reglab/statecodes huggingface dataset:
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter D - NURSING HOME REFORM-STATEMENT OF POLICY › PREADMISSION SCREENING PROGRAM › Section 1181.541 - Preadmission screening program

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Section 1396r(e)(7)(A) of 42 U.S.C.A.
					 provides: "Effective January 1, 1989, the State must have in effect a
					 preadmission screening program, for making determinations using criteria
					 developed under 42 U.S.C.A.
					 §
												1396r(f)(8) and
					 described in 42 U.S.C.A.
					 §
												1396r(b)(3)(F) for
					 mentally ill and mentally retarded individuals (as defined in subparagraph G)
					 who are admitted to nursing facilities on or after January 1, 1989. The failure
					 of the Secretary (of HHS) to develop minimum criteria . . . shall not relieve
					 any State of its responsibility to have a preadmission screening program under
					 this subparagraph."
(b) Section
					 1396r(b)(3)(F) of 42 U.S.C.A. provides: "A nursing facility must not admit, on
					 or after January 1, 1989, any new resident who-"
(1) "is mentally ill (as defined in
					 (42 U.S.C.A. §
													1396r(e)(7)(G)(i))) unless
					 the State mental health authority has determined (based on an independent
					 physical and mental evaluation performed by a person or entity other than the
					 State mental health authority) prior to admission that, because of the physical
					 and mental condition of the individual, the individual requires the level of
					 services provided by a nursing facility, and, if the individual requires such
					 level of services, whether the individual requires active treatment for mental
					 illness, or"
(2) "is mentally
					 retarded (as defined in (42
					 U.S.C.A. §
													1396r(e)
					 (7)(G)(ii))) unless the State mental
					 retardation or developmental disabilities authority has determined that,
					 because of the physical and mental condition of the individual, the individual
					 requires the level of services provided by a nursing facility, and, if the
					 individual requires such level of services, whether the individual requires
					 active treatment for mental retardation."
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter D - NURSING HOME REFORM-STATEMENT OF POLICY › PREADMISSION SCREENING PROGRAM › Section 1181.544 - Where and how evaluations will be made

Current through Register Vol. 54, No. 28, July 13, 2024
The designated agency managing the evaluations in the
						county in which the applicant is located-either as the result of residence or
						temporary accommodation in a residential or medical facility-shall conduct the
						evaluation. The agency shall conduct the evaluations using Form PA-PASARR-EV
						and following the protocol noted in Appendix M. Appendix M details kinds of
						information and medical records necessary for the preadmission screening
						process. Evaluations will be conducted at specified locations in the county,
						but, if necessary because of the condition of the applicant, at the applicant's
						place of residence or place of care. The agencies will coordinate the place and
						time of each evaluation with the applicant.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter D - NURSING HOME REFORM-STATEMENT OF POLICY › PREADMISSION SCREENING PROGRAM › Section 1181.545 - Charges for screening

Current through Register Vol. 54, No. 28, July 13, 2024
A person eligible for Medical Assistance will not be
						charged fees or copayments as part of the preadmission screening process,
						either by the nursing facility or by another agency or department. A person who
						is not eligible for Program benefits may be charged, but at no more than
						cost.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter D - NURSING HOME REFORM-STATEMENT OF POLICY › PREADMISSION SCREENING PROGRAM › Section 1181.546 - How providers and applicants will be notified

Current through Register Vol. 54, No. 28, July 13, 2024
When the evaluation process has been completed, Form
						PA-PASARR-EV, along with documentation and data required by Appendix M, will be
						forwarded by the evaluation agency to the Department. The Department will
						determine whether the applicant requires the level of services provided in a
						nursing facility. The Department will notify the applicant and the evaluation
						agency using Form PA-PASARR-YN. The applicant is responsible for providing the
						nursing facility with Form PA-PASARR-YN as part of the admissions process. The
						nursing facility shall verify the Form PA-PASARR-YN with the Department. A
						provider may obtain verification of Form PA-PASARR-EV from the evaluation
						agency indicated on the Form, but shall include the control number indicated on
						the PA-PASARR-EV in a request. Verification is provided using Form
						PA-PASARR-OK.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter D - NURSING HOME REFORM-STATEMENT OF POLICY › PREADMISSION SCREENING PROGRAM › Section 1181.547 - How long it will take to get a determination

