West Virginia Code of State Rules › Agency 65 - Health Care Authority › Title 65 - LEGISLATIVE RULE HEALTH CARE AUTHORITY › Series 65-20 - Conversion Of Acute Care Beds To Skilled Nursing Care Beds › Section 65-20-10 - Criteria and Standards

Current through Register Vol. XLI, No. 28, July 12, 2024
Statement of Purpose: In order to ensure an appropriate
				  supply of health services to the citizens of West Virginia while discouraging
				  unnecessary duplication and high costs, the Health Care Cost Review Authority
				  shall conduct a through public review and evaluation of proposed
				  projects.
The goal of the Certificate of Need Program is to provide for
				  the continued orderly development of the health care system in West Virginia
				  through a public review of proposed applications that are evaluated in
				  accordance with established Criteria and Standards. The purpose of the Criteria
				  and Standards is twofold:
(1) To serve as guidelines in the continued orderly
				  development of the health care system in West Virginia in accordance with the
				  Certificate of Need statute; and
(2) To promote cost-effective alternatives to higher-cost
				  services.
10.1. An existing hospital
				may apply to convert acute care beds to skilled nursing beds.
10.1.1. There shall be a minimum of ten (10)
				beds and a maximum of twenty-five (25) beds per unit or per
				application.
10.1.2. The hospital
				must convert at least one (1) acute care bed into one (1) medicare certified
				only skilled nursing care bed. The Authority may require a hospital to
				delicense up to and including three (3) acute care beds for each medicare
				certified only skilled nursing bed.
10.1.3. All acute care beds converted shall
				be permanently deleted from the hospital's acute care be complement and the
				hospital may not thereafter add, by conversion or otherwise, acute care beds to
				its bed complement without satisfying the requirements of W. Va. Code
				'16-2D-3(d)
				for which purposes such an addition, whether by conversion or otherwise, is
				considered a substantial change to the bed capacity of the hospital
				notwithstanding the definition of that term found in W. Va. Code '16-2D-2(ee).
10.1.4. The hospital must use existing space
				for the medicare certified only skilled nursing care beds. Under no
				circumstances shall the hospital construct new space, lease or acquire
				additional space for the purpose of developing a skilled nursing care
				unit.
10.1.5. The hospital must
				provide evidence that an acute care patient prior to transfer to the medicare
				skilled nursing care unit, will be notified of the existence of facilities with
				skilled nursing care beds which are located in or near the patient's county of
				residence and of the availability of admission to such nursing
				facility.
10.1.6. The hospital
				shall meet all federal and state licensing certification and operational
				requirements applicable to nursing homes including a requirement that all
				skilled care beds converted shall be located in distinct-part, long-term care
				unit.
10.1.7. The hospital must
				demonstrate a need for the number of medicare skilled nursing care beds
				proposed for the distinct-part unit. The methodology for demonstrating need
				shall be quantitative and be directly related to the hospital proposing the
				conversion to skilled nursing care beds. The methodology shall be DRG based and
				involve 94 DRG's which have a high probability of resulting in skilled nursing
				services. A complete listing of the 94 DRG's is attached at the end of this
				rule. The first step is to determine a discharge base by finding the number of
				discharges with a length-of-stay of eight (8) days or more. A need projection
				can then be calculated by multiplying the number of discharges of eight (8)
				days or more time fifteen (15), the average length of stay for a skilled
				nursing unit. This product is divided by three hundred sixty-five (365) days
				and again divided by .90 (average acceptable occupancy rate for a skilled
				nursing unit) to determine the projected need for skilled nursing beds which
				the hospital can demonstrate from its own patient data.
10.1.8. A hospital with an existing skilled
				nursing care unit is not eligible to apply for additional skilled nursing care
				beds until the existing unit exceeds an aggregate average occupancy rate of
				ninety percent (90%) for the previous twelve (12) months.
10.1.9. A hospital which converts acute care
				beds to medicare certified only skilled nursing beds is prohibited from billing
				for any medicaid reimbursement for any beds converted pursuant to this rule.
