NOTICES
DEPARTMENT OF HEALTH
Intent to Apply Uniform Standard to Both Skilled and Intermediate Care Patients in Long Term Care Facilities
[26 Pa.B. 712] For all long term care facility licensure surveys ending on or after January 1, 1996, the Department of Health (Department) will apply the intermediate care standard to all patients in enforcing those licensure regulations which set forth different standards for both skilled and intermediate care.
The Department of Public Welfare's case-mix reimbursement regulations (25 Pa.B. 4477--4505), were effective as of January 1, 1996. Medical Assistance reimbursement methodology no longer distinguishes between skilled care and intermediate care but utilizes a case-mix adjustment based on the classification of residents into 44 separate groups known as Resource Utilization Groups (RUG-III). (25 Pa.B. 4505).
The Omnibus Budget and Reconciliation Act of 1987, P. L. 100-203, 42 U.S.C.A. §§ 1395i-3, 1396r (OBRA 1987) and subsequent amendments, eliminated the Federal distinction between skilled nursing facilities and intermediate care facilities. As a result, all long term care facilities participating in the Medicare and/or Medicaid programs are subject to the same Federal certification standards regardless of the level of services provided.
The Department of Health (Department) is in the process of reviewing its licensure regulations for long term care facilities in light of both the case-mix regulations and the changes to the Federal standards in the wake of OBRA 1987. As part of this process, the Department is considering amendments to some of its licensure regulations which would eliminate the distinction between licensure standards applied to skilled and intermediate care residents. Until such time as new regulations are published as final and take effect, the Department, in enforcing the licensure regulations at 28 Pa. Code §§ 211.2(b), (c), (e); 211.8(e); 211.9(e); 211.12(n); and 211.13(f), intends to apply the standard for intermediate care patients to all patients as set forth herein.
For those regulatory sections listed, the Department will exercise its prosecutorial discretion not to enforce the standard for skilled patients unless providers have not complied with the lesser intermediate standard. Should a long term care facility fail to comply with the standard for intermediate care patients in one or more of the above-listed regulatory sections, the stricter standards for skilled care will apply for enforcement purposes.
Application of the intermediate care standards in those regulations listed, to all patients, will not result in diminished quality of care in long term care facilities. The Department's survey review of quality indicators such as skin integrity, drug therapy, rehabilitative potential, nutritional adequacy, infection control, cognitive function and appropriate use of chemical or physical restraints will continue to reveal any problems with resident care.
Providers must continue to comply with State licensure regulations at 28 Pa. Code § 211.11, which require an interdisciplinary team of professionals, including physicians, to develop and implement a written plan of care to meet the needs of every patient. These plans of care are to be reviewed and updated according to change in patient status. Therefore, should a patient's status change, the plan of care and physician orders would have to be reviewed and adjusted as necessary. Further, most of Pennsylvania's long term care providers participate in the Medicare and Medicaid programs and are subject to Federal regulations which also require appropriate and timely assessments, care planning and treatment.
The Department's application of a uniform standard as described herein is not meant as a substantive change to the long term care licensure regulations (28 Pa. Code §§ 201.1--211.22) currently in effect. However, until further notice, the Department will enforce the regulations at 28 Pa. Code §§ 211.2(b)(c)(e); 211.8(e); 211.9(e); 211.12(n); and 211.13(f) as follows:
§ 211.2. Medical services.
(b) A patient shall be under the current care of a physician. A skilled care patient shall be seen by the attending physician at least every 30 days and an intermediate care patient at least every 60 days, or more often as necessary.
The Department will accept compliance with the 60 day time period for all patients. Individual patients must still be seen more often if necessary.
(c) A patient's total program of care, including medications, care and treatments, shall be reviewed during a visit by the attending physician at least once every 30 days for a skilled care patient and every 60 days for an intermediate care patient. Revisions shall be made as necessary. The physician shall indicate on the patient's medical record that the review has been made. Entries made by the physician on the medical record shall be dated and signed with the original signature of the physician. A physician's orders shall be renewed at least once every 30 days for skilled care patients and every 60 days for intermediate care patients.
The Department will accept compliance with the 60 day time period for all patients. Revision to the program of care must still be made more often if necessary.
Medicare and/or Medicaid participating providers must also continue to comply with the Federal regulation at 42 CFR 483.40(c)(1), which states that a physician, or physician designee as permitted in 42 CFR 483.40(e), must see a resident at least once every 30 days for the first 90 days of admission and at least once every 60 days thereafter.
(e) The attending physician shall be responsible for the medical evaluation of the patient and shall prescribe a planned regimen of total patient care. This regimen shall incorporate all of the components of the patient's care and shall designate the patient's appropriate level of care.
For licensure purposes, the physician will no longer be required to designate the patient's level of care but will be required to review the patient's total program of care as required by § 211.2(c). However, the patient's health care needs must support placement or continued stay in a long term care facility.
§ 211.8. Use of restraints.
(e) The physician shall document the reason for the restraint order and shall review the need for the order by evaluating the patient. If the order is to be continued, the order shall be renewed for at least every 30 days for skilled patients and every 60 days for intermediate care patients by the physician in accordance with the patient's total program of care.
The Department will accept compliance with the 60 day renewal requirement for all patients.
§ 211.9. Pharmaceutical services.
(e) Each patient shall have a written physician's order for each medication received. This includes both proprietary and nonproprietary medications. These physician's orders shall be on each patient's individual chart and shall be reviewed, renewed, signed and dated by the physician every 30 days for skilled patients and 60 days for intermediate care patients.
The Department will accept compliance with the 60 day requirement for all patients.
§ 211.12. Nursing services.
(n) A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totalled for the entire facility, be a minimum of 2.7 hours of direct patient care for each skilled care patient and a minimum of 2.3 hours of direct patient care for each intermediate care patient. The total number of daily required hours shall be computed by multiplying the number of intermediate care patients by 2.3 hours and by multiplying the number of skilled care patients by 2.7 hours. The two figures shall be added; the sum shall be the minimum total number of hours of general nursing provided in each 24-hour period for the entire facility.
The Department will accept compliance with the requirement of 2.3 hours of general nursing care per each 24-hour period for each patient of the facility.
§ 211.13. Rehabilitative services.
(f) The patient's progress shall be reviewed regularly by the physician and the therapist. They shall reevaluate the plan of rehabilitative services as necessary, but at least every 30 days for skilled patients and every 60 days for intermediate care patients.
The Department will accept compliance with the 60 day requirement for all patients. Reevaluation of the plan for rehabilitative services must still be done more often if necessary.
Questions regarding the above may be directed to William A. Bordner, Director, Division of Nursing Care Facilities, P. O. Box 90, Harrisburg, PA 17108, (717) 787-1816.
Persons with a disability who require an alternative format (for example, large print, audio tape, braille) of this document should contact William Bordner so that he may make the necessary arrangements. Alternative formats may also be requested by using TDD: (717) 783-6514.
PETER J. JANNETTA, M.D.,
Secretary
[Pa.B. Doc. No. 96-217. Filed for public inspection February 16, 1996, 9:00 a.m.]
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