WEST VIRGINIA DEPARTMENT OF HEALTH & HUMAN RESOURCES SUMMARY AND DECISION OF THE STATE HEARING OFFICER
|
|
- Gillian Francis
- 6 years ago
- Views:
Transcription
1 WEST VIRGINIA DEPARTMENT OF HEALTH & HUMAN RESOURCES SUMMARY AND DECISION OF THE STATE HEARING OFFICER I. INTRODUCTION: This is a report of the State Hearing Officer resulting from a fair hearing concluded on May 12, 2005 for. This hearing was held in accordance with the provisions found in the Common Chapters Manual, Chapter 700 of the West Virginia Department of Health and Human Resources. This fair hearing was convened on March 23, 2005 on a timely appeal filed February 15, It should be noted here that was not receiving benefits under the Children with Disabilities Community Services Program at the time of the fair hearing. A pre-hearing conference was not held between the parties. did not have legal representation. All parties took an oath to provide truthful information. II. PROGRAM PURPOSE: Medicaid (Title XIX of the Social Security Act) is a federal/state funded program that provides health care coverage to low-income and medically needy West Virginians. The program was enacted into law by Congress in The Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 allowed the State of West Virginia to elect the option of providing the Children with Disabilities Community Services Program (Federal title Disabled Child In-Home Care Program ) under Medicaid. The Children with Disabilities Community Service Program provides medical services for disabled children who would otherwise be at risk of institutionalization so that they may reside in their family homes. The medical services must be more cost effective for the State than placement in a medical institution such as a nursing home, ICF/MR facility, acute care hospital or approved Medicaid psychiatric facility for children under the age of 21. III. PARTICIPANTS:, Claimant/Father of Susan Striar-May, Consultant Bureau for Medical Services Sandra Joseph, M. D., Medical Director Bureau for Medical Services The fair hearing was conducted by conference call to all parties, at the request of Mr..
2 Presiding at the hearing was Ray B. Woods. Jr., M. L. S., State Hearing Officer and, a Member of the State Board of Review IV. QUESTIONS TO BE DECIDED: Does meet the medical eligibility for the Children with Disabilities Community Services Program? V. APPLICABLE POLICY: Medicaid Program Instruction Memorandum MA-03-65, December 1, VI. LISTING OF DOCUMENTARY EVIDENCE ADMITTED: Department Exhibits: D-1 Information Sheet Children with Disabilities Community Services Program (Formerly TEFRA) D-2 Program Eligibility Criteria D-3 Memorandum to Fayette County Community Services Manager from Office of Behavioral and Alternative Care dated 02/02/05 Denial D-4 Annual Medical Evaluation (DD-2A) dated 07/22/04 D-5 Annual Medical Evaluation (DD-2A) undated D-6 PAS-2000 assessed 09/27/04 D-7 WVDHHR Comprehensive Psychological Evaluation (Triennial) (DD-3) dated 07/29/04 D-8 Individualized Education Program (IEP) Fayette County dated 05/19/04 D-9 Fayette County Child Development dated 04/29/04 D-10 Family Support Program Social History Updated dated 11/03/04 D-11 WVDHHR CDCSP Cost Estimate Worksheet dated 09/04 D-12 Memorandum to from Office of Behavioral and Alternative Care dated 11/23/04 - Request for additional information D-13 Charleston Area Medical Hospital Records D-14 Report from WVU Pediatric Feeding & Swallowing Management Clinic dated 05/24/04 D-15 Memorandum from Office of Maternal, Child and family Health to Division of Specialty Care dated 11/29/04 Listing of services D-16 Memorandum from Bureau for Medical Services to State Hearing Officer re: Exhibits Claimants Exhibits: None
3 VII. FINDINGS OF FACT: 1) A Memorandum from the Office of Behavioral and Alternative Care to the Fayette County Community Manager on February 2, 2005 stated in part, A review of s records to determine his eligibility for CDCSP services finds that he does not meet criteria for this program. According to the PAS-2000, does not have deficits in five areas of performing his Activities of Daily Living, (ADLs) which excludes him from requiring a nursing level of care in order to remain in the community. According to the IEP, is not developmentally delayed to the extent that he would require an ICF-MR (Intermediate Care Facility for people with mental retardation) level of care in order to remain in the community. The absence of a need for psychiatric care of course excludes him from an inpatient psychiatric level of care. In addition, the lack of documentation of emergency room visits or hospitalizations since 2003, with no indication from his specialists regarding a worsening of his condition, the need for acute care is not apparent. Moreover, the IEP demonstrates an improvement of his ability to function in the school environment without special needs. 2) An Annual Medical Evaluation for Children with Disabilities Community Services Program (DD-2A) was completed on July 22, was 5 ½ years of age. The Physical Examination indicated that had Abnormalities in the areas of his Throat - Bifid Uvula; Scoliosis; Asthma and; Abdomen G tube feeding. Problems Requiring Special Care: Mobility Ambulatory; Continence Status Continent; Mealtime Needs Assistance, Gastric Tube and Special Diet; Personal Hygiene Needs Assistance; Mental and Behavioral Status Child. Additional Treatment Recommendations: Speech and Physical Therapy. Diagnosis: Mental Nothing stated; Physical G tube feed; Scoliosis; Asthma and Allergies. The Prognosis was listed as Satisfactory. The Physician indicated that did not require the level of care provided in an Intermediate Facility; Psychiatric Facility; Nursing Facility or; Acute Care Facility. The Physician did certify that could be served by the Children With Disabilities Community Services Program. 3) An Annual Medical Evaluation for Children with Disabilities Community Services Program (DD-2A) was completed on September 28, The DD-2A was completed by the same Physician as previously stated. The Physician did not mark whether required the level of care provided in an Intermediate Facility; Psychiatric Facility; Nursing Facility or; Acute Care Facility. The Physician did certify that could be served by the Children With Disabilities Community Services Program.
