CHAPTER He-M 1300 SPECIALIZED SERVICES
PART He-M
1301 Medical
Assistance Services Provided by Education Agencies
Statutory
Authority: RSA 186-C:25
PART He-M 1302 NURSING FACILITY PREADMISSION SCREENING AND
RESIDENT REVIEW (PASRR)
Statutory Authority:
He-M 1302.01 Purpose. The purpose of these rules is to describe the
screening process and criteria for determining the appropriateness of admitting
or continuing placement of applicants with mental illness or developmental
disability to Medicaid certified nursing facilities. Each applicant for admission is screened to
confirm mental illness or developmental disability, to determine if the
applicant requires nursing facility services, and, if found appropriate for
admission, to determine whether the applicant requires specialized services in
addition to those typically provided by nursing facilities.
Source. #6063 eff 8-1-95; ss by #7920, INTERIM, eff
8-2-03, EXPIRED: 1-29-04
New. #8035, eff 2-7-04, EXPIRED: 2-7-12
New. #10123, INTERIM, eff 4-30-12, EXPIRES:
10-29-12; ss by #10216, eff 10-29-12
He-M
1302.02 Definitions. The words and phrases used in these rules
shall mean the following:
(a) “Applicant” means an individual who applies
for residence in a Medicaid certified nursing facility.
(b) “Appropriate placement” means an individual’s
needs are such that he or she meets the minimum standards for admission pursuant
to He-M 1302.07 and the individual’s needs for treatment do not exceed the
level of services which can be delivered in the nursing facility to which the
individual is admitted either through nursing facility services alone or, where
necessary, through nursing facility services supplemented by specialized
services provided by or arranged for by the department.
(c) “Bureaus” means the bureau of developmental
services and the bureau of behavioral health of the
(d) “Developmental disability (DD)” means “mental
retardation” as defined in 42 CFR 483.102 (b)(3) and as described in the
American Association on Mental Retardation’s Manual on Classification in Mental
Retardation (1983).
(e) “Department” means the
(f) “Informed decision” means a choice made by an
applicant or, where appropriate, the applicant’s legal representative, that is
reasonably certain to have been made subsequent to a rational consideration on
the applicant’s part of the advantages and disadvantages of each course of
action open to the applicant.
(g) “Licensed medical professional” means a
licensed nurse, advanced practice registered nurse, physician, physician assistant,
physical therapist, or occupational therapist.
(h) “Mental illness (MI)” means a condition such
that:
(1) The disorder is
classified in the Diagnostic and Statistical Manual of Mental Disorders, Third
Edition, Revised, as:
a. A schizophrenic, mood,
paranoid, panic, or other severe anxiety disorder;
b. A somatoform disorder;
c. A personality disorder;
d. Another psychotic
disorder; or
e. Another mental disorder that
may lead to a chronic disability;
(2) There is not a primary
diagnosis of dementia, including Alzheimer’s disease or a related disorder, or
a non-primary diagnosis of dementia, unless the primary diagnosis is a mental
disorder identified in (1) above;
(3) The disorder has
resulted in functional limitations in major life activities within the past 3
to 6 months that would be appropriate for the individual’s developmental stage,
such that the individual has at least one of the following characteristics on a
continuing or intermittent basis:
a. Serious difficulty
interacting appropriately and communicating effectively with other persons,
including a possible history of altercations, evictions, firing, fear of
strangers, avoidance of interpersonal relationships, or social isolation;
b. Serious difficulty in
sustaining focused attention for a long enough period to permit the completion
of tasks commonly found in work settings or in work-like structured activities
occurring in school or home settings, including:
1. Difficulties in concentration;
2. Inability to complete simple tasks within an
established time period;
3. Making frequent errors; or
4. Requiring assistance in the completion of
simple tasks; or
c. Difficulty in adapting to typical changes in
circumstances associated with work, school, family, or social interaction as
demonstrated by:
1. Agitation, exacerbated signs
and symptoms associated with the illness, or withdrawal from the situation; or
2. Need of intervention by the mental health or
judicial system; and
(4) The treatment history
indicates that the individual has experienced at least one of the following
within the past 2 years:
a. Psychiatric treatment
more intensive than outpatient care; or
b. Due to the mental
disorder, an episode of significant disruption to the normal living situation:
1. For which
supportive services were required to maintain functioning at home or in a
residential treatment environment; or
2. Which resulted
in intervention by housing or law enforcement officials.
