allowable costs
					 of a facility shall be apportioned between third-party payors and other
					 patients so that the share borne by MA is based upon actual services and costs
					 related to MA patients. For purposes of MA reimbursement, the return on net
					 equity and net worth is not reimbursable.
(c) The Department will recognize
					 depreciation and interest as an allowable cost for general and county nursing
					 facilities subject to the following conditions:
(1) Depreciation and interest on new or
					 additional beds is an allowable cost only if one of the following applies:
(i) The facility was issued either a Section
					 1122 approval or letter of nonreviewability under 28 Pa. Code Chapter 301
					 (relating to limitation on Federal participation for capital expenditures) or a
					 Certificate of Need or letter of nonreviewability under 28 Pa. Code Chapter 401
					 (relating to Certificate of Need Program) for the project by the Department of
					 Health no later than August 31, 1982.
(ii) The facility was issued a Certificate of
					 Need or letter of nonreviewability under 28 Pa. Code Chapter 401 for the
					 construction of a nursing facility, and there was no nursing facility,
					 including county, private or hospital-based, located within the
					 county.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.66 - Setting ceilings on allowable net operating costs

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department will establish maximum
					 group per diem rate ceilings for allowable net operating costs for each level
					 of care for general and county operated nursing facilities. Effective April 1,
					 1988, these ceilings will be based on 115% of the median of year-end reported
					 costs excluding depreciation and interest. Facilities will not be reimbursed
					 for net operating costs above the maximum group per diem rate ceilings. Costs
					 which are not reimbursed within the established ceilings for a fiscal year may
					 not be carried forward or backward to other fiscal years. The ceilings for
					 general and county operated nursing facilities will be established as follows:
(1) The Department will use only year-end
					 cost reports that cover a period of at least 180 days, are acceptable and
					 received at least 90 days prior to the implementation date of the new ceilings.
					 An acceptable cost report is one in which the following requirements are met:
(i) Applicable items are fully completed in
					 accordance with the instructions incorporated in the Department's cost report,
					 including the necessary original signatures on the required number of
					 copies.
(ii) Computations carried
					 out on the form are accurate and consistent with other related
					 computations.
(iii) The treatment
					 of costs conforms to the applicable requirements of this subchapter and
					 Subchapters B and C (relating to manual for allowable cost reimbursement for
					 skilled nursing and intermediate care facilities; and Reserved).
(iv) Required documentation is
					 included.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.67 - Setting interim per diem rates

Current through Register Vol. 54, No. 28, July 13, 2024
The Department establishes interim per diem rates on the
						basis of the following methods and in accordance with §
											1181.68 (relating to upper limits
						of payment):
(1) For general and
					 county nursing facilities, interim per diem rates within the ceilings on net
					 operating costs will be established by the Department based on the latest
					 adjusted reported net operating cost of the facility plus an allowance for
					 depreciation and interest. For the period July 1, 1995, through December 31,
					 1995, the interim rate will be calculated in this manner, except that if the
					 interim rate for a nursing facility (excluding depreciation and interest) is
					 less than the ceiling on net operating costs to be applied during this period,
					 the interim rate for the nursing facility will be increased by 2% to reflect
					 inflation up to the upper limits on payment as stated in §
					 1181.68.
(2) For State-operated
					 intermediate care facilities for the mentally retarded, interim per diem rates
					 will be established by the Department based on the latest adjusted reported
					 costs and approved budgets. For non-State intermediate care facilities for the
					 mentally retarded, interim per diem rates will be established by the Department
					 based on the latest adjusted cost report plus an inflationary factor, or a
					 submitted budget if a waiver is granted in accordance with Subchapter C
					 (Reserved).
(3) For psychiatric
					 transitional facilities, interim per diem rates will be established by the
					 Department based on latest adjusted reported costs and approved
					 budgets.
(4) For facilities
					 entering the program and for facilities in the programs with changes of
					 ownership, except for intermediate care facilities for the mentally retarded,
					 the facility's projected MA-11 cost report will be used to set the interim rate
					 for MA during the initial period of operation pending the filing of the first
					 year-end cost report.
See 22 Pa.B. 3749 (July 18, 1992) for nursing home
						  pooling provisions.
The provisions of this §
													1181.67 amended under sections
						  201, 403 and 443.1(2) and (3) of the Public Welfare Code (62 P. S. §§
														201,
						  403 and
						  443.1(2) and
						  (3)).
This section cited in 55 Pa. Code §
													1181.52 (relating to payment
						  conditions); and 55 Pa. Code §
													1181.101 (relating to facility's
						  right to a hearing).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.68 - Upper limits of payment

