Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-30 - Utilization control: Long-stay acute care hospitals (nonmental hospitals)

Current through Register Vol. 40, No. 24, July 15, 2024
A. Services for
				adults in long-stay acute care hospitals. The population to be served includes
				individuals requiring mechanical ventilation, ongoing intravenous medication or
				nutrition administration, comprehensive rehabilitative therapy services and
				individuals with communicable diseases requiring universal or respiratory
				precautions.
1. Long-stay acute care hospital
				stays shall be preauthorized by the submission of a completed comprehensive
				assessment instrument, a physician certification of the need for long-stay
				acute care hospital placement, and any additional information that justifies
				the need for intensive services. Physician certification must accompany the
				request. Periods of care not authorized by DMAS shall not be approved for
				payment.
2. These individuals must
				have long-term health conditions requiring close medical supervision, the need
				for 24-hour licensed nursing care, and the need for specialized services or
				equipment needs.
3. At a minimum,
				these individuals must require physician visits at least once weekly, licensed
				nursing services 24 hours a day (a registered nurse whose sole responsibility
				is the designated unit must be on the nursing unit 24 hours a day on which the
				resident resides), and coordinated multidisciplinary team approach to meet
				needs that must include daily therapeutic leisure activities.
4. In addition, the individual must meet at
				least one of the following requirements:
a.
				Must require two out of three of the following rehabilitative services:
				physical therapy, occupational therapy, speech-pathology services; each
				required therapy must be provided daily, five days per week, for a minimum of
				one hour each day; individual must demonstrate progress in overall
				rehabilitative plan of care on a monthly basis; or
b. Must require special equipment such as
				mechanical ventilators, respiratory therapy equipment (that has to be
				supervised by a licensed nurse or respiratory therapist), monitoring device
				(respiratory or cardiac), kinetic therapy; or
c. The individual must require at least one
				of the following special services:
(1)
				Ongoing administration of intravenous medications or nutrition (i.e. total
				parenteral nutrition (TPN), antibiotic therapy, narcotic administration,
				etc.);
(2) Special infection
				control precautions such as universal or respiratory precaution (this does not
				include handwashing precautions only);
(3) Dialysis treatment that is provided
				on-unit (i.e. peritoneal dialysis);
(4) Daily respiratory therapy treatments that
				must be provided by a licensed nurse or a respiratory therapist;
(5) Extensive wound care requiring
				debridement, irrigation, packing, etc., more than two times a day (i.e. grade
				IV decubiti; large surgical wounds that cannot be closed; second- or
				third-degree burns covering more than 10% of the body); or
(6) Ongoing management of multiple unstable
				ostomies (a single ostomy does not constitute a requirement for special care)
				requiring frequent care (i.e. suctioning every hour; stabilization of feeding;
				stabilization of elimination, etc.).
5. Utilization review shall be performed to
				determine if services are appropriately provided and to ensure that the
				services provided to Medicaid recipients are medically necessary and
				appropriate. Services not specifically documented in the individuals' medical
				records as having been rendered shall be deemed not to have been rendered and
				no coverage shall be provided.
6.
				When the individual no longer meets long-stay acute care hospital criteria or
				requires services that the facility is unable to provide, then the individual
				must be discharged.