Nursing Facility Level of Care An Overview

1. Nursing Facility Level of Care An Overview

2. Training Objectives • NF Documentation and Eligibility • NFLOC Factors • LOC Review & Length of Stay Determination • Transfer / Reintegration • Reconsideration / Appeals / Fair Hearings • Role of Care Coordinators • Scenarios & FAQs • Appedix

3. Nursing Facility Level of Care Documentation Requirement

4. NFLOCDocumentation Requirements • All requests must include the Minimum Data Set (MDS) and the MDS must be current for the time frame requested; • A valid physician’s order for either High Nursing Facility (HNF) or Low Nursing Facility (LNF) level of care for Nursing Home Residents. • Initial Request (Documents must be completed and submitted within 30 calendar days of admission) • MDS • A Valid Physician Order dated within six (6) months of documentation submission date • PASRR Level 1screen pass; if failed a PASRR Level 1, then an approved PASRR Level II • History and Physical (H & P) examination completed within six(6) months of the documentation submission date • Continuation Stay Request • MDS • Physician Order dated within twelve (12) months of documentation submission date • Physician Progress Notes, signed and dated within 90 days of the document submission date • H & P examination completed within twelve (12) months of documentation submission date

5. Physician Order Content Requirements • A valid physician order for NFLOC request must have the following elements: • Signed by a physician, certified nurse practitioner, physician assistant or clinical nurse specialist ; OR • Signed by the RN or LPN who took the verbal or telephone order indicating the name of the provider who provided the LOC order (The R.N. or L.P.N. must clearly indicate that the order is a telephone or verbal order with the name of the provider who gave the LOC order); telephonic order does not need MD signature at time of submission • Date of the order; AND • LOC indication –either HNF or LNF

6. Continuation Stay Request When requesting HNF, in addition to requirements for continued stay (slide 4), NF must send documentation supporting the daily skilled needs of the resident for the timeframe requested. If nursing facility (NF) is treating a wound/s, include any and all wound care documentation including wound measurements, location of wound, and treatments ordered that applies  for the time period you are requesting. If NF is providing therapies (PT, OT, etc.), include therapy evaluations, therapy notes, grids and therapy treatment plan for  the time period you are requesting. If NF is providing other daily skilled services such as cancer treatments, respiratory treatment or other skilled treatment, submit supporting documentation reflecting the treatment provided. Include the interdisciplinary treatment plan with the goals, objectives, interventions and progress towards goals.

7. Readmission The following procedure will be followed when a resident spends more than 3 midnights outside of the NF: • The NF has to submit a re-admit NF LOC request within thirty (30) calendar days for HNF determination with the following documentation: • Valid order for HNF (defined in slide 5) • The resident’s hospital discharge summary and/or resident’s admission note back to the NF • If resident is readmitted for LNF LOC certification, the NF needs to notify the MCO of the readmission via fax using the Communication Form. • If resident has less than thirty (30) days left on the NF LOC certification, the NF should submit a NF LOC continued stay request.

8. Discharge Status Eligibility Discharge Status occurs when a resident no longer meets HNF or LNF level of care, but there is no option for community placement of the resident at that time. Discharge Status does not mean the resident is being discharged from the facility. Discharge Status is considered when residents may be at risk for failure to thrive outside the nursing facility and discharging the resident places the resident’s health at risk.

9. Discharge Status Documentation Requirements • A valid LOC order • Physician orders are valid for 60 days from date of receipt; • ALL packets must include the MDS. Documentation must be current for time frame requested; • Submission of a Continued Stay request for a resident in Discharge Status must acknowledge the resident’s Discharge Status and document the facility’s ongoing attempts, in conjunction with Care Coordinator’s effort, to find and develop appropriate community placement options for the resident; and • The facility should document why the resident must remain in the nursing home until the resident can be safely discharged to the community.