Current through Register Vol. 54, No. 28, July 13, 2024
The Department will issue a determination within 5
						working days of its receipt of Form PA-PASARR-EV from the evaluation agency.
						Subject to the cooperation of the applicant, the evaluation agency will
						complete the evaluation and file Form PA-PASARR-EV with the Department as soon
						as possible after its receipt of Form PA-PASARR-ID from the nursing facility.
						The nursing facility should be able to complete and file Form PA-PASARR-ID in 3
						working days.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter D - NURSING HOME REFORM-STATEMENT OF POLICY › PREADMISSION SCREENING PROGRAM › Section 1181.548 - What happens if active treatment is required

Current through Register Vol. 54, No. 28, July 13, 2024
OBRA-87 permits the Secretary of Health and Human
						Services to define the meaning of "active treatment," but provides that its
						meaning may not include those services which a nursing facility is required to
						provide or arrange for its residents under OBRA-87 (42 U.S.C.A. §
												1396r(e)(7)(G)(iii)). Health
						and Human Services has issued draft definitions which significantly limit
						determinations that an individual requires active treatment but has not yet
						established official criteria for the preadmission screening programs. The
						Department has adopted the Health and Human Services draft definitions under
						its authority under OBRA-87. See
						42 U.S.C.A. §
												1396r(e)(7)(A).
(1)
Active treatment.
The
					 Health and Human Services draft defines active treatment as follows:
(i)
For individuals with mental
					 illness.
The implementation of an individualized plan of care
					 developed under and supervised by a physician, provided by a physician and
					 other qualified mental health professionals, that prescribes the specific
					 therapies and activities for the treatment of persons experiencing an acute
					 episode of severe mental illness, which necessitates supervision by trained
					 mental health personnel.
(ii)
For individuals with mental retardation or other related
					 conditions
. A continuous program which includes aggressive, consistent
					 implementation of a program of specialized and generic training, treatment,
					 health services and related services that is directed toward the acquisition of
					 the behaviors necessary for the client to function with as much self
					 determination and independence as possible and the prevention or deceleration
					 of regression or loss of current optimal functional status. Active treatment
					 does not include services to maintain generally independent clients who are
					 able to function with little supervision or in the absence of a continuous
					 active treatment program. See
					 42 CFR
					 435.1009 (relating to definitions relating to
					 institutional status).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter D - NURSING HOME REFORM-STATEMENT OF POLICY › PREADMISSION SCREENING PROGRAM › Section 1181.549 - Confidentiality of information

Current through Register Vol. 54, No. 28, July 13, 2024
Information collected as part of the preadmission
						screening process is considered confidential and may only be released for
						purposes directly connected to the administration of the MA Program.
						PA-PASARR-ID Forms are subject to review by the Department, HHS, the Department
						of Health and their authorized agents.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter D - NURSING HOME REFORM-STATEMENT OF POLICY › APPEALS OF ADVERSE DETERMINATIONS › Section 1181.561 - Process to appeal adverse determinations in the preadmission screening program

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 Section 1396r(e)(7)(F) of the Social Security Act (42 U.S.C.A. §
												1396r(e)(7)(F)) provides:
					 "Each State, as a condition of approval (of its State Plan), effective January
					 1, 1989, must have in effect an appeals process for individuals adversely
					 affected by determinations under (42 U.S.C.A. §§
												1396r(e)(7)(A) and
					 1396r(e)(7)(B)
					 (relating to the pre-admission screening program and to the annual resident
					 review program))."
(b) An
					 applicant-including a legal or personal representative acting on behalf of the
					 applicant-for admission to a nursing facility participating as a provider in
					 the MA Program has the right to appeal from an adverse determination made as
					 part of the preadmission screening program established under OBRA-87. The
					 Department currently has regulations in effect which provide for appeals in
					 Chapter 275 (relating to appeal and fair hearing and administrative
					 disqualification hearings).
(c)
					 Under Chapter 275, an applicant for admission to a nursing facility who is
					 seeking or is already eligible for MA benefits has the right to appeal to the
					 Department's Office of Hearings and Appeals with respect to a decision
					 affecting the applicant's rights to receive Program benefits. Chapter 275 will
					 be applied to appeals of adverse determinations in the OBRA-87 preadmission
					 screening process where the appeals are filed by or on behalf of individuals
					 who are seeking or receiving MA.
(d) The OBRA-87 preadmission screening
					 process can also adversely affect an applicant for admission who is not seeking
					 or receiving MA. Appeals by or on behalf of those individuals shall still be
					 filed with the Office of Hearings and Appeals. These appeals will be heard
					 under the authority established in 1 Pa. Code Part II (relating to general
					 rules of administrative practice and procedure).
This section cited in 55 Pa. Code §
													1181.542 (relating to who is
						  required to be screened).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter D - NURSING HOME REFORM-STATEMENT OF POLICY › APPEALS OF ADVERSE DETERMINATIONS › Section 1181.562 - Adverse determinations