4 4) Mrs. Striar-May reviewed the PAS-2000 completed on October 7, 2004 and, how it was evaluated by the Bureau of Medical Services. It provided the following information: Question #25 In the event of an emergency, the individual is [c] Unable to vacate a building. 0 Deficits. (A 5 year old would not be expected to vacate a building). Question #26 1. Eating Level 2 1 Deficit (Feeding Tube); 2. Bathing Level 1 0 Deficit; 3. Grooming Level 2 0 Deficit (A 5 year old is not expected to groom themselves); 4. Dressing Level 2 0 Deficit (A 5 year old is not expected to dress themselves); 5. Continence Level 1 0 Deficit; 6. Orientation Level 1 0 Deficit; 7. Transfer Level 1 0 Deficit; 8. Walking Level 1 0 Deficit; 9. Wheeling Level 1 0 Deficit 1 Deficit Question #27 The child has skilled nursing needs in one or more of these areas, [g] suctioning, [h] tracheotomy, [i] ventilator, [k] parenteral fluids, [l] sterile dressings, or [m] irrigations. [The use of oxygen is not a deficit.] 0 Deficits. Question #28 The child is [c] not capable of administering his/her own medications. No Child 0 Deficits. Mrs. Striar-May read Medicaid Program Instruction MA-03-65, December 1, 2003 Section B which states in part, A child must have five [5] deficits to qualify medically. The capabilities of the child will be compared to other children his/her own age. It was Mrs. Striar-May s testimony that, the ADL s would be more applicable to 9 and 10 year old children. The total deficits received on the PAS-2000 assessed October 7, 2004 were 1 Deficit.
5 5) A Comprehensive Psychological Evaluation was completed by on July 29, According to Mrs. Striar-May, the evaluation is not typical of those received on children. The Psychologist did not use any evaluations measuring Cognitive and Adaptive Behaviors. The evaluation focused mainly on s eating skills. In the absence of any testing, Mrs. Striar-May did not understand how the psychologist determined the following information, unless through personal observations. The Developmental Findings/Conclusions stated: Per interview, patient is severely delayed in feeding behavior. The Placement Recommendations stated: Continued intervention at school, continued Occupational and Physical Therapy. Psychotherapy intervention when oral motor skills improve. 6) An Individualized Education Program (IEP) was completed by the Fayette County Schools on May 19, The report provided the following information: Present Levels of Educational Performance: Personal/Social Skills - greets and responds to adults and peers. He separates easily from his parents. He will take turns and share. He follows classroom rules and directions. He has difficulty participating in competitive play activities and solving problems on his own. According to Mrs. Striar-May, there is nothing of great need. Adaptive Behavior can take care of his own toilet needs. He can feed himself and drink through a straw. He can ignore distractions and complete table work in required time. He needs help putting on his coat. He needs reminders to eat and not talk. He needs to improve his chewing and swallowing skills. According to Mrs. Striar-May this is average for a child in kindergarten. It still centers on eating. Walking and Balancing Skills Able to walk and balance independently. Again, typical for a 5 year old child. Fine Motor Skills can write his name and all letters of the alphabet uppercase. He can write numbers 1 to 10. he can cut with scissors staying within ¼ of a line. Again not untypical of a child in kindergarten. Cognitive Skills can match and identify six basic shapes. He can count to ten, and identify all uppercase letters of the alphabet. He has difficulty telling a story. spends 96% of the time in Regular Education and 4% of the time in Special Education. 7) The Fayette County Child Development (Student Level of Performance Sheet) was apparently completed on April 29th. The year was not clear on Mrs. Striar-May s copy or the copies provided to the State Hearing Officer or Mr. s. The document was not signed or state who completed the assessment. The assessment
6 reiterates the same information provided in the Psychological Evaluation and Individualized Education Plan. 8) A Family Support Program Social History Update was dated November 3, It is not signed by the Case Manager. The Update states in part: Educational does well in school. He does not have any problems at this time. He is in regular education. tries shard and makes good grades. Functional functions at the level of a typical child his age. physical/health keeps him from functioning at the level of a normal child his age. needs assistance with all daily living/self-care skills. Recreational/Leisure enjoys church and playing outside. Legal Status s parent are his guardians at this time. requires an ICF/MR level of care. is diagnosed with PDD; Scoliosis; G-tube ad a Cyst. According to Mrs. Striar-May, is not receiving continued active treatment and, there is no documentation of PDD. 9) The Cost Estimate Worksheet was not considered as part of the eligibility process because, was not deemed eligible for any of the four (4) categories. 