10. Nursing Facility (NF) Eligibility NF General Eligibility (also Low NF eligibility) Member's functional level is such that two or more Activities of Daily Living (ADLs) cannot be accomplished without consistent, ongoing, daily assistance in some or all of the following levels of service; skilled, intermediate and/or assistance level. Functional limitations of the individual must be secondary to a condition for which general treatment plan oversight by a physician is medically necessary –New Mexico Administrative Code 8.312.2 NMAC.

11. High Nursing Facility (HNF) Eligibility • The resident’s functional level must first meet the general eligibility requirements for LNF. • In addition, the recipient meets a minimum of 2 High NF requirements in 2 separate categories (The exception to this is rehabilitative therapy. Therapies in excess of 300 minutes per week shall be considered as meeting the 2 HNF requirements in 2 separate categories, thus meeting HNF criteria). • Determination is based on detailed documentation in interdisciplinary progress notes and care plans.

12. Nursing Facility Level of Care HNF Factors

13. Factors for HNF: Oxygen • OXYGEN • Resident is demonstrating unstable and changing oxygen needs which require specific direct skilled monitoring and/or intervention on a daily basis that is documented in interdisciplinary progress notes and care plans to maintain adequate oxygenation and to assess for respiratory depression. Evidence of a re-established baseline would not be evidence of significant change in oxygen therapy over 30 days. • It is medically necessary for the resident to receive respiratory therapy at least once per day such that in the absence of such therapy there is a significant risk of pulmonary compromise due to known and predictable complications of a physician-diagnosed condition. The necessary therapy cannot be self-administered by the resident. This factor includes tracheostomy suctioning. • The resident is ventilator dependent, but otherwise medically stable per documentation provided and the facility provides chronic ventilator management capability.

14. Factors for HNF: Oxygen B. Not Consistent with HNF Resident requires supplemental oxygen which can be self-administered. The oxygen needs are stable. The recipient does not require daily skilled observation. Resident requires intermittent respiratory therapy that may be administered by family or self-administered in a non-institutional setting. The resident is ventilator dependent and has medical needs which cannot safely be met at a nursing facility.

15. Factors for HNF: Orientation/Behavior A. Orientation/Behavior: Demonstrates behavior on an ongoing and regular basis which threatens patient or other residents’ safety and requires daily direct clinical skilled interventions which are documented in interdisciplinary progress notes and care plan. (Identify the presence of certain behaviors that may reflect the level of an individual’s emotional functioning and need for intervention. Behaviors should be assessed based on the documentation of interventions within the past 30 days for HNF. Documentation should include frequency, type of behavior, and if there has been or will be a request for Behavioral Health Services.) Requires a detailed care plan that documents a coordinated and consistent approach that occurs on a daily basis to either prevent or terminate behavior as documented in interdisciplinary progress notes and care plan.

16. Factors for HNF: Orientation/Behavior B. Not Consistent with HNF • Does not have a cognitive impairment, but is trying to leave • Paces due to anxiety, nervousness or boredom • Wanders but does not require intervention • Uses profanity to express anger • Behavior is stable and does not require changes in care plan

17. Factors for HNF: Medication Administration A. Initiation (first 30 days) or adjustment of medications (7 days after adjustment) in the following categories: • Anti-asthmatics/COPD: only during a respiratory exacerbation • Anti-infectives: only when given IV • Anti-hypertensives: only for med adjustments for systolic BP<=90 or >180/120 • Analgesics: only when given parenteral • Antiarrhythmics • Anti-diabetic agents: only following hypoglycemic reactions requiring glucagon or IV dextrose • Antipsychotics - daily monitoring by skilled staff for potential adverse reactions and daily documentation of changes in problematic behavior. • Anticonvulsants only when given parenteral AND Where at least every shift direct skilled monitoring of vital signs (respiratory rate, pulse, Oxygen saturation, blood pressure, temperature) and objective signs of pain or other distress are necessary to ensure appropriate therapeutic effect of the medication as well as to detect signs of complications due to the medication that is documented in interdisciplinary progress notes and care plan.