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
					 OBRA-87 requires an appeal process for an individual adversely affected by
					 determinations made in the preadmission screening process effective January 1,
					 1989. An adverse determination is one which denies or conditions the individual
					 admission to the nursing facility. The preadmission screening process involves
					 the following kinds of adverse determinations:
(1) Classification as an individual who is
					 subject to the preadmission screening process administered by the Department of
					 Aging under OBRA-87-not including the existing LAMP site review
					 process-including the issue of whether the individual is mentally ill, mentally
					 retarded or has a related condition (Form PA-PASARR-ID Appeals).
(2) Classification as an individual who may
					 not be admitted to a nursing facility (Form PA-PASARR-YN Appeals).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter D - NURSING HOME REFORM-STATEMENT OF POLICY › APPEALS OF ADVERSE DETERMINATIONS › Section 1181.563 - Who may appeal

Current through Register Vol. 54, No. 28, July 13, 2024
Only the applicant-including a legal or personal
						representative acting on behalf of the applicant-has the right to appeal. A
						provider does not have the right to appeal unless it has the applicant's power
						of attorney to act as the applicant's personal
						representative.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter D - NURSING HOME REFORM-STATEMENT OF POLICY › APPEALS OF ADVERSE DETERMINATIONS › Section 1181.564 - When an appeal is required to be filed

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An appeal from an adverse determination
					 in the preadmission screening process shall be filed within 30 days of the date
					 of written notice of the determination involved. Additional time will be
					 permitted only as provided at §
											275.3(b)
					 (relating to requirements).
(b) For
					 purposes of OBRA-87 adverse determination appeals, the notice required by
					 §
											275.3(b) will be
					 issued by the following:
(1) Notice of
					 classification as an individual who requires a determination by the Department
					 of Aging will be issued by the service provider-the nursing home-using Form
					 PA-PASARR-ID.
(2) Notice that an
					 individual referred to the Department of Aging may not be admitted to a nursing
					 facility will be issued by the Department, using Form PA-PASARR-YN.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter D - NURSING HOME REFORM-STATEMENT OF POLICY › APPEALS OF ADVERSE DETERMINATIONS › Section 1181.565 - What an appeal is required to contain

Current through Register Vol. 54, No. 28, July 13, 2024
An appeal from an adverse determination may be made by
						letter. No formal pleadings are required. The letter shall identify the name of
						the individual on whose behalf the appeal is being filed, the name of the
						nursing facility involved, the date of the written notice of the adverse
						determination, the agency or provider that issued the adverse determination and
						the address of the person to whom information from the Office of Hearings and
						Appeals should be sent. In addition, the appeal shall include a copy of the
						written notice of adverse determination in question. There are no filing fees
						or other charges.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter D - NURSING HOME REFORM-STATEMENT OF POLICY › APPEALS OF ADVERSE DETERMINATIONS › Section 1181.566 - Where appeals should be filed

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An
					 appeal shall be filed with the Department's Office of Hearings and Appeals at
					 the following address:
Office of Hearings and Appeals
Department of Human Services
Post Office Box 2675
Harrisburg, Pennsylvania 17105-2675
(b) The Office of Hearings and Appeals is
					 currently located in Room 305, Capitol Associates Building, Seventh and Forster
					 Streets, in Harrisburg.
(c)
					 Information concerning the filing of appeals can be obtained by calling the
					 Office of Hearings and Appeals at the following telephone numbers: Harrisburg,
					 (717) 783-3950; Reading, (215) 378-4188; Philadelphia, (215) 560-2385;
					 Pittsburgh, (412) 565-5213; and Scranton, (717) 963-3016.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter D - NURSING HOME REFORM-STATEMENT OF POLICY › APPEALS OF ADVERSE DETERMINATIONS › Section 1181.567 - How and where hearings will be conducted

Current through Register Vol. 54, No. 28, July 13, 2024
Hearings on matters involving adverse determinations in
						the preadmission screening process will be conducted on an informal basis.
						Hearings will be held at the regional offices of the Office of Hearings and
						Appeals-Harrisburg, Reading, Philadelphia, Pittsburgh and Scranton-as well as,
						in extraordinary cases, at local County Assistance Offices. The parties may
						agree to submit documentation in advance and conduct the hearing by telephone.
						The individual on whose behalf the appeal was filed may handle the case or may
						be represented by an attorney or personal representative.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter D - NURSING HOME REFORM-STATEMENT OF POLICY › APPEALS OF ADVERSE DETERMINATIONS › Section 1181.568 - How long it will take to get a decision

