§ 1181.54. Payment conditions related to the recipient’s continued need for care.
(a) Recertification of continued need for care.
(1) A physician, a physician assistant under the supervision of 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 enter into the recipient’s medical record a signed and dated statement that the recipient continues to need skilled, heavy care/intermediate or intermediate level of care, as applicable. For a certification for the skilled level of care to be considered valid, the physician, physician assistant, nurse practitioner or clinical nurse specialist shall certify that the criteria specified in Appendix E (relating to skilled nursing care) have been met. For a certification for the heavy care/intermediate level of care to be considered valid, the physician, physician assistant, nurse practitioner or clinical nurse specialist shall certify that the criteria in Appendix F (relating to heavy care/intermediate services) have been met.
(2) Recertification of the need for care of a recipient receiving care in an ICF/MR shall be made at least once every 365 days after the initial certification as specified in Appendix Q (Reserved).
(3) Recertification of the need for care of a recipient receiving skilled nursing facility services shall be made as follows:
(i) At least 30 days after the date of the initial certification.
(ii) At least 60 days after the date of the initial certification.
(iii) At least 90 days after the date of the initial certification and every 60 days thereafter.
(4) Recertification of the need for care of a recipient receiving heavy care/intermediate or intermediate care services shall be made as follows:
(i) At least 60 days after the date of the initial certification.
(ii) At least 180 days after the date of the initial certification.
(iii) At least 12 months after the date of the initial certification.
(iv) At least 18 months after the date of the initial certification.
(v) At least 24 months after the date of the initial certification and every 12 months thereafter.
(b) Continued stay reviews by the Utilization Review Committee.
(1) The Utilization Review Committee of a facility shall document in the medical record of the recipient the continued stay review date and need determination of the Committee.
(2) If the Utilization Review Committee recommends that a recipient’s continued stay at the skilled level of care is needed, the Committee shall complete the Skilled Nursing Care Assessment form substantiating that the recipient meets the minimum medical requirements for skilled level of care specified in § 1181.53(b)(2) (relating to payment conditions related to the recipient’s initial need for care). The Skilled Nursing Care Assessment form shall be completed each time the Utilization Review Committee recommends that the recipient’s continued stay be at the skilled level of care. The form shall be signed by the Utilization Review Committee chairperson and retained in the medical record of the recipient. If the Utilization Review Committee recommends that a recipient’s level of care be changed to or from the skilled level of care, the original of the Skilled Nursing Care Assessment form shall accompany the Committee’s notification (Utilization Review Request for Change Summary) to the Department. Copies of the forms shall be retained in the recipient’s medical record.
(3) If the Utilization Review Committee recommends that a recipient’s level of care be changed to intermediate care from skilled or heavy care/intermediate, the Committee shall notify the Department of the Committee’s recommendation on the Utilization Review Request for Change Summary form. A copy of the form shall be retained in the recipient’s medical record.
(4) If the Utilization Review Committee recommends that a recipient’s level of care be changed to heavy care/intermediate from skilled or intermediate, the Committee shall notify the Department of the Committee’s recommendation on the Utilization Review Request for Change Summary form. A copy of the form shall be retained in the recipient’s medical record. The Committee shall also submit documentation to the Department to substantiate that the recipient meets the minimum medical requirements for the heavy care/intermediate level of care specified in Appendix F (relating to heavy care/intermediate services).
(5) If the Utilization Review Committee recommends that a recipient not continue to receive the level of care for which payment is authorized, the Committee shall notify the Department of the Committee’s recommendation on the Utilization Review Request for Change Summary form. A copy of the form shall be retained in the recipient’s medical record.
(c) Adverse decisions by the Inspection of Care team. If the Department’s Inspection of Care team determines that a recipient no longer needs the level of care for which payment is authorized, the Inspection of Care team shall direct the Department to take action to authorize payment for alternate care.
(d) Recipient notice of adverse decisions. Upon notification of the recommended change in the level of care, the Department will notify the recipient and facility of its decision. If the recipient or the representative of the recipient appeals the decision within 10 calendar days from the date the notice is mailed, payment for the present level of care will continue pending the outcome of the hearing. If the recipient does not respond to the notice within 10 calendar days, the Department will deny payment in a case where care is no longer needed or authorize payment for the appropriate level of care no earlier than 10 calendar days from the date the notice was mailed to the recipient.
(e) Continued review of plan of care. The plan of care shall comply with the following:
(1) For recipients receiving skilled nursing care, the attending or staff physician and other personnel involved in the care of the recipient shall review each plan of care at least every 60 days and document the date of the review in the record of the patient.
(2) For recipients receiving intermediate, heavy care/intermediate or intermediate care for the mentally retarded, the interdisciplinary team shall review each plan of care at least every 90 days and document the date of the review in the record of the recipient.
(f) Attending physician decision on level of care.
(1) In response to changes in the recipient’s medical condition, the attending physician may order a change in the recipient’s level of care which is different from the level of care for which payment is authorized.