18. Factors for HNF: Medication Administration B. Not Consistent with HNF Resident can administer own oral medications if given assistance in scheduling and assisted dispensing units. The resident can administer own subcutaneous insulin in pre-filled syringes, can administer own subcutaneous or intramuscular medications, and is cognitively capable of reporting any adverse reactions to medications. Medication dosing is stable.

19. Factors for HNF: Rehabilitative Therapy A. Rehabilitative Therapy It is medically necessary that the resident receive one or more of the following documented therapies on a weekly basis: Speech, physical, and/or occupational therapy. Therapy must be directed toward significant treatable functional limitations which affect ADLs. Therapy must be individualized, goal oriented, and in accordance with specific treatment plan goals in order to maximize recovery. Goals, expectation for improvement, and duration of therapy are medically reasonable and are documented in interdisciplinary progress notes and care plan. Therapy minutes should be documented on the Therapy Administration Record. In the aggregate, such therapy must occur no less than 150 minutes per week. Therapies at least 300 minutes per week shall be considered as meeting the 2 HNF requirements in 2 separate categories thus meeting HNF criteria.

20. Factors for HNF: Rehabilitative Therapy B. Not consistent with HNF The resident requires maintenance speech, physical, and/or occupational therapy performed on an outpatient basis. Transportation needs are not considered, or the resident requires maintenance speech, physical, and/or occupational therapy which can be performed independently or with home-based assistance.

21. Factors for HNF: Rehabilitative Therapy FOR DUAL Members 1 – Cannot be receiving skilled Part A benefits concurrently. MCO responsible for 20% co-pay of Part A services for days 21-100. 2 – Cannot count Rehabilitative Therapy if eligible for those services through Medicare Part B services 3 - To count rehabilitative service’s time, SNF will need to submit denial (COB) from Medicare for payment for the applicable Part A and Part B services: a – if Medicare denial is for “not a covered benefit” (length or amount over benefit limit), MCO can review for medical necessity b – if Medicare denial is for “lack of medical necessity”, then MCO will deny also.

22. Factors for HNF: Skilled Nursing A. Skilled Nursing • Resident has a new ostomy (first 30 days), and there is documentation in the interdisciplinary progress notes and care plan that the resident requires active teaching, and requires direct skilled nursing monitoring and intervention of the ostomy.

23. Factors for HNF: Skilled Nursing Continued • Wound Care • One or more documented stage III or IV decubitus ulcers requiring direct skilled nursing intervention and daily monitoring that is documented in inter-disciplinary progress notes and care plan which includes location, class/stage, size, base tissues, exudates, odor, edge/perimeter, pain and an evaluation for infection. OR • Documented skilled nursing intervention for two or more Stage II decubitus ulcers at separate anatomic sites. Interventions are documented in the interdisciplinary progress notes and care plan no less than every 7 days, which include location, class/stage, size, base tissues, exudates, odor, edge/perimeter, pain and an evaluation for infection. OR • Requires documented daily or more frequent sterile dressing changes (and/or irrigation) for significant, unstable lesions that require frequent nursing observation such as poorly healing, or infected wounds. The resident must be unable to accomplish wound care.

24. Factors for HNF: Skilled Nursing Continued B. Not Consistent with HNF Resident receives services outside of the NF that are billed separately, i.e., dialysis, therapies, transfusions, wound care at a wound care clinic, etc. or has an indwelling Foley catheter, suprapubic tube, or drain.

25. Factors for HNF: Other Clinical Factors A. Other Clinical Factors • The resident is comatose, in a persistent vegetative state, or is otherwise totally bed bound and totally dependent for all ADLs related to a documented medical condition requiring direct skilled intervention (not monitoring) by a licensed nurse or licensed therapist to prevent or treat specific, identifiable medical conditions which pose a risk to health. The resident’s ability to communicate needs, report symptoms, and participate in care is severely limited and is documented in the interdisciplinary progress notes and care plan.