(i) “Nursing
facility” means an institution or a distinct part of an institution that is:
(1) Participating in the
Medicaid program;
(2) Meeting the
requirements of Section 1919 of the Social Security Act, 42 USC 1396r;
(3) Not primarily an institution for
mental diseases (IMD) as defined in 42 CFR 435.1010, or an intermediate care
facility for the mentally retarded (ICF/MR) as defined in 42 CFR 440.150; and
(4) Providing one or more
of the following:
a. Skilled nursing care and
related services for residents who require medical or nursing care;
b. Rehabilitative services
for the rehabilitation of injured, disabled or sick individuals; or
c. Health-related care and
services to individuals who, because of their mental or physical condition,
require care and services that are above the level of room and board, and that
can be made available to them only through an institution.
(j) “PASRR office” means that office delegated
the functional responsibility by the department of:
(1) Carrying
out preadmission screenings; and
(2) Performing
reviews pursuant to He-M 1302.13.
(k) “Referral agent” means:
(1) Hospitals;
(2) Nursing
facilities;
(3) Area
agencies;
(4) Community
mental health centers; or
(5) Any other
person or entity seeking to place a person in a nursing facility.
(l) “Skilled nursing care” means those health
related services, above the level of room and board, which meet the criteria
used by the Medicare program for skilled nursing care, per 42 USC 1395i3.
(m) “Specialized services for DD” means those services
that, combined with services provided by the nursing facility, result in a
continuous active treatment program, which:
(1) Includes
aggressive, consistent implementation of a program of specialized and generic
training, treatment, health services, and related services; and
(2) Is directed
toward the acquisition of the behaviors necessary for the individual to
function with as much self determination and
independence as possible.
(n) “Specialized services for MI” means those
services that, combined with services provided by the nursing facility, result
in continuous and aggressive implementation of an individualized plan of care
which:
(1) Is
developed and supervised by an interdisciplinary team which includes a
physician, qualified mental health professionals, and, as appropriate, other
professionals;
(2) Prescribes
specific therapies and activities for the treatment of persons experiencing an
acute episode of serious mental illness which requires intervention by trained
behavioral health personnel, and
(3) Is directed
toward:
a. Diagnosing and reducing the person’s behavioral symptoms that
necessitate institutionalization;
b. Improving his/her level
of independent functioning; and
c. Achieving a functioning
level that permits reduction in the intensity of mental health services to
below the level of specialized services at the earliest possible time.
(o) “Terminal condition” means a condition caused
by injury, disease, or illness for which there is no reasonable medical
probability of recovery and which can be expected to cause death within 2 years
as determined by a physician.
Source. #6063 eff 8-1-95; ss by #7920, INTERIM, eff
8-2-03, EXPIRED: 1-29-04
New.
#8035, eff 2-7-04, EXPIRED: 2-7-12
New.
#10123, INTERIM, eff 4-30-12, EXPIRES: 10-29-12; ss by #10216, eff
10-29-12
He-M
1302.03 Identifying and Referring
Nursing Facility Applicants with MI or DD – the Level I Screen.
(a) A referral agent shall conduct a level I
screen for every applicant seeking admission to a Medicaid certified nursing
facility to identify each applicant who is suspected of:
(1) Having MI
as defined in He-M 1302.02(h); or
(2) Having DD
as defined in He-M 1302.02(d).
(b) The referral agent shall use “PASSR Level 1
Review Form” (11/2012 edition) for conducting the level I screen.
(c) Every applicant’s medical record at the
nursing facility shall contain a completed “PASSR Level 1 Review Form” (11/2012
edition).
(d) For each applicant identified in (a) above,
the referral agent shall submit the following, as applicable, to the PASRR
office for a level II evaluation:
(1) The
applicant’s name and address;
(2) The name
and address of the referring agency and the receiving agency;
(3) The
applicant’s date of birth;
(4) The name,
address, telephone number, and relationship of the applicant’s nearest relative
or, if applicable, legal representative;
(5) The
applicant’s Medicaid claim number and information regarding the applicant’s
other insurance and resources, as available;
(6) The date of
admission to the referring agency and the date of transfer to the receiving
agency, if available;
(7) The
applicant’s suspected MI or DD diagnosis;
(8) The applicant’s physical history and current
functional, mental, and physical status, including:
a. Current
medications;
b. Sensory
impairments;
c. Functional
assessments;
d. Physical
disabilities; and
e. Need for
assistive devices;
(9) The applicant’s
rehabilitation goals and the estimated length of stay, if applicable;
(10) The
physician’s name;
(11)
Psychiatric history and consultations covering at least the past 2
years, including:
a.