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Maximum rate of payment
. Except as provided in this section,
					 the Department's maximum rate of payment to an enrolled facility will be the
					 lower of the following:
(1) The facility's
					 lowest charge to private pay patients for the same level of care.
(2) The facility's Medicare rate, which is
					 either of the following:
(i) As compared to
					 the facility's Medical Assistance interim per diem rate, the facility's
					 Medicare interim per diem rate that is in effect on the date the facility's
					 request for an interim per diem rate is postmarked or, if hand delivered, the
					 date the request is received by the Department as documented by the
					 Department's date stamp.
(ii) As
					 compared to the facility's Medical Assistance final rate, the Medicare interim
					 per diem rate in effect on the day of the facility's exit conference.
(3) The facility's Medical
					 Assistance final per diem rate.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › PAYMENT FOR NURSING FACILITY CARE › Section 1181.69 - Annual adjustment

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An
					 annual payment adjustment will be made by the Department or facility based on
					 total audited costs related to the total Department interim claims for services
					 for the fiscal year and any interim cost settlement for the fiscal years paid
					 under subsection (c).
(b) For cost
					 reporting periods ending on or after October 1, 1985, if the total amount of MA
					 payment for interim claims for services during the fiscal year exceeds the
					 total audited costs, the Department will recover the overpaid amount from the
					 provider under §
											1101.69(b)
					 (relating to overpayment-underpayment).
(c) During Fiscal Years 1992-1993, 1993-1994
					 and 1994-1995, the Department will pay facilities interim cost settlements on
					 acceptable year-end cost reports as follows:
(1) A facility's interim cost settlement will
					 be equal to 90% of the amount by which the facility's total adjusted allowable
					 costs for MA reported in the facility's acceptable fiscal year-end cost report
					 exceed the amount of MA interim payments received by the facility attributable
					 to the fiscal period covered by the cost report.
(2) For the purpose of paragraph (1),
					 "adjusted allowable costs" means the facility's total reported costs for MA as
					 adjusted for the following limitations:
(i)
					 The applicable ceiling on net operating costs, as stated in §
													1181.68(b)
					 (relating to upper limits of payment).
(ii) The per bed ceiling on allowable
					 depreciation and interest costs as stated in §§
													1181.259(s) and
					 1181.260(k)
					 (relating to depreciation allowance; and interest allowance) in effect on
					 February 1, 1993, or in effect during the cost report period, whichever is
					 greater.
(iii) The moratorium on
					 reimbursement of depreciation and interest costs as stated in §§
					 1181.259(r) and 1181.260(a).
(iv)
					 The Medicare rate and private pay rate upper limitations on payment, as stated
					 in §
													1181.68(a)(1) and
					 (2). In adjusting the facility's reported
					 costs for the Medicare rate and the private pay rate limitations, the
					 Department will apply the facility's most recent Medicare and private pay rates
					 reported on the MA 58 form filed with the fiscal year end cost report on which
					 the interim cost settlement is based.
(3) Interim cost settlements will not be paid
					 on the basis of interim or final cost reports.
(4) An interim cost settlement will not be
					 paid to a facility which has filed an interim cost report for the fiscal period
					 covered by the interim cost settlement unless the facility waives its rights to
					 a revised interim rate for the fiscal period.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › REPORTING AND AUDITING REQUIREMENTS › Section 1181.71 - Annual reporting

