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 F - HEAVY CARE/INTERMEDIATE SERVICES

Current through Register Vol. 54, No. 28, July 13, 2024
I.
Introduction.
The Department has developed criteria to be used in
						determining whether an applicant or recipient is medically eligible for the
						heavy care/intermediate level of care. To be determined medically eligible for
						the heavy care/intermediate level of care, a recipient shall meet the
						requirements in Section II. If any one of the requirements specified in Section
						II are not met, the recipient cannot be determined to be medically eligible for
						the heavy care/intermediate level of care.
II.
Heavy care/intermediate services.
(a) Heavy care/intermediate services shall be provided in
						a dually certified skilled bed and are subject to the same limits on nursing
						hours as skilled care services.
(b) Heavy care/intermediate services are services
						provided to patients who are functionally impaired to the following extent with
						respect to the following activities of daily living:
(1)
Eating
-requires total care. Requires
						total care means that the individual must be hand fed by another person, is
						tube fed, or is in a feeding retraining program. Functional impairment shall be
						at level 3 or 4.
(2)
Dressing
-requires total care.
						Requires total care means that the individual must be dressed by another
						person. Functional impairment shall be at level 3.
(3)
Continence of urine
-is incontinent or
						has an indwelling bladder catheter. Incontinent means incontinent more than 50%
						of the time. Functional impairment shall be at level 3 or 4.
(4)
Mental status
-confused or
						speech-aphasic with behavioral problems. Confused means confused most of the
						time, semi-comatose or comatose. Functional impairment shall be at level 3, 4
						or 5. Speech-aphasic with behavioral problems means unable to communicate for
						whatever reason. Functional impairment shall be at level 3 and there shall be
						behavioral problems.
(5)
Mobility
-wheelchair/mobile. Mobility
						includes those categories of mobility status which are wheelchair/mobile,
						cane/walker, chairbound or bedfast. Functional impairment shall be at level 2,
						3, 4 or 5.
ITEM
LEVEL
								1
LEVEL 2
LEVEL
								3
LEVEL 4
LEVEL 5
[][]Eating
Self
With
								Assistance
Total Care
Tube Fed
[][]Bathing
Self
With
								Assistance
Total Care
[][]Dressing
Self
With
								Assistance
Total Care
[][]Continence of Urine
Continent
Occas. Incontinent
Incontinent
Catheter
[][]Continence of Bowel
Continent
Occas. Incontinent
Incontinent
Colostomy
[][]Mental Status
Clear
Occas.
								Confused
Confused
Semi Comatose
Comatose
[][]Noisy
Never
Occasionally
Most of the Time
[][]Combative
Never
Occasionally
Most of the Time
[][]Withdrawn
Never
Occasionally
Most of the Time
[][]Wanders
Never
Occasionally
Most of the Time
[][]Suicidal
Never
Occasionally
Most of the Time
[][]Mobility
Ambulatory
Wheelchair/Mobile
Cane/Walker/Asst.
Chairbound
Bedfast
[][]Sight
Not Impaired
Impaired
Blind
[][]Hearing
Not Impaired
Impaired
Deaf
[][]Speech
Not Impaired
Impaired
Aphasic
(c) Documentation justifying the need for heavy
						care/intermediate services on an inpatient basis shall be recorded in the
						patient's medical record at least monthly.
This section cited in 55 Pa. Code §
													1181.2 (relating to definitions);
						  and 55 Pa. Code §
													1181.54 (relating to payment
						  conditions related to the recipient's continued need for
						  care).