Identification of one or more of the disorders as defined in He-M
1302.02(h);
b. A
description of how the disorder has resulted in functional limitations in major
life activities within the past 3 to 6 months;
c. A
description of the last 2 years’ psychiatric treatment history and in-patient
psychiatric treatment; and
d. A
description of interventions from social service or law enforcement
representatives relative to the MI;
(12) If
referred from a hospital setting, intake, history and physical, and
consultation reports;
(13) The written
notice pursuant to (e) below; and
(14) Any other
information that is considered by the referral agent to be necessary to make an
accurate determination pursuant to He-M 1302.06(a).
(e) For each applicant identified in (a) above,
the referral agent shall give the applicant, or his or her legal guardian or
legal representative, a written notice explaining that the applicant is being
referred to the PASRR office for level II evaluation pursuant to He-M
1302.03(d).
Source. #6063 eff 8-1-95; ss by #7920, INTERIM, eff
8-2-03, EXPIRED: 1-29-04
New. #8035, eff 2-7-04, EXPIRED: 2-7-12
New. #10123, INTERIM, eff 4-30-12, EXPIRES:
10-29-12; ss by #10216, eff 10-29-12
He-M
1302.04 Level II Evaluations and
Determinations.
(a) For all applicants referred in accordance
with He-M 1302.03 above, the PASRR office shall perform a level II evaluation
and determination to:
(1) Confirm the
existence of MI or DD; and
(2) For those for
whom the existence of MI or DD is confirmed:
a. Determine if
the applicant needs nursing facility services pursuant to He-M 1302.07;
b. Determine if
the nursing facility is an appropriate placement;
c. Specify
whether the applicant requires specialized services pursuant to He-M 1302.10 or
He-M 1302.11; and
d. Specify the
supports the individual needs to reside in the community.
(b) The PASRR office shall terminate the level II
evaluation and determination process for those for whom a diagnosis of MI or DD
is not confirmed.
(c) Exemptions and exclusions to (a) above shall
be as listed in He-M 1302.05 below.
(d) Categorical decisions regarding predetermined
eligibility for nursing facility services as described in He-M 1302.06 shall
preclude the requirement for a level II evaluation and determination except as
noted in He-M 1302.06(f), (h), (i), and (j).
(e) The PASRR office shall complete the report
pursuant to He-M 1302.12(a) for all preadmission referrals within 9 working
days.
(f) For all applicants who are confirmed to have
MI or DD, the PASRR office shall maintain records of evaluations and
determinations in a confidential manner for 6 years.
Source. #6063 eff 8-1-95; ss by #7920, INTERIM, eff
8-2-03, EXPIRED: 1-29-04
New.
#8035, eff 2-7-04; ss by #8430, eff 9-17-05; ss by #10216, eff 10-29-12
He-M
1302.05 Exemptions and Exclusions.
(a) An applicant shall be exempt from level II
evaluation and determination if he or she:
(1) Is admitted
to a nursing facility from a hospital after receiving acute care;
(2) Needs
nursing facility services;
(3) Requires
services for the condition for which he or she received acute care at the
hospital; and
(4) Has a
physician who certifies that the individual is likely to require nursing
facility services for less than 30 days.
(b) For persons admitted pursuant to (a) above
whose nursing facility stay exceeds 30 days, the PASRR office shall perform a
level II evaluation and determination before the 40th day from the individual’s
admission to the nursing facility.
(c) An applicant with a diagnosis of dementia and
MI shall be excluded from the level II evaluation and determination if:
(1) The MI will
not likely be the focus of treatment again; and
(2) The
referral source has documented that:
a. Dementia is
the primary diagnosis; and
b. The dementia
is advanced such that the MI will not likely be the primary focus of treatment.
(d) An applicant who has MI or DD shall be exempt
from level II evaluation and determination if he or she has a notice on file
with the PASRR office per He-M 1302.03(e) and:
(1) Is being
re-admitted to a nursing facility from a hospital; or
(2) Is
transferring from one nursing facility to another with or without an
intervening hospital stay.