(2) If the attending physician recommends a change in the recipient’s level of care to or from the skilled level of care, the attending physician shall document the change in the recipient’s medical record and sign a completed Skilled Nursing Care Assessment form which substantiates that the recipient meets or does not meet the minimum medical criteria for skilled level of care specified in § 1181.53(b)(2). The attending physician shall sign and date the entry in the medical record. The original of the Skilled Nursing Care Assessment form shall accompany the Attending Physician Request for Change Summary form to the Department. Copies of the forms shall be retained in the recipient’s medical record. The facility shall make the change immediately and notify the Department of the change. The Department will issue a Confirming Notice to the recipient or the person acting on behalf of the recipient and to the nursing facility.
(3) If the attending physician recommends a change in the recipient’s level of care to the intermediate level of care, the attending physician shall document the change in the recipient’s medical record and notify the Department of the level of care change on the Attending Physician Request for Change Summary form. A copy of the form shall be retained in the recipient’s medical record.
(4) If the attending physician recommends a change in the recipient’s level of care to the heavy care/intermediate level of care, the attending physician shall document the change in the recipient’s medical record. The facility shall notify the Department of the level of care change on the Attending Physician Request for Change Summary form. A copy of the form shall be retained in the recipient’s medical record. The facility shall also submit documentation to the Department to substantiate that the recipient meets the minimum medical requirements for the heavy care/intermediate level of care in Appendix F.
(5) If the recipient’s level of care is changed as a result of a determination by the Department’s Inspection of Care team as described in subsection (c), the attending physician may order a change in the recipient’s level of care only if the recipient’s medical condition changes subsequent to the date of the Inspection of Care team’s determination and the change in the recipient’s medical condition warrants another level of care. The physician shall date and sign the documentation of the change in the medical condition and state the alternate care recommendation in the recipient’s record.
(i) If ordering the skilled level of care, the attending physician shall sign and date a completed Skilled Nursing Care Assessment form substantiating that the recipient meets the minimum medical requirements for skilled level of care specified in § 1181.53(b)(2). The original of the Skilled Nursing Care Assessment form substantiating the recipient’s medical eligibility shall accompany the Attending Physician Request for Change Summary form to the Department. Copies of the forms shall be retained in the recipient’s medical record.
(ii) If ordering the intermediate level of care, the attending physician shall complete an Attending Physician Request for Change Summary form, and the original copy shall be sent to the Department. A copy of the form shall be retained in the recipient’s medical record.
(iii) If ordering the heavy care/intermediate level of care, the attending physician shall complete an Attending Physician Request for Change Summary form. The original of the Attending Physician Request for Change Summary form and documentation to substantiate that the recipient meets the minimum medical requirements for the heavy care/intermediate level of care in Appendix F, shall be sent to the Department. A copy of the form shall be retained in the recipient’s medical record.
(g) Payment pending appeal. If the recipient or the person or the nursing facility acting on behalf of the recipient appeals an action of the Department to change the level of care for which payment is authorized within the time period specified on the advance notice issued by the Department, the Department will make payment to the facility for the level of care the recipient is presently receiving pending the outcome of the hearing under § 275.4(a)(3)(iii) (relating to procedures). If the Department is sustained in its action, the Department will recover from the facility payments in excess of the amount that would have been made if the action of the Department had not been appealed. The period for which the Department will recover excess payment runs from the effective date specified on the advance notice to the date that the appropriate change in the level of care for which payment is authorized is made.
Authority The provisions of this § 1181.54 amended under sections 403(a) and (b) and 443.1(2) and (3) of the Public Welfare Code (62 P. S. § § 403(a) and (b) and 443.1(2) and (3)).
Source The provisions of this § 1181.54 codified July 24, 1981, effective July 25, 1981, 11 Pa.B. 2610; amended July 2, 1982, effective July 1, 1982, 12 Pa.B. 2070; amended January 7, 1983, effective January 8, 1983, 13 Pa.B. 148; amended May 3, 1985, effective retroactively to July 1, 1984, 15 Pa.B. 1629; amended March 10, 1989, effective immediately and applies retroactively to February 23, 1988, 19 Pa.B. 999; amended June 29, 1990, effective June 30, 1990, 20 Pa.B. 3595. Immediately preceding text appears at serial pages (135889) to (135894).
Notes of Decisions This section is not arbitrary and capricious and furthers the Commonwealth’s interest in maintaining a solvent Medicaid Program. Centennial Spring Health Care Centers v. Department of Public Welfare, 541 A.2d 806 (Pa. Cmwlth. 1988).
It is not unreasonable for the Department of Public Welfare to recoup overpayments made for services actually rendered following a provider or recipient appeal when the Department of Public Welfare’s reclassifications are sustained. Centennial Spring Health Care Centers v. Department of Public Welfare, 541 A.2d 806 (Pa. Cmwlth. 1988).
Cross References This section cited in 55 Pa. Code § 1181.52 (relating to payment conditions); 55 Pa. Code § 1181.83 (relating to inspections of care); and 55 Pa. Code § 1181.94 (relating to failure to adhere to certification requirements).
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