Current through Register Vol. 54, No. 28, July 13, 2024
Under Chapter 275 (relating to appeal and fair hearing
						and administrative disqualification hearings), a decision on appeals will be
						issued within 90 days of the date on which the appeal is received by the Office
						of Hearings and Appeals. Chapter 275 provides that the decisions are subject to
						reconsideration by the Department and, if the decision is adverse to the
						individual who filed the appeal, subject to appellate review before the
						Commonwealth Court of Pennsylvania.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter D - NURSING HOME REFORM-STATEMENT OF POLICY › APPEALS OF ADVERSE DETERMINATIONS › Appendix H

Current through Register Vol. 54, No. 28, July 13, 2024
State Offices and Contact Persons for Determination
						of Eligibility
or Active Treatment
For persons with mental illness
:
Estelle Richman, Area Director, Southeastern Area Office,
						Philadelphia State Office Building, 1400 Spring Garden Street, Philadelphia,
						Pennsylvania 19130.
Ford Thompson, Jr., Acting Area Director, Central Area
						Office, 2330 Ararat Boulevard, Harrisburg, Pennsylvania 17110.
Kathleen D. Reese, Acting Area Director, Northeastern
						Area Office, Scranton State Office Building, 100 Lackawanna Avenue, Scranton,
						Pennsylvania 18503.
Shirley Dumpman, Acting Area Director, Western Area
						Office, Pittsburgh State Office Building, Pittsburgh, Pennsylvania
						15222.
For persons with mental
						retardation
:
Vicki Stillman-Toomey, MR Program Manager, Southeastern
						Area Office, 306 State Office Building, 1400 Spring Garden Street,
						Philadelphia, Pennsylvania 19130, (215) 560-2242.
Marvin Meyers, MR Program Manager, Northeastern Area
						Office, 100 Lackawanna Avenue, Post Office Box 1127, Scranton, Pennsylvania
						18503, (717) 963-4393.
Ed Manning, MR Program Manager, Central Area Office, 2330
						Ararat Boulevard, Harrisburg, Pennsylvania 17105, (717) 657-4471.
Mary Puskarich, MR Program Manager, Western Area Office,
						1403 State Office Building, 300 Liberty Avenue, Pittsburgh, Pennsylvania 15222,
						(412) 565-5144.
For persons with other related developmental
						disabilities
:
Final Determinations Contact
						Person
Tammy McElfresh-Tyburski, Department of Public Welfare,
						Office of Social Programs, Room 529, Health and Welfare Building, Harrisburg,
						Pennsylvania 17120, (717) 787-5753.
This appendix cited in 55 Pa. Code §
													1181.548 (relating to what happens
						  if active treatment is required).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1181 - NURSING FACILITY CARE › Subchapter D - NURSING HOME REFORM-STATEMENT OF POLICY › APPEALS OF ADVERSE DETERMINATIONS › Appendix Q - Reserved

Current through Register Vol. 54, No. 28, July 13, 2024
This appendix cited in 55 Pa. Code §
													1181.53 (relating to payment
						  conditions related to the recipient's initial need for care); and 55 Pa. Code
						  §
													1181.54 (relating to payment
						  conditions related to the recipient's continued need for
						  care).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter A - GENERAL PROVISIONS › Section 1187.1 - Policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) This chapter
				  applies to nursing facilities, and to the extent specified in Chapter 1189
				  (relating to county nursing facility services), to county nursing
				  facilities.
(b) This chapter
				  governs MA payments to nursing facilities on the basis of the Commonwealth's
				  approved State Plan for reimbursement.
(c) The MA Program provides payment for
				  nursing facility services provided to eligible recipients by enrolled nursing
				  facilities. Payment for services is made subject to this chapter and Chapter
				  1101 (relating to general provisions).
(d) Extensions of time will be as follows:
(1) The time limits established by this
				  chapter for the filing of a cost report, resident assessment data, an appeal or
				  an amended appeal cannot be extended, except as provided in this
				  section.
(2) Extensions of time in
				  addition to the time otherwise prescribed for nursing facilities by this
				  chapter with respect to the filing of a cost report, resident assessment data,
				  an appeal or an amended appeal may be permitted only upon a showing of fraud,
				  breakdown in the Department's administrative process or an intervening natural
				  disaster making timely compliance impossible or unsafe.
(3) This subsection supersedes 1 Pa. Code
				  §
											31.15 (relating to extensions of
				  time).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter A - GENERAL PROVISIONS › Section 1187.2a - Clarification of the term "written"-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The term "written" in the definition of
				  "specially adapted DME" in §
										1187.2 (relating to definitions)
				  includes orders that are handwritten or transmitted by electronic
				  means.
(b) Written orders
				  transmitted by electronic means must be electronically encrypted or transmitted
				  by other technological means designed to protect and prevent access,
				  alteration, manipulation or use by any unauthorized person.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter B - SCOPE OF BENEFITS › Section 1187.11 - Scope of benefits for the categorically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Categorically needy recipients as defined in §
										1101.21 (relating to definitions)
					 are eligible for nursing facility services subject to the conditions and
					 limitations established in this chapter and Chapter 1101 (relating to general
					 provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter B - SCOPE OF BENEFITS › Section 1187.12 - Scope of benefits for the medically needy