10) On November 23, 2004, the Office of Behavioral Health and Alternative Care sent Mr. a Memorandum for additional medical documentation. Dr. Sandra Joseph confirmed the contents of the document which states in part, The records indicate that is capable of learning, communicating and ambulating, with his only deficiency in nutritional intake. This alone would not qualify him for services through CDCSP which are designed to allow the child to remain in the community. However, the available records do not adequately document that would need to be in a nursing facility or a hospital if he did not receive the services from this program. Therefore, additional information is necessary in order to determine s eligibility for services through CDCSP. Records from any and/all specialists, including the gastroenterologist, documenting the severity and prognosis of his condition, would be helpful, along with records from any hospitalizations and emergency visits from the past two years. In addition, since you indicated that you work, and information regarding insurance coverage available to you through your place of employment is necessary, along with reasons why cannot be placed on that policy if you are also covered. 11) The only reported hospitalization or emergency room visit was reported in October, was admitted on October 24, 2003 and discharged on October
7 30, The Admissions Diagnoses were listed as: Dumping Syndrome; Parainfleunza upper inspiratory infection; Cough during feeding; Scoliosis and; Diaphragmatic hernia. 12) Dr. Joseph referred to a letter dated May 24, 2004 from James E. McJunkin, MD, Professor of Pediatrics at West Virginia University to Chandrani Thakker, MD, Children s Medicine Center at Women & Children s Hospital. The letter sated in part, Impression: Persistent mild pharyngeal dysphasia but with adequate weight gain and is taking more foods by mouth than previously and receiving less tube feeds. He has had no symptoms of dumping syndrome. According to Dr. Joseph, there is no indication is at risk of being admitted to the hospital due to these conditions. The documentation states s conditions are improving. 13) Mrs. Striar-May and Dr. Joseph both testified that, the remaining exhibits submitted by the Department do not indicate is at risk of hospitalization. 14) Mr. referred to a letter dated January 11, 2005 written to Dr. Joseph from Chandrani Thakker, MD of the Women & Children s Hospital. The letter listed s list of medical problems. Mr. disagreed with the lack of deficits for Grooming and Dressing. has a brace on his leg that requires assistance. 15) The supporting documentation consisting of the Annual Medical Evaluation, Psychological Evaluation, Individual Educational Plan and Family Support Program Social History Update, support the PAS-2000 completed on October 7, VIII. CONCLUSIONS OF LAW: 1) Medicaid Program Instruction MA-03-65, December 1, 2003 states: This program instruction revises West Virginia Medicaid Program Eligibility Guide [September 1, 1994] requirements for children 18 years of age and under who have the need for Nursing Facility level of care and want to apply for Children with Disabilities Community Services Program [CDCSP]. This policy clarification does not apply to those children who apply under another level of care. Policy transmitted by this program instruction is effective upon receipt. Policy Provisions Medicaid [Title XIX of the Social Security Act] is a federal/state program that provides health care coverage to low income and medically needy West Virginians. The program was enacted into law by Congress in The Tax Equity and Fiscal Responsibility Act [TEFRA] of 1982 allowed the State of West Virginia to elect the option of providing the Children with Disabilities Community Services Program [Federal title Disabled Child In-Home Care Program ] under Medicaid.
8 A. To clarify the West Virginia Medicaid Program s requirements for determination of medical eligibility for CDCSP for Nursing Facility level of care, the following are to be included in the initial application/reapplication packet for children who have suspected need for this level of care: 1. PAS-2000 [Revised 01/03] completed within 90 days of submission; 2. Cost Estimate Worksheet DD6-CDCSP; 3. Social Assessment and History; 4. Individual Program Plan [IPP] and Individualized Education Program [IEP] or Individualized Family Service Plan [IFSP]: 5. Speciality evaluations if indicated [Physical, Occupational, Speech and Language, Nutrition, etc.] and; 6. Home Health Care Plan if receiving home health services. B. A child must have five [5] deficits to qualify medically. The capabilities of the child will be compared to other children his/her own age. The deficits will be derived from a combination of the following assessment elements of the PAS-2000: Question #26 1. Eating Level 2 or higher [physical assistance to get nourishment, not preparation]; 2. Bathing Level 2 or higher [physical assistance or more]; 3. Grooming Level 2 or higher [physical assistance or more]; 4. Dressing Level 2 or higher [physical assistance or more]; 5. Continence Level 3 or higher [must be incontinent]; 6. Orientation Level 3 or higher [totally disorientated, comatose]; 7. Transfer Level 3 or higher [one person or two persons assist in the home]; 8. Walking Level 3 or higher [one person assist in the home]; 9. Wheeling Level 3 or higher [must be Level 3 or 4 on walking in the home to use Level 3 or 4 for wheeling in the home. Do not count outside the home].