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
					 fiscal year for purposes of MA payments for skilled nursing and intermediate
					 care facilities will be either January 1 through December 31 or July 1 through
					 June 30 as designated by the facility.
(b) The fiscal year, for purposes of MA
					 payments for intermediate care facilities for the mentally retarded, will be
					 July 1 through June 30.
This section cited in 55 Pa. Code §
													1181.64 (relating to cost
						  reporting).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › REPORTING AND AUDITING REQUIREMENTS › Section 1181.72 - Interim reporting

Current through Register Vol. 54, No. 28, July 13, 2024
Except for intermediate care facilities for the mentally
						retarded, a facility may file an interim cost report as justification for an
						interim rate change. However, the interim report may not be filed prior to
						January 1 (a report received prior to that date will be returned), and shall
						cover a 6-month period. If an interim report is filed, a 12-month report
						covering the facility's fiscal year shall still be filed.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › REPORTING AND AUDITING REQUIREMENTS › Section 1181.73 - Final reporting

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
					 facility that enters into a termination agreement or an agreement of sale, or
					 is withdrawing or being terminated as a provider, or is otherwise undergoing a
					 change of ownership is required to file an acceptable final cost report and
					 outstanding annual cost reports with the Department within 45 days of the
					 effective date of the termination, transfer, withdrawal or change of ownership
					 and is required to provide financial records to the Department for auditing. An
					 acceptable cost report is one that meets the requirements of §
											1181.66(a)(1)(i)-(iv)
					  (relating to setting ceilings on allowable
					 net operating costs).
(b) Except
					 for an intermediate care facility for the mentally retarded, a facility may
					 request an extension to file its final cost reports as required by subsection
					 (a) of up to 30 days from the date the cost reports are due if the facility's
					 request is received by the Department prior to the expiration of the 30th day
					 of the 45-day period specified in subsection (a), specifies the reasons for the
					 extension request and the amount of time requested and is for reasons beyond
					 the control of the provider. No further extensions will be granted. The denial
					 of a request shall be an adverse action appealable under §
											1101.84(c)
					 (relating to provider right of appeal). Failure to timely appeal a denial shall
					 preclude any attack on the denial in another proceeding.
This section cited in 55 Pa. Code §
													1181.45 (relating to ongoing
						  responsibilities of providers); and 55 Pa. Code §
													1181.91 (relating to failure to
						  file a cost report).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › REPORTING AND AUDITING REQUIREMENTS › Section 1181.74 - Auditing requirements related to cost reports

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Except in cases of provider delay or
					 delay requested by State or Federal agencies investigating possible criminal or
					 civil fraud, the Department will audit each cost report within 1 year of the
					 latter of its receipt in acceptable form, as defined in §
											1181.66 (relating to setting
					 ceilings on allowable net operating costs) or, if the facility participates in
					 Medicare and has reported home office costs to the Department on its cost
					 report, the Department's receipt of the facility's Medicare home office audit,
					 to verify, to the extent possible, that the facility has complied with:
(1) This chapter.
(2) Chapter 1101 (relating to general
					 provisions).
(3) The limits
					 established in Subchapters B and C (relating to manual for allowable cost
					 reimbursement for skilled nursing and intermediate care facilities; and
					 Reserved).
(4) The instructions
					 attached to the Financial and Statistical Report for Skilled Nursing and
					 Intermediate Care facilities.
(5)
					 The HIM-15, for State-operated intermediate care facilities for the mentally
					 retarded.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › REPORTING AND AUDITING REQUIREMENTS › Section 1181.75 - Auditing requirements related to patient fund management

Current through Register Vol. 54, No. 28, July 13, 2024
Nursing facilities are required to maintain records
						relating to the facility's management of MA patients' personal funds for a
						minimum of 4 years and make them available to Federal and State representatives
						upon request. MA patients' fund accounts will be audited at the time the annual
						cost reports are validated for a facility. If discrepancies are proven and the
						facility is found to be at fault, the facility will be required to make
						restitution to the patients for funds improperly handled, accounted for, or
						disbursed. The facility has the right of appeal in accordance with §
											1181.101 (relating to facility's
						right to a hearing).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › UTILIZATION CONTROL › Section 1181.81 - Scope of claims review procedures