Source. #6063 eff 8-1-95; ss by #7920, INTERIM, eff
8-2-03, EXPIRED: 1-29-04
New. #8035, eff 2-7-04; amd
by #8430, eff 9-17-05; paras (a)-(c) expired 2-7-12; amd
by #10123, INTERIM, eff 4-30-12, EXPIRES: 10-29-12; ss by #10215, eff 10-29-12
He-M
1302.06 Categorical Decisions.
(a) An applicant shall be predetermined eligible
for nursing facility services if he or she needs nursing facility services
pursuant to He-M 1302.07 and meets one of the following criteria:
(1) Has a
terminal condition and is not a danger to self or others;
(2) Has a
severe physical condition that has resulted in extreme impairment, such as
coma, ventilator dependence, or functioning at the brain stem level;
(3) Requires a
temporary admission because further assessment cannot be made until delirium
resolves;
(4) Requires
emergency admission for protective services;
(5) Requires
respite for the caregiver of the applicant with MI or DD; or
(6) Requires convalescent care and rehabilitative
services, is admitted directly from an acute care hospital, and requires
services for the condition for which he or she received care at the hospital.
(b) An applicant admitted pursuant to (a)(3)
above shall be predetermined eligible for facility admission and services for
30 days.
(c) An applicant admitted pursuant to (a)(4)
above shall be predetermined eligible for facility admission and services for 7
days.
(d) An applicant admitted pursuant to (a)(5)
above shall be eligible for services totaling 20 days during any one-year
period beginning on the month and day of the earliest date of respite service.
(e) An applicant admitted pursuant to (a)(6) above
shall be predetermined eligible for the number of days specified by the
applicant’s physician if:
(1) The
admission is ordered by the applicant’s physician;
(2) The order
does not exceed 99 days;
(3) Notice was
provided pursuant to He-M 1302.03(e); and
(4) The
referring physician has indicated that the applicant does not need long-term
placement in a nursing facility but does need short-term convalescence or
rehabilitation to allow the applicant to return to a residential placement in
the community.
(f) An applicant admitted pursuant to (a)(1) or
(2) above shall be evaluated for the need for specialized services pursuant to
He-M 1302.10 or He-M 1302.11 if the medical condition improves to the extent
that the individual might respond to services for his or her MI or DD.
(g) A nursing facility shall notify the PASRR
office no less than 9 days prior to the expiration of the time period allowed
under (b), (d), or (e) above that the applicant’s stay is likely to exceed the
allowed period.
(h) An applicant admitted pursuant to (a)(3)–(6)
above and whose nursing facility stay is expected to continue beyond the number
of days allowed under (b)–(e) shall undergo a level II evaluation and
determination prior to the end of the allowed timeframe.
(i) For the purposes
of (a)(2) above, cerebral palsy, in and of itself, shall not constitute a
severe physical condition or be a criterion for predetermination of eligibility
for nursing facility services.
(j) An applicant with a diagnosis of DD shall be
screened for the need for nursing facility services regardless of a diagnosis
of Alzheimer’s disease, dementia, or a related disorder.
(k) Applicants admitted pursuant to (a)(3)–(5)
above shall be predetermined to not require specialized services.
Source. #6063 eff 8-1-95; ss by #7920, INTERIM, eff
8-2-03, EXPIRED: 1-29-04
New. #8035, eff 2-7-04; amd
by #8430, eff 9-17-05; paras (a)-(d) and (f)-(g) expired 2-7-12; amd by #10123, INTERIM, eff 4-30-12, EXPIRES: 10-29-12; ss
by #10216, eff 10-29-12
He-M 1302.07 Determination of Need for Nursing Facility
Services.
(a)
The PASRR office shall conduct an evaluation that assesses whether:
(1) The individual’s total needs are such that
his or her needs can be met in an appropriate community setting;
(2) The individual’s total needs are such that
they can be met only on an inpatient basis, which may include the option of
placement in a home and community-based services waiver program, but for which
the inpatient care would be required; and
(3) If inpatient
care is appropriate and desired, the NF is an appropriate placement.
(b) The PASRR office shall determine
that an applicant needs nursing facility services if he or she meets the
clinical eligibility requirements for nursing facility services in RSA 151-E:3,
I(a), namely, the person requires 24-hour care for one or more of the following
purposes, as determined by a registered nurse appropriately trained to use an
assessment instrument and employed by the department, or a designee acting on
behalf of the department:
(1) Medical monitoring and nursing care when the
skills of a licensed medical professional are needed to provide safe and
effective services;
(2) Restorative nursing or rehabilitative care
with patient-specific goals;
(3) Medication administration
by oral, topical, intravenous, intramuscular, or subcutaneous injection, or
intravenous feeding for treatment of recent or unstable conditions requiring
medical or nursing intervention; or
(4) Assistance with 2 or more activities of daily
living involving eating, toileting, transferring, bathing, dressing, and
continence.
Source. #6063 eff 8-1-95; ss by #7920, INTERIM, eff
8-2-03, EXPIRED: 1-29-04
New.