9 Question #25 In the event of an emergency, the individual is [c] mentally and/or [d] physically unable to vacate a building. Question #27 The child has skilled nursing needs in one or more of these areas, [g] suctioning, [h] tracheotomy, [i] ventilator, [k] parenteral fluids, [l] sterile dressings, or [m] irrigations. [The use of oxygen is not a deficit.] Question #28 The child is [c] not capable of administering his/her own medications. C. The evaluations must demonstrate that a child has a diagnosis of a severe, chronic disability which is attributable to a physical impairment or medical condition requiring a Nursing Facility Level of Care. The child s need for this level of care and its corresponding services must be for an extended duration. D. It is also necessary that the level of services provided in the community must serve the child as well as or better than comparable services in a nursing facility and the total costs must be less than the same services delivered at that level of care. IX. DECISION: It is the decision of this State Hearing Officer that does not meet the medical eligibility for the Children with Disability Community Services Program. X. RIGHT OF APPEAL: See Attachment XI. ATTACHMENTS: The Claimant s Recourse to Hearing Decision Form IG-BR-29
February 2, Eligibility for the CDCSP Program is based on current policy and regulations. Some of these regulations state as follows:
Joe Manchin III Governor State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 4190 Washington Street West Charleston, WV 25313 Martha Yeager Walker
DEPARTMENT OF HEALTH AND HUMAN RESOURCES
Joe Manchin III Governor State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 2699 Park Avenue, Suite 100 Huntington, WV 25704 Martha Yeager Walker
Dear Ms : Sincerely, Jennifer Butcher State Hearing Officer Member, State Board of Review
Joe Manchin III State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 4190 w Washington Street Charleston, WV 25313 304-746-2360 Ext 2227 Martha Yeager
Romney, WV May 9, 2011
State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review Earl Ray Tomblin P.O. Box 1736 Governor Romney, WV 26757 Michael J. Lewis, M.D., Ph.D Cabinet
State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review PO Box 6165 Wheeling, WV 26003
Joe Manchin III Governor State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review PO Box 6165 Wheeling, WV 26003 Martha Yeager Walker Secretary January
STATE OF WEST VIRGINIA
STATE OF WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES OFFICE OF INSPECTOR GENERAL Earl Ray Tomblin BOARD OF REVIEW Karen L. Bowling Governor 1400 Virginia Street Cabinet Secretary Oak Hill, WV
Patsy A. Hardy, FACHE, MSN, MBA Governor February 3, 2010
State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review Joe Manchin III P.O. Box 1736 Patsy A. Hardy, FACHE, MSN, MBA Governor Cabinet Secretary Dear
DEPARTMENT OF HEALTH AND HUMAN RESOURCES
Joe Manchin III Governor State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 4190 Washington Street, West Charleston, WV 25313 October 20, 2009 Patsy
State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 1027 N. Randolph Ave.
Earl Ray Tomblin Governor State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 1027 N. Randolph Ave. Elkins, WV 26241 October 5, 2012 Rocco S. Fucillo
DEPARTMENT OF HEALTH AND HUMAN RESOURCES
State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 4190 Washington Street, West Charleston, WV 25313 Joe Manchin III Governor ----- ----- -----
November 22, Evidence presented at the hearing fails to demonstrate medical necessity.
State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 9083 Middletown Mall White Hall, WV 26554 Earl Ray Tomblin Michael J. Lewis, M.D., Ph. D. Governor
DEPARTMENT OF HEALTH AND HUMAN RESOURCES
State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 2699 Park Avenue, Suite 100 Huntington, WV 25704 Earl Ray Tomblin Michael J. Lewis, M.D., Ph.
State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 203 E. 3 rd Avenue.
State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 203 E. 3 rd Avenue Earl Ray Tomblin Governor Rocco S. Fucillo Cabinet Secretary November 20,
DEPARTMENT OF HEALTH AND HUMAN RESOURCES
State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Joe Manchin III Office of Inspector General Martha Yeager Walker Governor Board of Review Secretary PO Box 29 Grafton WV 26354 September
State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 203 E. 3 rd Avenue Williamson, WV 25661
Joe Manchin III Governor State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 203 E. 3 rd Avenue Williamson, WV 25661 Patsy A. Hardy, FACHE, MSN,
Date: July 27, ATTACHMENTS: Pediatric Patient Review Instrument (available on-line)
+------------------------------------------+ LOCAL COMMISSIONERS MEMORANDUM +------------------------------------------+ DSS-4037EL (Rev. 9/89) Transmittal No: 92 LCM-113 Date: July 27, 1992 Division:
Based on the comprehensive assessment of a resident, the facility must ensure that:
7. QUALITY OF CARE Each resident must receive, and the facility must provide, the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing,
State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 203 E. 3 rd Avenue Williamson, WV 25661
Earl Ray Tomblin Governor State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 203 E. 3 rd Avenue Williamson, WV 25661 Rocco S. Fucillo Cabinet Secretary
Patsy A. Hardy, FACHE, MSN, MBA Governor. Romney, WV April 7, 2010
State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review Joe Manchin III P.O. Box 1736 Patsy A. Hardy, FACHE, MSN, MBA Governor Romney, WV 26757 Cabinet
Based on the comprehensive assessment of a resident, the facility must ensure that:
13.A. Quality of Care Each resident must receive, and the facility must provide, the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being,
OHIO DEPARTMENT OF MEDICAID LEVEL OF CARE ASSESSMENT
OHIO DEPARTMENT OF MEDICAID LEVEL OF CARE ASSESSMENT I. DEMOGRAPHICS Assessment / / II. REASON FOR REQUEST a. Name a. NF Admission (check one of the following) New Admission b. Address Readmit: original
DIVISION CIRCULAR #3 (N.J.A.C. 10:46) DEPARTMENT OF HUMAN SERVICES DIVISION OF DEVELOPMENTAL DISABILITIES
DIVISION CIRCULAR #3 (N.J.A.C. 10:46) DEPARTMENT OF HUMAN SERVICES DIVISION OF DEVELOPMENTAL DISABILITIES EFFECTIVE DATE: March 24, 2011 DATE ISSUED: April 27, 2011 (Rescinds Division Circular #3, Determination
State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 1400 Virginia Street Oak Hill, WV 25901
Earl Ray Tomblin Governor State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 1400 Virginia Street Oak Hill, WV 25901 Michael J. Lewis, M.D., Ph.D.
Connecticut LTC Level of Care Determination Form To be maintained in the individual s medical record.