Current through Register Vol. 54, No. 28, July 13, 2024
All claims submitted for payment under the Medical
						Assistance Program are subject to the utilization review procedures established
						in Chapter 1101 (relating to general provisions). In addition, the Department
						will perform the reviews specified in these sections for controlling the
						utilization of nursing facility services.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › UTILIZATION CONTROL › Section 1181.82 - Review of need for admission

Current through Register Vol. 54, No. 28, July 13, 2024
The Department's Review Team will evaluate each
						applicant's or recipient's need for admission by reviewing and assessing the
						appropriate departmental form completed by the attending physician or
						interdisciplinary team as required for the specifically prescribed level of
						care needed. The facility and recipient will be notified of the decision on
						forms designated by the Department.
The provisions of this §
													1181.82 amended under sections
						  403(a) and (b) and 443.6 of the Public Welfare Code (62 P. S. §§
														403(a) and (b) and
						  443.6).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › UTILIZATION CONTROL › Section 1181.83 - Inspections of care

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Inspection team.
The Department's Inspection of Care team will
					 inspect the care and services provided to each recipient in a participating
					 nursing facility at least annually. The Department will not give the facility
					 more than 48 hours notice of the time and date of the scheduled arrival of the
					 team. The facility shall make readily available to the team the patient's
					 complete medical records for the year since the last review of the team. The
					 team's inspection will include:
(1) Personal
					 contact with and observation of each recipient in a skilled nursing facility,
					 intermediate care facility, or intermediate care facility for the mentally
					 retarded.
(2) Review of each
					 recipient's medical record. The record must include timely certification and
					 recertifications by the physician that the services are needed and a written
					 individual plan of care developed either by an interdisciplinary team or the
					 attending or staff physician, whichever is applicable. The plan of care must
					 indicate time limits and measurable care objectives and goals to be
					 accomplished and who is to give each element of care.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › UTILIZATION CONTROL › Section 1181.84 - Facility course of action

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 The nursing facility shall return a copy of the summary report with appropriate
					 corrective actions written thereon to the Department within 30 days of the
					 control date indicated on the summary report. The facility's planned course of
					 corrective action shall include proposed time frames for correcting findings of
					 deficient care or services and narrative recommendations.
(b) The Inspection of Care team may conduct a
					 follow-up visit to determine if the deficiencies and recommendations are
					 corrected and report to the Bureau of Long Term Care Programs.
The provisions of this §
													1181.84 amended under sections
						  403(a) and (b) and 443.1(2) and (3) of the Public Welfare Code (62 P. S.
						  §§
														403(a) and (b)
						  and 443.1(2) and (3)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › UTILIZATION CONTROL › Section 1181.85 - Facility utilization review requirements

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Each enrolled nursing facility furnishing
					 services to eligible MA recipients shall have in effect a written Utilization
					 Review Plan that provides for review of each recipient's need for the
					 services.
(b) If the Utilization
					 Review Committee of a facility finds that the continued stay of a recipient at
					 a specific level of care is not needed, the committee shall request additional
					 information as follows:
(1) If the recipient
					 is receiving care in a skilled nursing facility, the committee shall request
					 additional information from the attending physician who shall respond within 7
					 days. Two physician members of the committee shall review the additional
					 information and make the final recommendation. If the attending physician does
					 not respond to the committee's request within 7 days, the committee's
					 recommendation shall be deemed final.
(2) If the recipient is receiving care in an
					 intermediate care facility, the committee shall, within 1 working day of its
					 decision, request additional information from the recipient's attending
					 physician, who shall respond within 2 working days. A physician member of the
					 committee, in cases involving a medical determination, or the Utilization
					 Review Committee, in cases not involving a medical determination, shall review
					 the additional information and make the final recommendation. If the attending
					 physician does not respond to the committee's request within 2 working days,
					 the committee's recommendation shall be deemed final.
(3) If the recipient is receiving care in an
					 intermediate care facility for the mentally retarded, the committee shall,
					 within 1 working day of its decision, request additional information from the
					 recipient's qualified mental retardation professional, who shall respond within
					 2 working days. A physician member of the committee, in cases involving a
					 medical determination, or the Utilization Review Committee, in cases not
					 involving a medical determination, shall review the additional information and
					 make the final recommendation. If the additional information is not received
					 within 2 working days, the committee's decision will be deemed
					 final.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › UTILIZATION CONTROL › Section 1181.86 - Provider misutilization