#8035, eff 2-7-04; amd by #8430, eff 9-17-05;
paras (a) & (c) expired 2-7-12; amd by #10123,
INTERIM, eff 4-30-12, EXPIRES: 10-29-12; ss by #10216, eff 10-29-12
He-M 1302.08 Determination of Appropriateness for
Nursing Facility Services.
(a)
For applicants who require nursing facility services pursuant to He-M
1302.07, but could be served in a community setting with supports identified in
He-M 1302.04(a)(2)d., the PASRR office shall:
(1) Advise the applicant or his or her legal
representative that the individual could receive services in a home or other
community-based setting;
(2) Advise the applicant or his or her legal
representative of the community-based programs provided by the regional area
agency, community mental health center, or other agencies;
(3) Inform the applicant or his or her legal
representative that the applicant may choose to receive services in a setting
of his or her choice, including a nursing facility, following an informed
decision; and
(4) Provide written notice of the information provided
in (1) – (3) above to the applicant or his or her legal representative.
(b)
If an applicant is determined to need nursing facility services pursuant
to He-M 1302.07, and either, after making an informed decision not to accept
services in a community setting pursuant to (e) below or it is determined that
the person cannot be served in the community, the PASRR office shall determine
whether a specific nursing facility is an appropriate placement for the
applicant.
(c)
For applicants requiring services pursuant to He-M 1302.07, the PASRR
office shall specify length of stay allowances based on an applicant’s specific
needs and circumstances.
(d)
Applicants shall not be approved for nursing facility services:
(1) If they do not meet the criteria of He-M
1302.07; or
(2) If no nursing facility is an appropriate
placement.
(e)
If an applicant wishes to make an informed decision to reside in a
nursing facility after it is determined by the PASRR office that the applicant
meets the minimum standard for nursing facility services pursuant to He-M
1302.07 and identifies programs that provide community-based supports, the
PASRR office shall request that the person sign a statement indicating that he
or she is making an informed decision to receive nursing facility services in a
nursing facility.
(f)
In those cases where the decision of an applicant or applicant’s legal
representative pursuant to (e) above jeopardizes the health, safety, or welfare
of the applicant, the PASRR office shall, as applicable:
(1) Seek the appointment of a guardian pursuant
to RSA 464-A:9, III;
(2) Seek the appointment of a guardian ad litem
pursuant to RSA 464-A:41;
(3) Seek the termination of a power of attorney pursuant
to RSA 506:7 or RSA 137-J:16; or
(4) In those situations where abuse, neglect, or
exploitation of applicants is suspected, make a referral to adult protective
services of the bureau of elderly and adult services and make a report to the
department’s office of client and legal services.
(g)
The PASRR office shall inform the applicant of its determination and
recommendations in writing.
Source. #6063 eff 8-1-95; ss by #7920, INTERIM, eff
8-2-03, EXPIRED: 1-29-04
New. #8035, eff 2-7-04, EXPIRED: 2-7-12
New. #10123, INTERIM, eff 4-30-12, EXPIRES:
10-29-12; ss by #10216, eff 10-29-12 (from He-M 1302.06)
He-M 1302.09 Responsibility for Evaluations and
Determinations.
(a)
Evaluations required to make determinations relative to an applicant’s
need for nursing facility services and need for specialized services shall be
completed by:
(1) An entity other than the bureau of behavioral
health for persons with MI; or
(2) The bureau of developmental services or its
delegate for persons with DD.
(b)
If the bureaus delegate determination functions to another entity:
(1) The determinations as to the need for nursing
facility services and for specialized services shall be made based on an
analysis of information specified in He-M 1302.07, He-M 1302.08, He-M 1302.10,
and He-M 1302.11; and
(2) The other entity shall not be a nursing
facility or have a direct or indirect affiliation or relationship with a
nursing facility.
(c)
The evaluations performed pursuant to (a) above shall:
(1) Be adapted to the cultural background,
language, ethnic origin, and means of communication used by the applicant being
evaluated;
(2) If performed by more than one evaluator, be
coordinated among the various disciplines; and
(3) Involve the applicant, his or her legal
representative, and, if the applicant or legal representative agrees, the
applicant’s family, if available.
Source. #6063 eff 8-1-95; ss by #7920, INTERIM, eff
8-2-03, EXPIRED: 1-29-04
New. #8035, eff 2-7-04, EXPIRED: 2-7-12
New. #10123, INTERIM, eff 4-30-12, EXPIRES: 10-29-12;
ss by #10216, eff 10-29-12 (from He-M 1302.05)
He-M
1302.10 Specialized Services for
People with MI.