I. Demographics A. Individual First Name: Middle Initial: Mailing Address: City: State: Zip: Phone: Social Security #: Date of Birth: _/ / Marital Status: M S W D Gender: Male Female Connecticut LTC Level
State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 1027 N. Randolph Ave.
Earl Ray Tomblin Governor State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 1027 N. Randolph Ave. Elkins, WV 26241 Rocco S. Fucillo Cabinet Secretary
E. Guiding To show, indicate, or influence a course of action for an individual in order to promote independence.
D. Direct Assistance Hands-on physical care provided to an individual in need of assistance with Activities of Daily Living or Instrumental Activities of Daily Living. E. Guiding To show, indicate, or
Rulemaking Hearing Rule(s) Filing Form
Department of State For Department of State Use Only Division of Publications 312 Rosa l. Parks Avenue. 8th Floor Tennessee Tower Sequence Number: Nashville. TN 37243 Phone 615-741-2650 Rule 10(s): Fax:
OASIS-C Home Health Outcome Measures
OASIS-C Home Measures 1 End Result Grooming groom self. (M1800) Grooming 2 End Result Grooming same in ability to groom self. (M1800) Grooming 3 End Result Upper Body Dressing dress upper body. (M1810)
State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review. Williamson, WV September 17, 2012
Earl Ray Tomblin Governor ------ -------- ---------- Dear ------: State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 203 E. Third Avenue Williamson,
CNA OnSite Series Overview: Understanding Restorative Care Part 1 - Introduction to Restorative Care
Series Overview: Understanding Restorative Care Part 1 - Introduction to Restorative Care Administering the Program Read the Guide View the Video Review the Suggested Questions Complete Post-Test Answer
RESIDENT SCREENING SHEET
Department of County Human Services Aging, Disability & Veterans Services Adult Care Home Program RESIDENT SCREENING SHEET MCAR 023-080-200 through 023-080-225: To be completed by the operator before you
MEDICAL POLICY EFFECTIVE DATE: 08/25/11 REVISED DATE: 08/23/12, 08/22/13
MEDICAL POLICY SUBJECT: PERSONAL CARE AIDE (PCA) AND PAGE: 1 OF: 7 If the member's subscriber contract excludes coverage for a specific service it is not covered under that contract. In such cases, medical
Nursing Facility 90 Day Redetermination Online Referral for Medicaid Level of Care
12/15/2014 Nursing Facility 90 Day Redetermination Online Referral for Medicaid Level of Care Quarterly MDS Assessment Results This screen will be completed based on certain values from the first quarterly
Department of Veterans Affairs VHA DIRECTIVE Veterans Health Administration Washington, DC December 7, 2005
Department of Veterans Affairs VHA DIRECTIVE 2005-061 Veterans Health Administration Washington, DC 20420 VA NURSING HOME CARE UNIT (NHCU) ADMISSION CRITERIA, SERVICE CODES, AND DISCHARGE CRITERIA 1. PURPOSE:
September 12, Enclosed is a copy of the decision resulting from the hearing held in the above-referenced matter.
State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 203 East Third Avenue Williamson, WV 25661 Earl Ray Tomblin Governor September 12, 2014 Karen
CLINICAL CRITERIA FOR UM DECISIONS Skilled Nursing Facilities
COMMERCIAL CLINICAL CRITERIA FOR UM DECISIONS Skilled Nursing Facilities Capital Health Plan (CHP) will provide coverage for care in a skilled nursing facility, subject to the benefit limitations of the
Michigan Medicaid Nursing Facility Level of Care Determination
Michigan Department of Health and Human Services Michigan Medicaid Nursing Facility Level of Care Determination Applicant's Name: Medicaid ID: Field 1 (Last) (First) (M.I.) Field 2 Date of Birth: Field
Acute Care to Rehab & Complex Continuing Care (CCC) Referral
o General Rehabilitation Low Intensity Rehabilitation (GRH, SJHCG) o (CMH, GRH, SJHCG) o Chronic Assisted Ventilator (GRH only) o o Ischemic o Hemorrhagic Stroke Rehab: Program Readiness Date: Complex
DEPARTMENT OF HEALTH AND HUMAN RESOURCES
State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Joe Manchin III Office of Inspector General Martha Yeager Walker Governor Board of Review Secretary PO Box 29 Grafton WV 26354 February 20
The Royal Hospital Donnybrook Referral Form
The Royal Hospital Donnybrook Referral Form Admissions Office Ph: (01) 406 6742 E-mail: admissions@rhd.ie Fax: (01) 496 7571 Each section must be completed by the treating health professional and goals
Provider Certification Standards Adult Day Care
Provider Certification Standards Adult Day Care December 2015 1 Definitions: Activities of Daily Living (ADL s)- Includes but is not limited to the following personal care activities: bathing, dressing,
Georgia Department of Behavioral Health & Developmental Disabilities FOR. Effective Date: January 1, 2018 (Posted: December 1, 2017)
Georgia Department of Behavioral Health & Developmental Disabilities PROVIDER MANUAL FOR COMMUNITY DEVELOPMENTAL DISABILITY PROVIDERS OF STATE-FUNDED DEVELOPMENTAL DISABILITY SERVICES FISCAL YEAR 2018
December 11, Enclosed is a copy of the decision resulting from the hearing held in the above-referenced matter.