Current through Register Vol. 54, No. 28, July 13, 2024
Medically needy recipients as defined in §
										1101.21 (relating to definitions)
					 are eligible for nursing facility services subject to the conditions and
					 limitations established in this chapter and Chapter 1101 (relating to general
					 provisions).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter B - SCOPE OF BENEFITS › Section 1187.13 - Scope of benefits for State Blind Pension recipients

Current through Register Vol. 54, No. 28, July 13, 2024
State Blind Pension recipients are not eligible for nursing
					 facility services under the MA Program. Individuals who are blind or visually
					 impaired are eligible for nursing facility services if they qualify as
					 categorically or medically needy recipients.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter B - SCOPE OF BENEFITS › Section 1187.14 - Scope of benefits for qualified Medicare beneficiaries

Current through Register Vol. 54, No. 28, July 13, 2024
Qualified Medicare beneficiaries are eligible for nursing
					 facility services only if they qualify as categorically or medically needy
					 recipients.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter C - NURSING FACILITY PARTICIPATION › Section 1187.21 - Nursing facility participation requirements

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to meeting the participation requirements
					 established in Chapter 1101 (relating to general provisions), a nursing
					 facility shall meet the following requirements:
(1) The nursing facility shall be licensed by
				  the Department of Health.
(2) Every
				  bed licensed by the Department of Health in a nursing facility that
				  participates in the MA Program shall be certified for MA
				  participation.
(3) The nursing
				  facility shall abide by applicable Federal, State and local statutes and
				  regulations, including Title XIX of the Social Security Act (42 U.S.C.A. §§
											1396-1396q), sections 443.1-443.6 of
				  the Public Welfare Code (62 P. S. §§
											443.1-443.6) and applicable licensing
				  statutes.
(4) An MA-enrolled
				  nursing facility with 60 or more licensed beds providing skilled nursing and
				  rehabilitation services in accordance with the Medicare requirements shall also
				  be enrolled in the Medicare Program to the extent that it has sufficient beds
				  to accommodate the Medicare-eligible residents it is required to serve. This
				  does not preclude a nursing facility with a bed complement of under 60 beds
				  from enrolling in the Medicare Program.
(i) A
				  nursing facility certified to participate in the Medicare Program shall have
				  sufficient beds to accommodate its Medicare-eligible residents. Payment will be
				  based on criteria found in §
											1187.101(b)
				  (relating to general payment policy).
(ii) Failure to be enrolled and certified in
				  the Medicare Program will result in denial of claims for a resident with both
				  Medicare and MA coverage.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter C - NURSING FACILITY PARTICIPATION › Section 1187.21a - Reserved

Current through Register Vol. 54, No. 28, July 13, 2024
The provisions of this §
												1187.21a amended and reserved
						under section
						443.1(8) of the
						Public Welfare Code (62 P. S. §
													443.1(8)).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter C - NURSING FACILITY PARTICIPATION › Section 1187.22 - Ongoing responsibilities of nursing facilities

Current through Register Vol. 54, No. 28, July 13, 2024
In addition to meeting the ongoing responsibilities
					 established in Chapter 1101 (relating to general provisions), a nursing
					 facility shall, as a condition of participation:
(1) Assure that every individual applying for
				  admission to the facility is prescreened by the Department as required by
				  section 1919 of the Social Security Act (42 U.S.C.A. §
											1396r(e)(7)) and 42 CFR Part
				  483 , Subpart C (relating to preadmission screening and annual review of
				  mentally ill and mentally retarded individuals).
(2) Assure that every individual who receives
				  MA, who is eligible for MA or who is applying for MA, is reviewed and assessed
				  by the Department or an independent assessor and found to need nursing facility
				  services prior to admission to the nursing facility, or in the case of a
				  resident, before authorization for MA payment.
(3) Assure immediate access to a resident by
				  the following individuals:
(i) The resident's
				  physician.
(ii) A representative of
				  the Secretary of the United States Department of Health and Human
				  Services.
(iii) A representative of
				  the Commonwealth who is involved in the administration of the MA
				  Program.
(iv) An ombudsman
				  authorized by the Department of Aging, including those employed by a local area
				  agency on aging.
(v) A
				  representative of Pennsylvania Protection and Advocacy, the agency designated
				  under Subchapter III of the Developmental Disabilities Assistance and Bill of
				  Rights Act (42 U.S.C.A.
				  §§
												6041-6043) and the
				  Protection and Advisory for Mentally Ill Individuals Act of 1986 (42 U.S.C.A. §§
												10801-10851).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter C - NURSING FACILITY PARTICIPATION › Section 1187.23 - Nursing facility incentives and adjustments