Current through Register Vol. 54, No. 28, July 13, 2024
Nursing facilities determined to have billed for services
						inconsistent with Medical Assistance Program regulations, to have provided
						services outside the scope of customary standards of practice, or to have
						otherwise violated the standards set forth in the provider agreement, are
						subject to the sanctions described in this chapter and Chapter 1101 (relating
						to general provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › ADMINISTRATIVE SANCTIONS › Section 1181.91 - Failure to file a cost report

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Failure to file a cost report, other than
					 a final cost report, and annual cost reports due along with a final cost
					 report, when due, may result in termination of the provider agreement and shall
					 result in the suspension of interim payments to the provider until the reports
					 are filed in acceptable form. If the reports are not filed by the end of the
					 fifth month after the due date established by §
											1181.64 (relating to cost
					 reporting), including extensions of that date granted by the Department, the
					 Department may either determine payment for the cost reporting period involved
					 on the basis of the method established with respect to untimely final cost
					 reports in subsection (b) or may seek injunctive relief to require proper
					 filing, as the Department may deem is in the best interest of the efficient and
					 economic administration of the Program.
(b) Failure to file a final cost report and
					 outstanding annual cost reports, when due, under §
											1181.73 (relating to final
					 reporting) shall result in payment to the provider for all cost reporting
					 periods involved being determined on the basis of the lowest audited rate for a
					 provider, including a rate limited by §
											1181.68 (relating to upper limits
					 of payment) for the same level of care (SNF, ICF or ICF/MR) without regard to
					 the type of provider-for example, hospital-based or county facility-for
					 services rendered during the 6 months immediately preceding the beginning of
					 the fiscal periods involved. No payment will be made for depreciation expenses
					 incurred by the provider with respect to services during the 365 days preceding
					 the effective date of the event described in §
											1181.73(a) which
					 required the final cost report to be filed. Interim payments or payments after
					 audit of the depreciation expenses shall be offset against payments due to the
					 provider or shall be repaid to the Department by the provider if no payment is
					 due.
This section cited in 55 Pa. Code §
													1181.215 (relating to efficiency
						  incentive); 55 Pa. Code §
													1181.216 (relating to depreciation
						  and interest reimbursement); and 55 Pa. Code §
													1181.224 (relating to final per
						  diem rate).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › ADMINISTRATIVE SANCTIONS › Section 1181.92 - Failure to maintain adequate records

Current through Register Vol. 54, No. 28, July 13, 2024
When the Department determines that the nursing facility
						has not maintained financial and statistical records in accordance with the
						Department's regulations, thus preventing the Department from conducting an
						audit of the facility's records, the facility will be notified, by certified
						mail, that it has 60 days to correct the problem. The facility will be advised
						further that for failure to comply with the Department's notice, the Department
						will terminate the Medical Assistance Provider Agreement, unless the problem is
						corrected within the 60-day period.
This section cited in 55 Pa. Code §
													1181.215 (relating to efficiency
						  incentive); 55 Pa. Code §
													1181.216 (relating to depreciation
						  and interest reimbursement); and 55 Pa. Code §
													1181.224 (relating to final per
						  diem rate).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › ADMINISTRATIVE SANCTIONS › Section 1181.93 - Failure to correct deficiencies