STATE OF WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES OFFICE OF INSPECTOR GENERAL Earl Ray Tomblin BOARD OF REVIEW Karen L. Bowling Governor 4190 Washington Street, West Cabinet Secretary Charleston,
Guidance: Personal Care Assistance Service Agreement Fields
Guidance: Personal Care Assistance Service Agreement Fields As of December 30, 2015 Purpose The purpose of this document is to help lead agencies understand the data that is automatically populated from
APD & MHA RESIDENT SCREENING SHEET
Department of County Human Services Aging, Disability & Veterans Services Adult Care Home Program APD & MHA RESIDENT SCREENING SHEET MCAR 023-080-200 through 023-080-225: To be completed by the operator
HOSPICE POLICY UPDATE
#02-56-13 Bulletin June 24, 2002 Minnesota Department of Human Services # 444 Lafayette Rd. # St. Paul, MN 55155 OF INTEREST TO County Directors Administrative contacts AC, EW, CAC, CADI, TBI DD Waiver
CHILDREN S PERSONAL CARE SERVICES (CPCS): OVERVIEW & UPDATE VERMONT FAMILY NETWORK WEBINAR OCTOBER 28, 2015
1 CHILDREN S PERSONAL CARE SERVICES (CPCS): OVERVIEW & UPDATE VERMONT FAMILY NETWORK WEBINAR OCTOBER 28, 2015 2 PROGRAM OVERVIEW: WHAT CPCS IS Medicaid benefit for children diagnosed with verifiable longterm
OASIS-B1 and OASIS-C Items Unchanged, Items Modified, Items Dropped, and New Items Added.
Items Added. OASIS-B1 Items UNCHANGED on OASIS-C OASIS-C Item # M0014 M0016 M0020 M0030 M0032 M0040 M0050 M0060 M0063 M0064 M0065 M0066 M0069 M0080 M0090 M0100 M0110 M0220 M1005 M1030 M1200 M1230 M1324
OAR Changes. Presented by APD Medicaid LTC Policy
OAR 411-015 Changes 1 Presented by APD Medicaid LTC Policy Table of Contents 2 Service Priority OAR 411-015 Project Overview Why Are We Making These Changes Overarching Changes Changes to ADLS (each ADL
July 7, Enclosed is a copy of the decision resulting from the hearing held in the above-referenced matter. Sincerely,
Earl Ray Tomblin Governor State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 416 Adams St. Fairmont, WV 26554 July 7, 2015 Karen L. Bowling Cabinet
TITLE 317. OKLAHOMA HEALTH CARE AUTHORITY CHAPTER 50. HOME AND COMMUNITY BASED SERVICES WAIVERS SUBCHAPTER 5. SOONER SENIORS
TITLE 317. OKLAHOMA HEALTH CARE AUTHORITY CHAPTER 50. HOME AND COMMUNITY BASED SERVICES WAIVERS SUBCHAPTER 5. SOONER SENIORS 317:50-5-1. Purpose The Sooner Seniors Program is a Medicaid Home and Community
Personal Accident Claim - Doctor s Statement
Personal Accident Claim - Doctor s Statement SECTION 2 DOCTOR S STATEMENT (to be completed by the attending Doctor at claimant s expense) A) Patient s Particulars Name of Patient Gender NRIC/FIN or Passport
5101: Home health services: provision requirements, coverage and service specification.
Page 1 of 8 5101:3-12-01 Home health services: provision requirements, coverage and service specification. (A) Home health services includes home health nursing, home health aide and skilled therapies
Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE
Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE Subtitle 09 MEDICAL CARE PROGRAMS Chapter 07 Medical Day Care Services Authority: Health-General Article, 2-104(b), 15-103, 15-105, and 15-111, Annotated
Speech and Language Therapy Service Inpatient services
Speech and Language Therapy Service Inpatient services Management of Dysphagia in individuals on inpatient wards (excluding adults with acquired brain injury) Author(s) Joanna Brackley Amy Foster V03 Issue
3/12/2015. Session Objectives. RAI User s Manual. Polling Question
Session Objectives MDS 3.0 Coding Challenges: Questions, Answers, and Explanations Jen Pettis, BS, RN, WCC Associate March 19, 2015 Upon completion of the program, the participate will: Describe the four
APPENDIX J MEDICAID INSTRUCTIONS FOR THE PERSONAL CARE SERVICES PLAN OF CARE
APPENDIX J MEDICAID INSTRUCTIONS FOR THE PERSONAL CARE SERVICES PLAN OF CARE ITEM 1 - ALLERGIES Enter any known medicine or other allergies that the recipient has. If unknown, enter NKA ITEM 2 CERTIFICATION
Long-Term Care Services and Supports Transmittal Letter (LTCSSTL) No
March 22, 2012 Long-Term Care Services and Supports Transmittal Letter (LTCSSTL) No. 12-03 TO: Director, Ohio Department of Aging Director, Ohio Department of Developmental Disabilities Director, Ohio
NORTH DAKOTA LEVEL OF CARE FORM INSTRUCTIONS TO BE USED WITH LOC FORM ND
For this section, select which type of LOC screen is to be reviewed Requested Screen Type NORTH DAKOTA LEVEL OF CARE FORM INSTRUCTIONS Nursing Facility Swingbed CMFN PACE MFP Provisional MFP Final Tech.
*PLEASE NOTE THAT COMPLETION OF THE PRE-ADMISSION FORM DOES NOT GUARANTEE PLACEMENT AT THIS FACILITY.