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Department will make minimum
				  occupancy adjustments to encourage nursing facility efficiency and economy
				  associated with nursing facility occupancy levels. If the nursing facility's
				  overall nursing facility occupancy level is below 90%, the Department will make
				  an adjustment to total nursing facility resident days as though the nursing
				  facility were at 90% occupancy. The Department will apply this 90% occupancy
				  adjustment to the administrative cost component and the capital cost
				  center.
(b) The Department will pay
				  a disproportionate share incentive to a nursing facility that has a high
				  overall occupancy and a high proportion of MA residents in accordance with
				  §
										1187.111 (relating to
				  disproportionate share incentive payments).
This section cited in 55 Pa. Code §
												1187.96 (relating to price- and
						rate-setting computations).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter D - DATA REQUIREMENTS FOR NURSING FACILITY APPLICANTS AND RESIDENTS › Section 1187.31 - Admission or MA conversion requirements

Current through Register Vol. 54, No. 28, July 13, 2024
A nursing facility shall meet the following admission or MA
					 conversion requirements:
(1)
Prescreening
. The nursing facility shall ensure that
				  individuals applying for admission to the facility are prescreened by the
				  Department as required by section 1919 of the Social Security Act
				  (42 U.S.C.A. §
											1396r(e)(7)) and 42 CFR Part
				  483 Subpart C (relating to preadmission screening and annual review of mentally
				  ill and mentally retarded individuals).
(2)
Preadmission or MA conversion
				  evaluation and determination
.
(i)
				  The nursing facility shall ensure that before an MA applicant or recipient is
				  admitted to a nursing facility, or before authorization for MA payment for
				  nursing facility services in the case of a resident, the MA applicant,
				  recipient or resident has been evaluated by the Department or an independent
				  assessor and found to need nursing facility services.
(ii) The nursing facility shall maintain a
				  copy of the Department's or the independent assessor's notification of
				  eligibility in the business office.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter D - DATA REQUIREMENTS FOR NURSING FACILITY APPLICANTS AND RESIDENTS › Section 1187.32 - Continued need for nursing facility services requirements

Current through Register Vol. 54, No. 28, July 13, 2024
A nursing facility shall meet the following continued need
					 for nursing facility services requirements:
(1) The nursing facility shall complete a new
				  prescreening form for a resident whenever there is a change in the resident's
				  condition that affects whether the resident is a target resident. The nursing
				  facility shall maintain a copy of the new prescreening form in the resident's
				  clinical record and notify the Department within 48 hours of the change in the
				  resident's condition on forms designated by the Department.
(2) The nursing facility shall ensure that a
				  resident's attending physician, or a physician assistant or nurse practitioner
				  acting within the scope of practice as defined by State law and under the
				  supervision of the resident's attending physician, recertifies the resident's
				  need for nursing facility services in the resident's clinical record at the
				  time the attending physician's orders are reviewed and renewed, consistent with
				  Department of Health licensure time frames for renewing orders.
(3) The nursing facility shall notify the
				  Department within 48 hours whenever the facility or resident's attending
				  physician determines that the resident no longer requires nursing facility
				  services. The notification shall be submitted on forms designated by the
				  Department.
(4) The nursing
				  facility shall obtain a physician's certification and written order for the
				  resident's discharge whenever a resident no longer requires nursing facility
				  services.
The provisions of this §
												1187.32 amended under sections
						201(2), 206(2), 403(b) and 443.1(5) of the Public Welfare Code (62 P.S.
						§§
													201(2),
						206(2), 403(b) and
						443.1(5)).
This section cited in 55 Pa. Code §
												1187.32a (relating to
						clarification of the term "written"-statement of
						policy).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter D - DATA REQUIREMENTS FOR NURSING FACILITY APPLICANTS AND RESIDENTS › Section 1187.32a - Clarification of the term "written"-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The term "written" in §
										1187.32(4) 
				  (relating to continued need for nursing facility services requirements)
				  includes orders that are handwritten or transmitted by electronic
				  means.
(b) Written orders
				  transmitted by electronic means must be electronically encrypted or transmitted
				  by other technological means designed to protect and prevent access,
				  alteration, manipulation or use by any unauthorized person.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter D - DATA REQUIREMENTS FOR NURSING FACILITY APPLICANTS AND RESIDENTS › Section 1187.34 - Requirements related to notices and payments pending resident appeals