(a) Once the PASRR office finds an applicant with
MI appropriate for nursing facility services, it shall determine whether
specialized services are needed based on individualized evaluation.
(b) The individualized evaluation required by (a)
above shall include:
(1) A
comprehensive history and physical examination of the applicant that shall:
a. Include:
1. Complete medical history;
2. Review of all body systems, including
neurological; and
3. In cases of abnormal findings, additional
evaluations conducted by specialists; and
b. Either:
1. Be performed by a physician; or
2. Be reviewed by a physician concurring with
the conclusions of the evaluation;
(2) A
comprehensive drug history, including current and past use of medications that
could mimic or mask symptoms of MI;
(3) A
psychosocial evaluation, including evaluation of current living arrangements
and social, financial, and medical support systems;
(4) A
comprehensive psychiatric evaluation that includes:
a. Complete
psychiatric history;
b. Evaluation
of orientation and of intellectual and memory functioning;
c. Current attitudes
and overt behaviors;
d. Affect and
suicidal or homicidal ideation; and
e. Degree of
reality testing and hallucinations; and
(5) Functional
assessment of the applicant’s ability to engage in activities of daily living,
the level of support which would be needed to assist the applicant to perform
these activities while living in the community, and whether this level of
support can be provided to the applicant in an alternative community setting or
whether the level of support needed is such that nursing facility placement is
required, which shall address the following areas:
a.
Self-monitoring of health status;
b. Self-administering or scheduling of medical treatments,
including medication compliance;
c.
Self-monitoring of nutritional status;
d. Managing
money; and
e. Grooming and
dressing appropriately.
(c) Applicants who are found, after evaluation
pursuant to (a) above, to be experiencing MI and to require specialized
services as defined in He-M 1302.02(n) shall have a nursing facility plan of
care that:
(1) Is
developed and supervised by an interdisciplinary team which includes the
individual and, if applicable, his or her legal representative, a physician,
qualified mental health professional and, as appropriate, other professionals;
(2) Prescribes specific
therapies and activities for the treatment of persons experiencing an acute
episode of MI which necessitates supervision by trained mental health
professionals; and
(3) Is directed
toward diagnosing and reducing the applicant’s behavioral symptoms of MI and
improving his or her level of independent functioning, which ideally would lead
to services that are of a lesser intensity than specialized services.
Source. #6063 eff 8-1-95; ss by #7920, INTERIM, eff
8-2-03, EXPIRED: 1-29-04
New.
#8035, eff 2-7-04, EXPIRED: 2-7-12
New.
#10123, INTERIM, eff 4-30-12, EXPIRES: 10-29-12; ss by #10216, eff
10-29-12 (from He-M 1302.07)
He-M 1302.11 Specialized Services for People with DD.
(a)
Once the PASRR office finds an applicant with DD appropriate for nursing
facility services, it shall determine whether specialized services are needed
based on individualized evaluation.
(b)
The individualized evaluation required by (a) above shall include the
individual’s comprehensive history and physical examination results to identify
the following information or, in the absence of data, information that permits
a reviewer specifically to assess:
(1) The individual’s medical problems;
(2) The level of impact these problems have on
the individual’s independent functioning;
(3) All current medications used by the
individual and the current response of the individual to any prescribed
medications in the following drug groups:
a. Hypnotics;
b. Antipsychotics;
c. Mood stabilizers and antidepressants;
d. Antianxiety-sedative agents; and
e. Anti-Parkinson agents;
(4) Self-monitoring of health status;
(5) Self-administering and scheduling of medical
treatments;
(6) Self-monitoring of nutritional status;
(7) Self-help development such as toileting,
dressing, grooming, and eating;
(8) Sensorimotor development, such as ambulation,
positioning, transfer skills, gross motor dexterity, visual motor perception,
fine motor dexterity, eye-hand coordination, and extent to which prosthetic,
orthotic, corrective or mechanical supportive devices can improve the
individual’s functional capacity;
(9) Speech and language development, including:
a. Expressive language;
b. Receptive language;
c. The extent to which non-oral communication systems
can improve the individual’s function capacity; and
d. Auditory functioning and extent to which
amplification devices or a program of amplification can improve the
individual’s functional capacity;
(10) Social development, such as interpersonal
skills, recreation-leisure skills, and relationships with others;
(11) Educational development, including functional
learning skills;
(12) Independent living development, including:
a. Meal preparation;
b. Budgeting, shopping, and personal finances;
c. Survival skills;
d. Mobility skills;
e. Laundry, housekeeping, and care of clothing;
and
f. Orientation skills for individuals with
visual impairments;
(13) Vocational development, including present
vocational skills;
(14) Affective development, including expressing
emotions, making judgments, and making independent decisions; and
(15) The presence of identifiable maladaptive or
inappropriate behavior.