FALLON MEDICAL COMPLEX RESIDENT PROFILE PRE-ADMISSION/ADMISSION INFORMATION SHEET This Facility is owned and operated by Fallon Medical Complex, INC. This Facility accepts residents of all backgrounds
# December 29, 2000
#00-53-3 December 29, 2000 Minnesota Department of Human Services 444 Lafayette Rd. St. Paul, MN 55155 OF INTEREST TO! County Social Service Directors/Supervisors! County Designated LMHA for PASRR! County
Planning Worksheet Identifying EW Customized Living Components
Planning Worksheet Identifying EW Customized Living Components This tool is designed to facilitate discussion between EW lead agencies (counties, managed care organizations and/or tribes) and current or
HEALTH SERVICES POLICY & PROCEDURE MANUAL
PAGE 1 of 8 PURPOSE To provide guidelines on: 1. rating offenders using patient acuity, 2. how to properly handle offenders who are housed in facilities with conflicting acuity levels, 3. how to properly
Service Plan for: Carine Schmitt Richmond - North 1. This Service has been reviewed by the following: Resident: Responsible Party: Administrator:
Service Plan for: Printed: 6/28/2010 Carine Schmitt This Service has been reviewed by the following: Resident: Responsible Party: Administrator: Health Services Director: Program Director: Other: Date:
Intake Application. Please check which waiver you are applying for and which services you are interested in receiving.
Please check which waiver you are applying for and which services you are interested in receiving. OPWDD/HCBS WAIVER Day Habilitation Medicaid Service Coordination Residential Community Habilitation TRAUMATIC
DEPARTMENT OF HEALTH AND HUMAN RESOURCES
Earl Ray Tomblin Governor ---- ---- -------------- ------------------- State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 203 East Third Avenue
DISCLOSURE OF SERVICES
DISCLOSURE OF SERVICES NOTE: The use of the term we refers to the boarding home named at the top of the page. The boarding home licensee shall disclose to the residents, the residents legal representative
Children s Services. School Health
Children s Services School Health When should a referral be sent to the South East CCAC? Is there something a school should do first before making a referral? Teachers should utilize all resources available
Long-Term Care Division
Long-Term Care Division Eligibility Criteria for Nursing Facility B (NF-B) Level of Care (LOC) PRESENTERS Christine King-Broomfield, RN Nurse Evaluator IV Chief, In-Home Operations, Northern Section Christine.King@dhcs.ca.gov
1. PROPOSAL NARRATIVE REQUIREMENTS (Maximum 85 points)
Single Source Requirements for Adult Residential Care Facility Instructions: If Vendor is interested in an opportunity to contract for Adult Residential Care Facility (RCF) services in FY15 with the County,
Rhode Island HEALTH. Continuity of Care Form. Referral to: Phone:
0 Specific Discharging Agency: Rhode Island HEALTH Continuity of Care Form Home Address: Referral to: Being Discharged to: Address: Contact Person @ Discharging Facility: Phone/Beeper #: The following
Revised: November 2005 Regulation of Health and Human Services Facilities
Revised: November 2005 Regulation of Health and Human Services Facilities This guidebook provides an overview of state regulation of residential facilities that provide support services for their residents.
EW Customized Living Contract Planning Worksheet, Part I
Purpose of This Worksheet This planning worksheet is designed to: 1. Delineate component services that can be included in EW customized living and 24 hour customized living packages. 2. Serve as a tool
LOS ANGELES UNIFIED SCHOOL DISTRICT Policy Bulletin
TITLE: NUMBER: ISSUER: Guidelines for an Individualized Health Assessment and the Participation of the School Nurse in the Individualized Education Plan (IEP) Process BUL-2030.0 DATE: October 21, 2005
Michelle P Waiver Training
Michelle P Waiver Training Presented by Department for Medicaid Services and Department for Mental Health, Developmental Disabilities and Addiction Services 1 Workshop Outline I. History and Overview of
Attachment C: Itemized List of OASIS Data Elements
Attachment C: Itemized List of OASIS Data Item Description Number of Data SOC ROC FU TOC DTH DIS M0010 CMS Certification Number 1 1 M0014 Branch State 1 1 M0016 Branch ID Number 1 1 M0018 National Provider
MEDICAL POLICY No R5 PSYCHOLOGICAL EVALUATION AND MANAGEMENT OF NON-MENTAL HEALTH DISORDERS
PSYCHOLOGICAL EVALUATION AND MANAGEMENT OF NON-MENTAL HEALTH DISORDERS Effective Date: September 8, 2014 Review Dates: 10/07, 10/08, 10/09, 6/10, 6/11, 6/12, 6/13, 8/14, 8/15, 8/16, 8/17 Date Of Origin:
ADULT LONG-TERM CARE SERVICES
ADULT LONG-TERM CARE SERVICES Long-term care is a broad range of supportive medical, personal, and social services needed by people who are unable to meet their basic living needs for an extended period
Chapter 2: Patient Care Settings
Chapter 2: Patient Care Settings MULTIPLE CHOICE 1. While the home health nurse is doing the entry to service assessment on a home-bound patient, the wife of the patient asks whether Medicare will cover
INSTRUCTIONS TO LICENSED HEALTH CARE PROVIDERS: AFTER
RESIDENT HEALTH ASSESSMENT for ASSISTED LIVING FACILITIES TO BE COMPLETED BY FACILITY: INSTRUCTIONS TO LICENSED HEALTH CARE PROVIDERS: AFTER COMPLETION OF ALL ITEMS IN SECTIONS 1 AND 2 OF THIS FORM (pages
59G Preadmission Screening and Resident Review.