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  requirements relating to notices authorizing and discontinuing MA payments for
				  nursing facility services are as follows:
(1)
Notices authorizing MA payment.
(i) The nursing facility shall retain, in its
				  business office, a copy of the Department's notice authorizing MA nursing
				  facility services for each MA conversion resident and for each MA applicant or
				  recipient who is admitted as a resident.
(ii) The Department's notice authorizing MA
				  nursing facility services will specify the effective date of coverage and the
				  amount of money that the resident has available to contribute towards payment.
				  The nursing facility is responsible to obtain the resident's share of the
				  payment.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter E - ALLOWABLE PROGRAM COSTS AND POLICIES › Section 1187.51 - Scope

Current through Register Vol. 54, No. 28, July 13, 2024
(a) This subchapter
				  sets forth principles for determining the allowable costs of nursing
				  facilities.
(b)
The
				  Medicare Provider Reimbursement Manual
(CMS Pub. 15-1) and the Federal
				  regulations in 42 CFR Part 489 (relating to provider and supplier agreements)
				  appropriate to the reimbursement for nursing facility services under the
				  Medicare Program are a supplement to this chapter. If a cost is included in
				  this subchapter as allowable, the CMS Pub. 15-1 and applicable Federal
				  regulations may be used as a source for more detailed information on that cost.
				  The CMS Pub. 15-1 and applicable Federal regulations will not be used for a
				  cost that is nonallowable either by a statement to that effect in this chapter
				  or because the cost is not addressed in this chapter or in the MA-11. The CMS
				  Pub. 15-1 or applicable Federal regulations will not be used to alter the
				  treatment of a cost provided for in this subchapter or the MA-11.
(c) The Department's payment rate for nursing
				  facility services to eligible residents in participating nursing facilities
				  includes allowable costs for routine services. Routine services may include the
				  following:
(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 administration of oxygen and related medications, hand
				  feeding, incontinency care, tray service and enemas.
(3) Items furnished routinely and uniformly
				  to residents, such as resident gowns, water pitchers, basins and
				  bedpans.
(4) Items furnished,
				  distributed to residents or used individually by residents 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) Reusable items
				  furnished to residents, such as ice bags, bed rails, 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) Basic laundry services.
(8) Nonemergency transportation.
(9) Beauty and barber services.
(10) Other special medical services of a
				  rehabilitative, restorative or maintenance nature, designed to restore or
				  maintain the resident's physical and social capacities.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter E - ALLOWABLE PROGRAM COSTS AND POLICIES › Section 1187.52 - Allowable cost policies

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  Department will incorporate a nursing facility's direct and indirect allowable
				  costs related to the care of residents into the NIS database. The Department
				  will consider these costs in the setting of prices.
(b) Costs that are not recognized as
				  allowable costs in a fiscal year may not be carried forward or backward to
				  other fiscal years for inclusion in reporting allowable costs. For the cost to
				  be allowable, short-term liabilities shall be liquidated within 1 year after
				  the end of the cost reporting period in which the liability is
				  incurred.
This section cited in 55 Pa. Code §
												1187.61 (relating to movable
						property cost policies).
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter E - ALLOWABLE PROGRAM COSTS AND POLICIES › Section 1187.53 - Allocating cost centers

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The
				  nursing facility shall allocate costs between nursing facility and residential
				  in accordance with the allocation bases established by the Department as
				  contained in this chapter and the MA-11. If the nursing facility has its own
				  more accurate method of allocation, it may be used only if the nursing facility
				  receives written approval from the Department prior to the first day of the
				  applicable cost report year.
(b)
				  The absence of documentation to support allocation or the use of other methods
				  which do not properly reflect use of the Department's required allocation bases
				  or approved changes in bases shall result in disallowances being imposed for
				  each affected line item.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter E - ALLOWABLE PROGRAM COSTS AND POLICIES › Section 1187.54 - Changes in bed complement during a cost reporting period

