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 1181.53 - Payment conditions related to the recipient's initial need for care

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
Certification of need for care.
For skilled, heavy
					 care/intermediate, intermediate and intermediate care for the mentally retarded
					 levels of care, a physician, or a nurse practitioner or clinical nurse
					 specialist who is not an employe of the facility but is working in
					 collaboration with a physician, shall certify in writing on the medical record
					 that the applicant or recipient needs skilled, heavy care/intermediate,
					 intermediate care or intermediate care for the mentally retarded as applicable.
					 The certification shall be signed and dated by a physician, or a nurse
					 practitioner or clinical nurse specialist who is not an employe of the facility
					 but is working in collaboration with a physician, not more than 30 days prior
					 to the admission of an applicant or recipient to a facility, or, if an
					 individual applies for assistance while in a facility before the Department
					 authorizes payment for nursing facility care or intermediate care for the
					 mentally retarded.
(b)
Medical evaluation.
The medical evaluation shall consist of
					 the following:
(1) Before admission to a
					 facility for skilled nursing care or before authorization of payment, the
					 attending physician shall make a medical evaluation of the applicant's or
					 recipient's need for skilled nursing care.
(2) Before the latter of the admission of an
					 applicant or recipient to a skilled nursing facility or the Department's
					 authorization of payment for skilled nursing care, an applicant or recipient
					 shall be determined to be medically eligible for skilled nursing care in
					 accordance with the criteria specified in Appendix E (relating to skilled
					 nursing care). Skilled Nursing Care Assessment forms which are designed to
					 enable the Department to determine whether the criteria specified in Appendix E
					 are met by a recipient, will be supplied by the Department. The form shall be
					 completed by a physician.
(3)
					 Before admission to a facility for heavy care/intermediate, intermediate care
					 or intermediate care for the mentally retarded, or before authorization for
					 payment, an interdisciplinary team of health professionals shall make a
					 comprehensive medical and social evaluation and, when appropriate, a
					 psychological evaluation of each applicant's or recipient's need for heavy
					 care/intermediate, intermediate care or intermediate care for the mentally
					 retarded. In an intermediate care facility for the mentally retarded, the team
					 shall also make a psychological evaluation of need for care.
(4) The following criteria shall be met
					 before a person qualifies for an intermediate care facility for the mentally
					 retarded level (ICF/MR) of care:
(i) The
					 applicant or recipient has a diagnosis of mental retardation.
(ii) The applicant or recipient requires
					 active treatment.
(iii) The
					 applicant or recipient is recommended for an ICF/MR level of care based on
					 medical evaluation as specified in Appendix Q (Reserved).
(5) The evaluations required in this
					 subsection shall be recorded on the patient's medical record and on forms
					 issued by the Department and forwarded to the Department for review and
					 assessment. The Department's Review Team will evaluate the need for admission
					 and authorize payment for the appropriate level of care.
(6) The Department will send a written notice
					 of the authorization or denial of payment to the nursing facility and the
					 patient.
(7) The notice will
					 indicate the effective date of coverage and the amount of money the patient has
					 available to contribute toward the interim per diem rate. Obtaining the
					 patient's share of the interim per diem rate is the responsibility of the
					 nursing facility.