Subchapter C. NURSING FACILITY PARTICIPATION
Sec.
1187.21. Nursing facility participation requirements.
1187.21a. [Reserved].
1187.22. Ongoing responsibilities of nursing facilities.
1187.23. Nursing facility incentives and adjustments.
Cross References This subchapter cited in 55 Pa. Code § 1189.3 (relating to compliance with regulations governing noncounty nursing facilities).
§ 1187.21. Nursing facility participation requirements.
In addition to meeting the participation requirements established in Chapter 1101 (relating to general provisions), a nursing facility shall meet the following requirements:
(1) The nursing facility shall be licensed by the Department of Health.
(2) Every bed licensed by the Department of Health in a nursing facility that participates in the MA Program shall be certified for MA participation.
(3) The nursing facility shall abide by applicable Federal, State and local statutes and regulations, including Title XIX of the Social Security Act (42 U.S.C.A. § § 1396—1396q), sections 443.1—443.6 of the Public Welfare Code (62 P. S. § § 443.1—443.6) and applicable licensing statutes.
(4) An MA-enrolled nursing facility with 60 or more licensed beds providing skilled nursing and rehabilitation services in accordance with the Medicare requirements shall also be enrolled in the Medicare Program to the extent that it has sufficient beds to accommodate the Medicare-eligible residents it is required to serve. This does not preclude a nursing facility with a bed complement of under 60 beds from enrolling in the Medicare Program.
(i) A nursing facility certified to participate in the Medicare Program shall have sufficient beds to accommodate its Medicare-eligible residents. Payment will be based on criteria found in § 1187.101(b) (relating to general payment policy).
(ii) Failure to be enrolled and certified in the Medicare Program will result in denial of claims for a resident with both Medicare and MA coverage.
(5) The nursing facility shall meet the requirements of Subchapter L (relating to nursing facility participation requirements and review process).
Source The provisions of this § 1187.21 amended June 29, 2012, effective June 30, 2012, 42 Pa.B. 3733. Immediately preceding text appears at serial page (354198).
§ 1187.21a. [Reserved].
Authority The provisions of this § 1187.21a amended and reserved under section 443.1(8) of the Public Welfare Code (62 P. S. § 443.1(8)).
Source The provisions of this § 1187.21a adopted January 9, 1998, effective January 12, 1998, 28 Pa.B. 138; amended April 2, 2010, effective April 3, 2010, 40 Pa.B. 1766; reserved June 29, 2012, effective June 30, 2012, 42 Pa.B. 3748. Immediately preceding text appears at serial pages (354198) and (348915) to (348922).
§ 1187.22. Ongoing responsibilities of nursing facilities.
In addition to meeting the ongoing responsibilities established in Chapter 1101 (relating to general provisions), a nursing facility shall, as a condition of participation:
(1) Assure that every individual applying for admission to the facility is prescreened by the Department as required by section 1919 of the Social Security Act (42 U.S.C.A. § 1396r(e)(7)) and 42 CFR Part 483, Subpart C (relating to preadmission screening and annual review of mentally ill and mentally retarded individuals).
(2) Assure that every individual who receives MA, who is eligible for MA or who is applying for MA, is reviewed and assessed by the Department or an independent assessor and found to need nursing facility services prior to admission to the nursing facility, or in the case of a resident, before authorization for MA payment.
(3) Assure immediate access to a resident by the following individuals:
(i) The resident’s physician.
(ii) A representative of the Secretary of the United States Department of Health and Human Services.
(iii) A representative of the Commonwealth who is involved in the administration of the MA Program.
(iv) An ombudsman authorized by the Department of Aging, including those employed by a local area agency on aging.
(v) A representative of Pennsylvania Protection and Advocacy, the agency designated under Subchapter III of the Developmental Disabilities Assistance and Bill of Rights Act (42 U.S.C.A. § § 6041—6043) and the Protection and Advisory for Mentally Ill Individuals Act of 1986 (42 U.S.C.A. § § 10801—10851).
(4) Assure that it is necessary for each resident to remain in the nursing facility.
(5) Assure that the data in each resident’s Federally-approved PA Specific MDS are accurate and that all assessment records and tracking forms for the resident are completed and submitted to the Department as required by applicable Federal and State regulations and instructions, including the Centers for Medicare and Medicaid Services Long-Term Care Resident Assessment Instrument User’s Manual and the Resident Data Reporting Manual.
(6) Assure and verify that the information contained on the quarterly CMI report is accurate for the picture date as specified in § 1187.33(a)(5) (relating to resident data and picture date reporting requirements) and the Resident Data Reporting Manual.
(7) Assure that each invoice for nursing facility services provided to each MA resident is accurate.
(8) Have in operation a system for managing residents’ funds that, at a minimum, fully complies with the requirements established by Federal law and
Federal and State regulations in accordance with § 1187.78 (relating to accountability requirements related to resident personal fund management).
(9) Cooperate with reviews and audits conducted by the Department and furnish the residents’ clinical and fiscal records to the Department upon request.
(10) Provide written responses to the Department for UMR reports requiring corrective action.
(11) Take corrective action within acceptable time frames as described in UMR reports.
(12) File an acceptable cost report with the Department within the time limit specified in § 1187.73 or § 1187.75 (relating to annual reporting; and final reporting).
(13) In addition to meeting the reporting requirements of § 1101.43 (relating to enrollment and ownership reporting requirements), notify the Department in writing within 30 days of a change in the name or address of corporate officers.
(14) Submit a written request for MA nursing facility participation to the Department if the nursing facility changes ownership and the new owner wishes the nursing facility to participate in the MA Program. The agreement in effect at the time of the ownership change will be assigned to the new owner subject to applicable statutes and regulations and the terms and conditions under which it was originally issued.
(15) Assure that individual resident information collected in accordance with this chapter is kept confidential and released only for purposes directly connected to the administration of the MA Program.
(16) Maintain a separate written record in accordance with instructions by the Department, identifying the requests or physician’s orders received by the facility for exceptional DME or other DME as specified by the Department.
(17) Notify the Department in writing within 15 days if an MA eligible resident refuses DME that the Department has determined is medically necessary.
(18) Submit the initial Federally-approved PA Specific MDS record for each resident admitted to the nursing facility to the Department within 7 calendar days of the date the record is completed.
Authority The provisions of this § 1187.22 amended under sections 201(2), 206(2), 403(b) and 443.1(5) of the Public Welfare Code (62 P.S. § § 201(2), 206(2), 403(b) and 443.1(5)).
Source The provisions of this § 1187.22 amended February 8, 2002, effective October 1, 2001, 32 Pa.B. 734; amended June 23, 2006, effective July 1, 2006, with the exception of § 1187.22(18) effective October 1, 2006, 36 Pa.B. 3207. Immediately preceding text appears at serial pages (287007) to (287008).
Cross References This section cited in 55 Pa. Code § 1187.158 (relating to appeals).
§ 1187.23. Nursing facility incentives and adjustments.
(a) The Department will make minimum occupancy adjustments to encourage nursing facility efficiency and economy associated with nursing facility occupancy levels. If the nursing facility’s overall nursing facility occupancy level is below 90%, the Department will make an adjustment to total nursing facility resident days as though the nursing facility were at 90% occupancy. The Department will apply this 90% occupancy adjustment to the administrative cost component and the capital cost center.
(b) The Department will pay a disproportionate share incentive to a nursing facility that has a high overall occupancy and a high proportion of MA residents in accordance with § 1187.111 (relating to disproportionate share incentive payments).
Cross References This section cited in 55 Pa. Code § 1187.96 (relating to price- and rate-setting computations).
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