(c)
Applicants who have DD and are found to require specialized services as
defined in He-M 1302.02(m) shall have a nursing facility plan of care that is:
(1) Developed by an interdisciplinary team,
including the individual and, if applicable, his or her legal representative,
nursing facility staff, representing areas that are relevant to identifying the
person’s needs and to designing services that meet his or her needs;
(2) Directed toward helping the applicant
continue to experience community-based opportunities and maintain social ties
with family and friends;
(3) Designed to assist the applicant to acquire
behaviors necessary to function with as much self-determination and
independence as possible; and
(4) Intended to prevent or decelerate the
regression or loss of current functional status.
(d)
An applicant with DD who requires nursing facility services shall be
determined not to require specialized services if he or she has a confirmed
primary diagnosis of dementia.
Source. #8035 eff 2-7-04, EXPIRED: 2-7-12
New.
#10123, INTERIM, eff 4-30-12, EXPIRES: 10-29-12; ss by #10216, eff
10-29-12
He-M
1302.12 Notification and
Documentation of Level II Evaluations and Determinations.
(a) A written report of the findings of the level
II evaluation and determination pursuant to He-M 1302.04 or resident review
pursuant to He-M 1302.13 shall be prepared by the PASRR office and conveyed to
the following:
(1) The
applicant and, if applicable, his or her legal representative;
(2) The
discharging hospital, if applicable;
(3) The
admitting or retaining nursing facility; and
(4) The
attending physician, if applicable.
(b) The written report shall include the
following:
(1) A listing
of the evaluations reviewed, including the evaluators’ names and professional
titles and dates prepared;
(2) The name
and title of the reviewer and date of review;
(3) An
interpretation of the results of the evaluations in terms of the applicant’s
functional status;
(4) A brief
summary of the applicant’s medical and social history;
(5) The
positive traits or developmental strengths of the individual;
(6) The
weaknesses or developmental needs of the individual;
(7) A
description of the supports identified in He-M 1302.04(a)(2)d. that the
individual would need to live in the community;
(8) If nursing
facility services are recommended, identification of the specific services
needed to meet the individual’s needs;
(9) If
specialized services are recommended, what specifically is required to meet the
individual’s needs;
(10) If
specialized services are not recommended, identification of any specific DD or
mental health services of lesser intensity that the individual requires to meet
his or her needs;
(11) The basis
for the report’s conclusions, including the specific reason for the determination
rendered and referenced section of the rule;
(12) The right
of the applicant or legal representative to appeal a nursing facility admission
determination;
(13) The right
of the applicant to have someone, including an attorney paid for by the
applicant, represent him or her at the hearing; and
(14) The
process for appealing the determination, including the names, addresses, and
phone numbers of the office of client and legal services of the department and
advocacy organizations such as the Disabilities Rights Center, Inc., that the
individual or guardian may contact for assistance in appealing the
determination.
Source. #10216, eff 10-29-12 (from He-M 1302.09)
He-M
1302.13 Resident Reviews.
(a) Whenever there has been a significant change
in the physical or mental condition of an individual with MI or DD:
(1) The nursing
facility shall report the change to the PASRR office; and
(2) The PASRR
office shall perform a resident review by:
a. Confirming
there has been a significant change; and
b. If there has been a significant change, conducting
a level II evaluation and determination.
(b) “Significant change” means when an individual’s
mental or physical condition has declined or improved such that the change:
(1) If a
decline, will not normally resolve itself without intervention by staff or by
implementing standard disease-related clinical interventions;
(2) Impacts more
than one area of the resident’s health status; and
(3) Requires
interdisciplinary review or revision of the plan of care, or both.
(c) Upon completion of a resident review, the
PASRR office shall convey the findings to the individual and his or her legal
representative pursuant to He-M 1302.12.
(d) The resident review shall include one of the
following determinations regarding continued placement for individuals with MI
or DD:
(1) Any
individual who does not require nursing facility services and does not need
specialized services shall be discharged from the nursing facility;
(2) Any
individual who requires the services provided by a nursing facility and is
currently receiving such services shall continue to receive services if he or
she chooses;
(3) An
individual shall be offered specialized services and may choose to move to
community living or continue to reside in the facility if he or she:
a. Has resided in
a nursing facility at least 30 consecutive months prior to the review date;
b. Does not
require the services provided by a nursing facility; and
c. Requires
specialized services; and
(4) An individual
shall be discharged from the nursing facility if he or she:
a. Has resided
in a nursing facility less than 30 consecutive months prior to the review date;
and
b. Does not
require the services provided by a nursing facility; and
c. Needs specialized
services.
