Subchapter D. DATA REQUIREMENTS FOR NURSING FACILITY APPLICANTS AND RESIDENTS
Sec.
1187.31. Admission or MA conversion requirements.
1187.32. Continued need for nursing facility services requirements.
1187.32a. Clarification of the term ‘‘written’’—statement of policy.
1187.33. Resident data and picture date reporting requirements.
1187.34. Requirements related to notices and payments pending resident appeals.
Cross References This section cited in 55 Pa. Code § 1189.3 (relating to compliance with regulations governing noncounty nursing facilities).
§ 1187.31. Admission or MA conversion requirements.
A nursing facility shall meet the following admission or MA conversion requirements:
(1) Prescreening. The nursing facility shall ensure that individuals applying for admission to the facility are 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) Preadmission or MA conversion evaluation and determination.
(i) The nursing facility shall ensure that before an MA applicant or recipient is admitted to a nursing facility, or before authorization for MA payment for nursing facility services in the case of a resident, the MA applicant, recipient or resident has been evaluated by the Department or an independent assessor and found to need nursing facility services.
(ii) The nursing facility shall maintain a copy of the Department’s or the independent assessor’s notification of eligibility in the business office.
(3) Notification to the Department.
(i) The nursing facility shall notify the Department on forms designated by the Department whenever an MA applicant or recipient is admitted to the nursing facility or whenever a resident is determined eligible for MA.
(ii) The nursing facility shall submit information regarding target residents to the Department on forms designated by the Department within 48 hours of the admission of a target resident to the nursing facility.
(4) Physician certification. Within 48 hours of admission of a resident to a nursing facility or, if a resident applies for MA while in the nursing facility before the Department authorizes payment for nursing facility services, the nursing facility shall ensure that a resident’s attending physician certifies in writing in the resident’s clinical record that the resident requires nursing facility services.
Authority The provisions of this § 1187.31 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 § 1187.31 amended June 23, 2006, effective July 1, 2006, 36 Pa.B. 3207. Immediately preceding text appears at serial pages (287009) to (287010).
§ 1187.32. Continued need for nursing facility services requirements.
A nursing facility shall meet the following continued need for nursing facility services requirements:
(1) The nursing facility shall complete a new prescreening form for a resident whenever there is a change in the resident’s condition that affects whether the resident is a target resident. The nursing facility shall maintain a copy of the new prescreening form in the resident’s clinical record and notify the Department within 48 hours of the change in the resident’s condition on forms designated by the Department.
(2) The nursing facility shall ensure that a resident’s attending physician, or a physician assistant or nurse practitioner acting within the scope of practice as defined by State law and under the supervision of the resident’s attending physician, recertifies the resident’s need for nursing facility services in the resident’s clinical record at the time the attending physician’s orders are reviewed and renewed, consistent with Department of Health licensure time frames for renewing orders.
(3) The nursing facility shall notify the Department within 48 hours whenever the facility or resident’s attending physician determines that the resident no longer requires nursing facility services. The notification shall be submitted on forms designated by the Department.
(4) The nursing facility shall obtain a physician’s certification and written order for the resident’s discharge whenever a resident no longer requires nursing facility services.
Authority The provisions of this § 1187.32 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 § 1187.32 amended June 23, 2006, effective July 1, 2006, 36 Pa.B. 3207. Immediately preceding text appears at serial page (287010).
Cross References This section cited in 55 Pa. Code § 1187.32a (relating to clarification of the term ‘‘written’’—statement of policy).
§ 1187.32a. Clarification of the term ‘‘written’’—statement of policy.
(a) The term ‘‘written’’ in § 1187.32(4) (relating to continued need for nursing facility services requirements) includes orders that are handwritten or transmitted by electronic means.
(b) Written orders transmitted by electronic means must be electronically encrypted or transmitted by other technological means designed to protect and prevent access, alteration, manipulation or use by any unauthorized person.
Source The provisions of this § 1187.32a adopted July 16, 2010, effective July 17, 2010, 40 Pa.B. 3963.
§ 1187.33. Resident data and picture date reporting requirements.
(a) Resident data and picture date requirements. A nursing facility shall meet the following resident data and picture date reporting requirements:
(1) The nursing facility shall submit the resident assessment data necessary for the CMI report to the Department as specified in the Resident Data Reporting Manual.
(2) The nursing facility shall ensure that the Federally approved PA specific MDS data for each resident accurately describes the resident’s condition, as documented in the resident’s clinical records maintained by the nursing facility.
(i) The nursing facility’s clinical records shall be current, accurate and in sufficient detail to support the reported resident data.
(ii) The Federally approved PA specific MDS shall be coordinated and certified by the nursing facility’s RNAC.
(iii) The records listed in this section are subject to periodic verification and audit.
(3) The nursing facility shall maintain the records pertaining to each Federally-approved PA Specific MDS record and tracking form submitted to the Department for at least 4 years from the date of submission.
(4) The nursing facility shall ensure that resident assessments accurately reflect the residents’ conditions on the assessment date.
(5) The nursing facility shall correct and verify that the information in the quarterly CMI report is accurate for the picture date and in accordance with paragraph (6) and shall sign and submit the CMI report to the Department postmarked no later than 5 business days after the 15th day of the third month of the quarter.