Current through Register Vol. 54, No. 28, July 13, 2024
(a) When the nursing facility's bed
				  complement changes during a cost reporting period, the allocation bases are
				  subject to verification at audit.
(b) The nursing facility shall keep adequate
				  documentation of the costs related to bed complement changes during a cost
				  reporting period. The nursing facility shall submit a supplemental Schedule C
				  (computation and allocation of allowable cost), which identifies costs being
				  allocated by the required statistical methods for each period of
				  change.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter E - ALLOWABLE PROGRAM COSTS AND POLICIES › Section 1187.55 - Selected resident care and other resident related cost policies

Current through Register Vol. 54, No. 28, July 13, 2024
Policies for selected resident care and other resident
					 related costs are as follows:
(1)
Drug services.
(i) The costs
				  of nonlegend drugs, such as laxatives, aspirin and antacids that are provided
				  directly by a nursing facility from its own supply are allowable costs if the
				  drugs are medically necessary and administered according to a physician's
				  written order or prescription.
(ii)
				  Costs of legend drugs are not allowable costs.
(iii) Costs related to a pharmacy consultant
				  shall be reported as general administrative costs on the cost report.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter E - ALLOWABLE PROGRAM COSTS AND POLICIES › Section 1187.55a - Clarification of the term "written"-statement of policy

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The term "written" in §
										1187.55(1)(i)
				  (relating to selected resident care and other resident related cost policies)
				  includes orders and prescriptions that are handwritten or transmitted by
				  electronic means.
(b) Written
				  orders and prescriptions transmitted by electronic means must be electronically
				  encrypted or transmitted by other technological means designed to protect and
				  prevent access, alteration, manipulation or use by any unauthorized
				  person.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter E - ALLOWABLE PROGRAM COSTS AND POLICIES › Section 1187.56 - Selected administrative cost policies

Current through Register Vol. 54, No. 28, July 13, 2024
Policies for selected administrative costs are as follows:
(1)
Administrative
				  allowance.
(i) The allowable
				  administrative costs incurred by a nursing facility to provide services are
				  subject to the following limitation: the allowable administrative costs will be
				  determined so that all other allowable costs, excluding capital costs, equal no
				  less than 88% of the allowable net operating costs.
(ii) Home office cost allocations and
				  management fees are subject to the following conditions and limitations:
(A) Home office cost allocations and
				  management fees between related parties shall be reported without markup by the
				  nursing facility.
(B) Costs which
				  are not allowable, such as those related to nonworking officers or officers'
				  life insurance, may not be included in home office allocations or management
				  fees.
(C) Documentation relating to
				  home office and management costs shall be provided to the Department's auditors
				  upon request.
(D) Home office
				  allocations, including administratively allowable depreciation and interest
				  costs shall be reported on the administrative line in the MA-11.
(iii) A nursing facility providing
				  nursing, residential and other services shall allocate the total administrative
				  cost to nursing, residential and other services on the basis of a percentage of
				  these costs to the total net operating costs.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter E - ALLOWABLE PROGRAM COSTS AND POLICIES › Section 1187.57 - Selected capital cost policies

Current through Register Vol. 54, No. 28, July 13, 2024
The Department will establish a prospective
					 facility-specific capital rate annually for each nursing facility. That rate
					 will consist of three components: the fixed property component, the movable
					 property component and the real estate tax component.
(1)
Fixed property
				  component
. The Department will base the nursing facility's fixed
				  property component on an assigned cost of $26,000 per allowable bed.
(2)
Movable property
				  component
. The Department will determine the movable property
				  component of each nursing facility's capital rate as follows:
(i) The Department will base the nursing
				  facility's movable property component on the nursing facility's audited cost of
				  major movable property, as set forth in that MA-11.
(ii) Each nursing facility shall report the
				  acquisition cost of all major movable property on the major movable property
				  line of its MA-11 and shall report the cost of minor movable property and the
				  cost of supplies as net operating costs in accordance with §
											1187.51 (relating to scope) and
				  instructions for the MA-11.
Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1187 - NURSING FACILITY SERVICES › Subchapter E - ALLOWABLE PROGRAM COSTS AND POLICIES › Section 1187.58 - Costs of related parties

Current through Register Vol. 54, No. 28, July 13, 2024
Costs applicable to services, movable property and
					 supplies, furnished to the nursing facility by organizations related to the
					 nursing facility by common ownership or control shall be included as an
					 allowable cost of the nursing facility at the cost to the related organization.
					 This cost may not exceed the price of comparable services, movable property or
					 supplies that could be purchased elsewhere.
This section cited in 55 Pa. Code §
												1187.61 (relating to movable
						property cost policies).