(e) The resident review shall also specify
service determinations and related actions documenting the need for the
continuation of specialized services, if applicable.
(f) For the purpose of establishing length of
stay in nursing facilities, the 30 months of continuous residence referenced in
(d)(3)-(4) above shall:
(1) Be
calculated back from the date of the first resident review determination which
finds that the individual is not in need of nursing facility services; and
(2) Include
temporary absences and consecutive residences in more than one nursing
facility.
Source. #10216, eff 10-29-12 (from He-M 1302.10)
He-M 1302.14 Appeals.
(a) Any applicant, or his or her legal
representative, may request an appeal of a determination regarding nursing
facility admission or continued nursing facility stay.
(b) A request for an appeal pursuant to (a) above
shall:
(1) Be in
writing;
(2) Be
submitted to the office of client and legal services; and
(3) Be filed in
accordance with He-C 200 within 35 days of the issuance of the determination.
(c) Funding for services provided to Medicaid recipients
for continuing stays shall be available during the period that an appeal is in
progress until a decision is rendered.
Source. #10216, eff 10-29-12 (from He-M 1302.11)
APPENDIX
|
Rule |
Specific State Statute the Rule Implements |
|
|
|
|
He-M 1301 All
Sections (Specific sections implementing specific statutes are listed below) |
RSA 186-C:25;
P.L. 100-360, amending 42-U.S.C. 1396b |
|
He-M 1301.01 |
RSA 171-A:6, RSA
135-C:1 |
|
He-M
1301.02 |
RSA
171-A:6, RSA 135-C:1, 42 CFR 483.106 |
|
He-M
1301.03 |
RSA
171-A:6, RSA 135-C:1, 42 CFR 483.106 |
|
He-M
1301.04 |
RSA
186-C:25 |
|
He-M
1301.05 |
42
CFR 440, Subpart A |
|
He-M
1301.06 |
RSA
186-C:25 |
|
He-M
1301.07 |
RSA
171-A:6; 135-C:1; 42 CFR 483.132 |
|
He-M 1301.08 |
RSA 171-A:6;
135-C:1; 42 CFR 483.132 |
|
He-M 1302.01 –
1302.02 |
RSA 171-A:6;
135-C:1 |
|
He-M 1302.02(i) |
42 CFR
483.102(b) |
|
He-M 1302.03 |
RSA 171-A:6;
135-C:1; 42 CFR 483.106 |
|
He-M 1302.04 |
RSA 171-A:6;
135-C:1; 42 CFR 483.112 |
|
He-M 1302.05 |
RSA 171-A:6;
135-C:1; 42 CFR 483.106(b) |
|
He-M
1302.05(a)-(e) |
RSA 171-A:6; 42
CFR 440.100 |
|
He-M 1302.05(d) |
RSA 171-A:6,
135-C:1 |
|
He-M 1302.05(e) |
RSA 171-A:6;
135-C:1; 42 CFR 483.132 |
|
He-M 1302.06 |
RSA 171-A:6; 135-C:1;
42 CFR 483.130 |
|
He-M
1302.06(a)-(d), (f)-(g) |
RSA 171-A:6; 42
CFR 440.100 |
|
He-M 1302.07 |
RSA 171-A:6;
135-C:1; 42 CFR 483.132 |
|
He-M
1302.07(a)(b) and (c) |
RSA 171-A:6;
135-C:1 42 CFR 483.134 |
|
He-M 1302.08 |
RSA 171-A:6; 135-C:1;
42 CFR 483.132 |
|
He-M 1302.09 |
RSA 171-A:6;
135-C:1; 42 CFR 483.106(d) |
|
He-M 1302.10 |
RSA 171-A:6;
135-C:1; 42 CFR 483.134 |
|
He-M 1302.11 |
RSA 171-A:6;
135-C:1; 42 CFR 483.136 |
|
He-M 1302.12 |
RSA 171-A:6;
135-C:1; 42 CFR 483.130(k), (l) |
|
He-M 1302.13 |
RSA 171-A:6;
135-C:1; 42 CFR 483.114; 42 USC 1396r |
|
He-M 1302.14 |
RSA 171-A:29;
135-C:1 |