(6) The CMI report must include resident assessment data for every MA and every non-MA resident included in the census of the nursing facility on the picture date.
(i) A resident shall be included in the census of the nursing facility on the picture date if all of the following apply:
(A) The resident was admitted to the nursing facility prior to or on the picture date.
(B) The resident was not discharged with return not anticipated prior to or on the picture date.
(C) Any resident assessment is available for the resident from which data may be obtained to calculate the resident’s CMI.
(ii) A resident who, on the picture date, is temporarily discharged from the nursing facility with a return anticipated shall be included in the census of the nursing facility on the picture date as a non-MA resident.
(iii) A resident who, on the picture date, is on therapeutic leave shall be included in the census of the nursing facility on the picture date as an MA resident if the conditions of § 1187.104(2) (relating to limitations on payment for reserved beds) are met on the picture date. If the conditions of § 1187.104(2) are not met, the resident shall be included in the census of the nursing facility as a non-MA resident.
(b) Failure to comply with the submission of resident assessment data.
(1) If a valid assessment is not received within the acceptable time frame for an individual resident, the resident will be assigned the lowest individual RUG-III CMI value for the computation of the facility MA CMI and the highest RUG-III CMI value for the computation of the total facility CMI.
(2) If an error on a classifiable data element on a resident assessment is not corrected by the nursing facility within the specified time frame, the assumed answer for purposes of CMI computations will be ‘‘no/not present.’’
(3) If a valid CMI report is not received in the time frame outlined in subsection (a)(5), the facility will be assigned the lowest individual RUG-III CMI value for the computation of the facility MA CMI and the highest RUG-III CMI value for the computation of the total facility CMI.
Authority The provisions of this § 1187.33 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 § 1187.33 amended June 23, 2006, effective July 1, 2006, with the exception of § 1187.33(a) effective October 1, 2006, 36 Pa.B. 3207; amended August 26, 2011, effective retroactive to July 1, 2010, 41 Pa.B. 4630. Immediately preceding text appears at serial pages (351452) and (354199).
Cross References This section cited in 55 Pa. Code § 1187.22 (relating to ongoing responsibilities of nursing facilities); 55 Pa. Code § 1187.32 (relating to continued need for nursing facility services requirements); 55 Pa. Code § 1187.91 (relating to database); 55 Pa. Code § 1187.92 (relating to resident classification system); 55 Pa. Code § 1187.97 (relating to rates for new nursing facilities, nursing facilities with a change of ownership, reorganized nursing facilities, and former prospective payment nursing facilities); 55 Pa. Code § 1187.104 (relating to limitations on payment for reserved beds); 55 Pa. Code § 1187.117 (relating to supplemental ventilator care and tracheostomy care payments); 55 Pa. Code § 1189.3 (relating to compliance with regulations governing noncounty nursing facilities); and 55 Pa. Code § 1189.105 (relating to incentive payments).
§ 1187.34. Requirements related to notices and payments pending resident appeals.
(a) The requirements relating to notices authorizing and discontinuing MA payments for nursing facility services are as follows:
(1) Notices authorizing MA payment.
(i) The nursing facility shall retain, in its business office, a copy of the Department’s notice authorizing MA nursing facility services for each MA conversion resident and for each MA applicant or recipient who is admitted as a resident.
(ii) The Department’s notice authorizing MA nursing facility services will specify the effective date of coverage and the amount of money that the resident has available to contribute towards payment. The nursing facility is responsible to obtain the resident’s share of the payment.
(2) Notices discontinuing MA payment.
(i) The nursing facility shall retain, in its business office, a copy of the Department’s notice discontinuing payment for MA nursing facility services for every resident who the Department determines is no longer eligible to receive MA nursing facility services. The Department’s determination may be based upon a review conducted by the Department or the resident’s attending physician.
(ii) The Department’s notice discontinuing payment for MA nursing facility services will specify the effective date of the discontinuance of coverage, that the resident may appeal the notice within 30 days and that the resident must appeal within 10-calendar days of the date the notice was mailed in order for payments to continue pending the outcome of the hearing on the resident’s appeal.
(b) The requirements relating to payments pending resident appeals and recovery of payments subsequent to appeals are as follows:
(1) Payments pending appeal.
(i) If the resident or a representative of the resident appeals the Department’s notice discontinuing payment for MA nursing facility services within 10-calendar days of the date on which the notice was mailed to the resident, the Department will continue payments to the nursing facility for nursing facility services rendered to the resident pending the outcome of the hearing on the resident’s appeal subject to paragraph (2).
(ii) If the resident or a representative of the resident does not appeal the Department’s notice discontinuing payment for MA nursing facility services, or appeals after 10-calendar days from the date on which the notice was mailed to the resident, the Department will cease payment to the nursing facility for services rendered to the resident beginning on the effective date of the discontinuance of coverage specified in the notice or the date on which the resident was discharged from the facility, whichever date occurs first.
(2) Payment recovery for services rendered pending appeal. If a resident’s appeal of a notice of discontinuance of payment for MA nursing facility services is denied, the Department will recover payments made to the nursing facility. The period for which the Department will recover payments will begin on the effective date of the discontinuance of coverage specified in the notice to the resident and end on the date on which payments were discontinued as a result of the outcome of the hearing on the resident’s appeal or the date of the resident’s discharge from the facility, whichever date occurs first.
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