Current through Register Vol. 54, No. 28, July 13, 2024
If the facility fails to correct a deficiency cited by
						the Department's Inspection of Care Team or causes delay in the review process
						which results in a penalty being imposed by the Department of Health and Human
						Services (DHHS) on the Department of Human Services the penalty will be imposed
						on the facility. Failure to correct gross deficiencies in patient care and
						services within 6 months following the receipt of report of Inspection of Care
						team's review will result in the termination of the facility's Medical
						Assistance Provider Agreement.
This section cited in 55 Pa. Code §
													1181.215 (relating to efficiency
						  incentive); 55 Pa. Code §
													1181.216 (relating to depreciation
						  and interest reimbursement); and 55 Pa. Code §
													1181.224 (relating to final per
						  diem rate).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › ADMINISTRATIVE SANCTIONS › Section 1181.94 - Failure to adhere to certification requirements

Current through Register Vol. 54, No. 28, July 13, 2024
If the facility's failure to comply with the requirements
						that the physician certify and recertify the need for care as described under
						§§
											1181.53 and
						1181.54 (relating to payment
						conditions related to the recipient's initial need for care; and payment
						conditions related to the recipient's continued need for care), results in a
						penalty being imposed by DHHS on the Department, the penalty will be imposed on
						the facility.
This section cited in 55 Pa. Code §
													1181.215 (relating to efficiency
						  incentive); 55 Pa. Code §
													1181.216 (relating to depreciation
						  and interest reimbursement); and 55 Pa. Code §
													1181.224 (relating to final per
						  diem rate).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › ADMINISTRATIVE SANCTIONS › Section 1181.95 - Failure to adhere to medical evaluation requirements

Current through Register Vol. 54, No. 28, July 13, 2024
If the facility fails to comply with the requirements
						that the physician perform a medical evaluation before admission or before
						authorization for payment, as described under §
											1181.53 (relating to payment
						conditions related to the recipient's initial need for care), which results in
						a penalty being imposed by DHHS on the Department, the penalty will be imposed
						on the facility.
This section cited in 55 Pa. Code §
													1181.215 (relating to efficiency
						  incentive); 55 Pa. Code §
													1181.216 (relating to depreciation
						  and interest reimbursement); and 55 Pa. Code §
													1181.224 (relating to final per
						  diem rate).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter A - NURSING FACILITY CARE › ADMINISTRATIVE SANCTIONS › Section 1181.96 - Failure to comply with requirements of maintaining patient's funds

Current through Register Vol. 54, No. 28, July 13, 2024
In the event discrepancies are identified by audit and
						the facility fails to make restitution to the patient, the Department may
						terminate the provider agreement for cause.
This section cited in 55 Pa. Code §
													1181.215 (relating to efficiency
						  incentive); 55 Pa. Code §
													1181.216 (relating to depreciation
						  and interest reimbursement); and 55 Pa. Code §
													1181.224 (relating to final per
						  diem rate).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter B - MANUAL FOR ALLOWABLE COST REIMBURSEMENT FOR SKILLED NURSING AND INTERMEDIATE CARE FACILITIES › GENERAL PROVISIONS › Section 1181.201 - Scope

Current through Register Vol. 54, No. 28, July 13, 2024
(a) This
					 subchapter, under applicable Federal and State statutes and regulations, sets
					 forth principles for determining the allowable costs of general and county
					 skilled and intermediate care facilities. This subchapter governs MA payments
					 to general and county skilled nursing and intermediate care facilities on the
					 basis of the Commonwealth's approved State Plan for reimbursement.
(b) The Medicare Provider Reimbursement
					 Manual (HIM-15) and the Federal regulations appropriate to the reimbursement of
					 nursing facility care under the Medicare program are a supplement to this
					 subchapter. If a cost is included in this subchapter as allowable, then the
					 HIM-15 and applicable Federal regulations will be used as a source of more
					 detailed information on that cost. The HIM-15 and applicable Federal
					 regulations will not be used for any cost that is determined to be nonallowable
					 either by a statement to that effect in this subchapter or by virtue of the
					 fact that the cost is not being addressed in this subchapter, nor will the
					 HIM-15 or applicable Federal regulations be used to alter the treatment of any
					 cost provided for in this subchapter.
(c) This subchapter is adopted under section
					 443.1(2) and (3) of the Public Welfare Code (62 P. S. §
												443.1(2) and (3)) and
					 supplements Subchapter A (relating to nursing facility care). To the extent
					 that this subchapter is inconsistent with the definitions and provisions of
					 Subchapter A, the provisions and definitions of this subchapter will control.
					 No section of this subchapter may be applied or interpreted out of context.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter B - MANUAL FOR ALLOWABLE COST REIMBURSEMENT FOR SKILLED NURSING AND INTERMEDIATE CARE FACILITIES › REIMBURSEMENT PRINCIPLES › Section 1181.212 - General principles