SKILLED NURSING UNIT DRG'S
DRG
GROUP
NUMBER
DESCRIPTION
009 Spinal Disorders & Injuries
010 Nervous System Neoplasms With CC
012 Degenerative Nervous Neoplasms With CC
014 Specific Cerebrovascular Disorders Except TIA
018 Cranial & Peripheral Nerve Disorders With CC
024 Seizure & Headache Age 17 With CC
034 Other Disorders Of Nervous System With CC
044 Acute Major Eye Infections
075 Major Chest Procedures
078 Pulmonary Embolism
079 Respiratory Infections & Inflammations Age 17 With
				  CC
082 Respiratory Neoplasms
083 Major Chest Trauma With CC
085 Pleural Effusion With CC
087 Pulmonary Edema & Respiratory Failure
088 Chronic Obstructive Pulmonary Disease
089 Simple Pneumonia & Pleurisy Age 17 With CC
094 Pneumothorax With CC
096 Bronchitis & Asthma Age 17 With CC
101 Other Respiratory System Diagnoses With CC
106 Cornary Bypass With Cardiac Cath
107 Cornary Bypass W/O Cariac Cath
110 Major Cardiovascular Procedures With CC
113 Amputation For Circ System Disorders Except Upper Limb
				  & Toe
115 Perm Cardiac Pacemaker Implant With Ami, Heart Failure or
				  Shock
121 Circulatory Disorders With Ami & C.V. Comp. Disch.
				  Alive
DRG
GROUP
NUMBER
DESCRIPTION
126 Acute & Subacute Endocarditis
127 Heart Failure & Shock
128 Deep Vein Thrombophlebitis
130 Peripheral Vascular Disorders With CC
132 Atherosclerosis With CC
134 Hypertension
135 Cardiac Congenital & Valvular Disorders Age 17 With
				  CC
138 Cardiac Arrhythmia & Conduction Disorders With
				  CC
140 Angina Pectoris
144 Other Circulatory System Diagnoses With CC
146 Rectal Resection With CC
148 Major Small & Large Bowel Procedures With CC
150 Peritoneal Adhesiolysis Age 69 And/Or CC
164 Appendectomy With Complicated Princ. Diag Age 69/And/Or
				  CC
172 Digestive Malignancy Age 69 And/Or CC
174 G.I. Hemorrhage Age 69 And/Or CC
179 Inflammatory Bowel Disease
180 G.I. Obstruction With CC
182 Esophagitis, Gastroent. & Misc. Digest. Disorders Age
				  17 With CC
188 Other Digistive System Diagnosis Ages 69 And/Or CC
191 Major Pancreas, Liver & Shunt Procedures With
				  CC
195 Total Cholecystectomy W C.D.E. With CC
197 Total Cholecystectomy W/O C.D.E. With CC
203 Malignancy Of Hepatobiliary System Or Pancreas
204 Disorders Of Pancreas Except Malignancy
205 Disorders Of Liver Exc Malig. Cirr. Alc Hepa With
				  Cc
207 Disorders Of The Biliary Tract With CC
209 Major Joint And Limb Reattachment Procedures
210 Hip & Femur Procedures Except Major Joint Age 17 With
				  Cc
213 Amputations For Musculoskeletal System & Conn. Tissue
				  Disorders
217 Wnd Debrid & Skn Grft Exc Hand, For Muscskeletal
				  & Conn. Tiss. Dis.
221 Major Shoulder/Elbow Proc. Or Other Upper Extremity Proc.
				  W CC
223 Upper Extremity Proc. Exc. Humerus + Hand Age 69 And/Or
				  CC
233 Other Musculoskelet Sys. & Conn. Tiss. O.R. Proc.
				  With CC
235 Fractures Of Femur
236 Fractures Of Hip & Pelvis
238 Osteomyelitis
239 Pathological Fractures & Musculoskeletal & Conn.
				  Tiss. Malignancy
240 Connective Tissue Disorders With CC
242 Septic Arthritis
244 Bone Diseases & Specific Arthropathies With CC
257 Total Mastectomy For Malignancy With CC
259 Subtotal Mastectomy For Malignancy With CC
263 Skin-Grafts And/Or Debrid Ulcer Or Cllulitis With
				  CC
271 Skin Ulcers
DRG
GROUP
NUMBERDESCRIPTION
272 Major Skin Disorders With CC
274 Malignant Breast Disorders With CC
277 Cellulitis Age 17 With CC
285 Amputation Of Lower Limb For Endocrine, Nutritional &
				  Metabolic Dis.
294 Diabetes Age = 35
296 Nutritional & Misc. Metabolic Disorders With
				  CC
300 Endocrine Disorders Age 69 And/Or CC
306 Prostatectomy With CC
310 Transurethral Procedures With CC
318 Kidney & Urinary Tract Neoplasms Age 17 With
				  CC
320 Kidney & Urinary Tract Infections Age 17 With
				  CC
331 Other Kidney & Urinary Tract Diagnoses Age 17 With
				  CC
336 Transurethral Prostatectomy With CC
346 Malignancy, Male Reproductive System With CC
366 Malignancy, Female Reproductive System With CC
400 Lymphoma And Leukemia With Major O.R. Procedure
401 Lymphoma And Non-Acute Leukemia With Other O.R. Proc.
				  With CC
403 Lymphoma And Non-Acute Leukemia With CC
416 Septicemia Age 17
423 Other Infectious & Parasitic Diseases
				  Diagnoses
444 Traumatic Injury Age 17 With CC
449 Poisoning And Toxic Effects Of Drugs Age 69 And/Or
				  CC
462 Rehabilitation