59G-1.040 Preadmission Screening and Resident Review. (1) Purpose. This rule applies to all Florida Medicaid-certified nursing facilities (NF), regardless of payer source; all providers rendering NF services
Center for Quality Aging
Center for Quality Aging Nutritional Issues in Long-Term Care: Research Findings and Practice Implications Sandra F. Simmons, PhD Associate Professor of Medicine, Vanderbilt VA Medical Center, GRECC Goals
Students with Special Health Care Needs Medically Fragile Children
Students with Special Health Care Needs Medically Fragile Children A. Regulations As used in this chapter unless the context requires otherwise: 1) Children with disabilities means those school-age children
APPENDIX A: WRITTEN EVALUATION
Unit 1 1. Feeding Assistants cannot assist residents with a history of aspiration or difficulty swallowing. 2. Feeding Assistants can assist with other Activities of Daily Living (ADL) care such as bathing
NOVA SCOTIA DEPARTMENT OF HEALTH AND WELLNESS CONTINUING CARE BRANCH
NOVA SCOTIA DEPARTMENT OF HEALTH AND WELLNESS CONTINUING CARE BRANCH Subject: Service Eligibility Policy Original Approved Date: November 19, 2004 Revised Date: January 24, 2011 Approved by: Original signed
LONG TERM CARE SETTINGS
LONG TERM CARE SETTINGS Long term care facilities assist aged, ill or disabled persons who can no longer live independently. In this section, we will briefly examine the history of long term care facilities
Resident Name Medicaid # - - If Pending Medicaid, Social Security # - - Medicare # Date of Birth / / Responsible Party. Responsible Party Address
URSIG FACILIT LEVEL OF CARE REQUEST FOR ADMISSIO Resident ame Medicaid # - - Room # Room Certified for Medicaid es o If Pending Medicaid, Social Security # - - Medicare # Date of Birth / / Marital Status
Benefits. Benefits Covered by UnitedHealthcare Community Plan
Benefits Covered by UnitedHealthcare Community Plan As a member of UnitedHealthcare Community Plan, you are covered for the following MO HealthNet Managed Care services. (Remember to always show your current
NORTH CAROLINA DEPARTMENT OF HEALTH & HUMAN SERVICES
NORTH CAROLINA DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Mental Health, Developmental Disabilities and Substance Abuse Services State-Funded MH/DD/SA SERVICE DEFINITIONS Revision Date: September
Medical Policy Definition of Skilled Care
Medical Policy Definition of Skilled Care Document Number: 015 Authorization required for skilled care and shortterm rehab Notification within 24 hours or next business day No notification or authorization
CASE MANAGEMENT POLICY
CASE MANAGEMENT POLICY Subject: Acuity Scale Determination Effective Date: March 21, 1996 Revised: October 25, 2007 Page 1 of 1 PURPOSE: To set a minimum standard across Cooperative agencies regarding
Part 3: Confirmation of eligibility and coverage for provincial home care - to be completed by the provincial home care case coordinator / manager.
Great-West Life Centre 100 Osborne Street N Winnipeg MB R3C 1V3 Dear Plan Member, To establish the amount of coverage available for nursing care under your group benefit plan, Great-West Life requires
Resident Health Assessment for Assisted Living Facilities
Resident Health Assessment for Assisted Living Facilities To Be Completed By Facility: Resident Information Facility Information Facility Name: Telephone Number: ( ) Street Address: Fax Number: ( ) City:
Initial Pool Process: Resident Interview
Initial Pool Process: Resident Interview Care Area Probes Response Options Choices Are you able to make choices about your daily life that are important to you? I d like to talk to you about your choices.
Medicaid Covered Services Not Provided by Managed Medical Assistance Plans
Medicaid Covered Services Not Provided by Managed Medical Assistance Plans This document outlines services not provided by MMA plans, but are available to Medicaid recipients through Medicaid fee-for-service.
Covered Services List and Referrals and Prior Authorizations for MassHealth Members enrolled in Partners HealthCare Choice
Covered Services Covered Services List and s and Prior Authorizations for MassHealth Members enrolled in Partners HealthCare Choice This chart tells you two things: 1. the covered services and benefits
NURSING HOME PRE-ADMISSION ASSESSMENT FORM
Clients Name: NHS No AIS No (if applicable) DOB: Home Address NOK Contact Details Telephone: Relationship: Other contact: Marital status Religion GP Details and Address Ethnic origin Date of Referral:
WakeMed Rehab Hospital Stroke Rehabilitation Scope of Service
WakeMed Rehab Hospital Stroke Rehabilitation Scope of Service WakeMed Rehab Hospital provides an integrated, comprehensive delivery of rehabilitation services utilizing evidenced-based practice directed
HAWAII HEALTH SYSTEMS CORPORATION
Entry Level Work HE-04 6.742 Full Performance Work HE-06 6.743 Function and Location This position works in a hospital, clinic or long term care facility and is responsible for providing direct patient/resident
An Initial Review of the CY Medicare Home Health Rule. CY2018 Proposed Medicare Home Health Rate Rule and Much More
An Initial Review of the CY 2018 2019 Medicare Home Health Rule Mary K. Carr William A. Dombi NAHC CY2018 Proposed Medicare Home Health Rate Rule and Much More Published July 25, 2017 https://www.cms.gov/medicare/medicare