Current through Register Vol. 54, No. 28, July 13, 2024
(a) A
					 facility's direct or indirect allowable costs related to patient care will be
					 considered in the finding and allocation of costs to the MA Program for its
					 eligible recipients.
(b) Total
					 allowable costs of a facility will be apportioned between third-party payors
					 and other patients so that, within the limits of this subchapter, the share
					 borne by MA under Title XIX of the Public Health Service Act, 42 U.S.C. Chapter
					 6A, Subchapter XIX is based upon those actual services and costs related to MA
					 recipients.
(c) Within the limits
					 of this subchapter, allowable costs include those costs necessary to provide
					 skilled or intermediate care. These may include costs related to all of the
					 following:
(1) Dietary and food.
(2) Laundry.
(3) Housekeeping.
(4) Plant operation and
					 maintenance.
(5) Nursing.
(6) Director of nursing.
(7) Related clerical staff.
(8) Practitioners.
(9) Medical director.
(10) Utilization and medical
					 review.
(11) Social
					 services.
(12) Patient
					 activities.
(13) Volunteer
					 services.
(14) Over-the-counter
					 drugs.
(15) Medical
					 supplies.
(16) Physical,
					 occupational and speech therapy.
(17) Oxygen.
(18) Rent.
(19) Amortization.
(20) Other interest.
(21) Insurance.
(22) Real estate taxes.
(23) Equipment rental.
(24) Depreciation.
(25) Interest on capital
					 indebtedness.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter B - MANUAL FOR ALLOWABLE COST REIMBURSEMENT FOR SKILLED NURSING AND INTERMEDIATE CARE FACILITIES › REIMBURSEMENT PRINCIPLES › Section 1181.213 - Cost reporting

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
					 facility shall identify for cost finding allowable direct, indirect, ancillary
					 and related organization costs that apply to patient care for each certified
					 level of care.
(b) The facility
					 shall submit a cost report (Financial and Statistical Report, MA-11) to the
					 Department in accordance with Departmental requirements. The cost report shall
					 be based on financial and statistical records maintained by the facility. The
					 cost information contained in the cost report and in the facility's records
					 shall be current, accurate, and in sufficient detail to support the claim for
					 cost reimbursement. The Financial and Statistical Report (MA-11) outlines the
					 expenses and revenues to be included in the cost report for MA.
(c) The facility shall maintain adequate
					 financial records and statistical data for proper determination of costs
					 payable under the MA Program. The financial records shall include all ledgers,
					 books, records, and original evidence of cost (purchase requisitions, purchase
					 orders, vouchers, vendor invoices, requisitions for supplies, inventories, time
					 cards, payrolls, bases for apportioning costs, and the like) which pertain to
					 the determination of reasonable costs and are auditable. The facility is
					 required to maintain the records pertaining to each cost report for a period of
					 not less than 4 years following the date the facility submits the cost report
					 to the Department. No cost will be allowed unless it is adequately documented
					 to the extent that it is capable of being audited.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter B - MANUAL FOR ALLOWABLE COST REIMBURSEMENT FOR SKILLED NURSING AND INTERMEDIATE CARE FACILITIES › REIMBURSEMENT PRINCIPLES › Section 1181.214 - Cost apportionment and allocation

Current through Register Vol. 54, No. 28, July 13, 2024
The allowable costs for skilled nursing and intermediate
						care will be apportioned to the Medical Assistance Program by multiplying the
						average per diem cost for each level of care by the number of Medical
						Assistance patient days for that level of care.