26. Factors for HNF: Other Clinical Factors Continued • Feeding: • Resident receives medically necessary parenteral nutrition (PN) solutions via non-permanent or permanent central venous catheter (Hickman, Groshong, Broviac, etc.), via peripherally inserted central catheter (PICC), or via peripheral access sites. • Resident receives some or all nutrition through a nasoenteric feeding tube (i.e., a tube placed through the nose) AND it is documented that one or more of the permissive conditions for nasoenteric feeding at the Low NF level are not met which include all of the following: the tube feeding is uncomplicated, the resident is alert with an intact gag reflex and the resident is able to be fed either upright in a chair or with a bed raised to at least 30 degrees. • Resident receives enteral nutrition via gastrostomy, jejunostomy, or other permanent tube feeding methods.

27. Factors for HNF: Other Clinical Factors Continued • Mobility/Transfer The resident is bed bound, unable to independently transfer, and has a clinical condition(s) such that the transfer itself is not routine, is reasonably viewed as posing unusual risks, and there is documentation in interdisciplinary progress notes and care plan that demonstrate that each transfer must be and is monitored by a licensed nurse to assure no clinical complications of the transfer have occurred.

28. Not Appropriate for NF care: The resident’s needs are too complex or inappropriate for NF, such that: • The resident requires acute level of care for adequate diagnosis, monitoring, and treatment or requires inpatient based acute rehabilitation services. • The resident is completing the terminal portion of an acute stay and the skilled services are only being used to complete the acute therapy. NF care is covered as a post acute benefit and does not need a NFLOC determination Residents who do not meet NF LOC criteria. • The resident requires services on an intermittent basis and has a functional level which does not require daily services at the skilled, professional, or assistance level in order to accomplish ADLs. • The resident requires homemaker services to accomplish one or more ADLs, but is functional in accomplishing ADLs 4 or more days of the week

29. Requests for Information (RFI) The Centennial Care MCO will review all documents provided by the provider. If any of the required documents are not included or there are incomplete documents with the request for LNF or HNF, the Centennial Care MCO will return the packet to the provider and the LOC determination will be suspended until the provider responds. (Refer to slide 5 for Documentation Requirements) The provider has 14 business days to submit the response to the MCO RFI. Should the provider fail to provide the response to RFI within 14 business days, the MCO will issue a technical denial of the request.

30. Change From Medicaid Pending to Medicaid Eligible • Centennial Care MCO will be selected by Medicaid Applicant prior to determination of Medicaid Eligibility • When the resident’s Medicaid eligibility is approved per the ISD office, the Nursing Facility (NF) is responsible for notifying the Centennial Care MCO of the effective date information. • The Centennial Care MCO will confirm Medicaid eligibility by reviewing the daily enrollment data. • The Centennial Care MCO will ensure the complete and current documentation for the period requested is on file, certify timeframes associated with approvals, and fax the approval on the authorization to the nursing facility. • If there is no current NF LOC certification, the Centennial Care MCO will request the submission of documentations.

31. Nursing Facility Level of Care Level of care reviews & length of stay determinations

32. Level of Care Reviews Approving NF Level of Care (LOC) • If the NF resident meets the NF LOC requested, the Centennial Care MCO will fax an approval authorization for the LOC requested to the provider. The authorization will indicate an approved LOC, HNF or LNF, and the approved Level of Care date span. • If the resident is pending Medicaid eligibility, the authorization number will not be placed on the authorization. An authorization number will be provided once the Member is financially eligible.

33. Level of Care Reviews Denying NF Level of Care • If the History and Physical (H & P), Minimum Data Set (MDS), and any additional information provided does not indicate the NF resident meets NF LOC, the information will sent to the MCO Medical Director for review. If the Medical Director confirms that the member does not meet NF LOC, the resident and facility will receive a LOC denial letter. The denial letter will detail the reason for denial with specific regulation information and reconsideration and appeal right information.

34. Modification of HNF LOC Requests • The Centennial Care MCO is authorized to issue modified/reduced NF LOC approvals for HNF LOC requests that clearly do not meet HNF criteria, but do meet Low NF criteria. • A formal Request for Information (RFI) to the provider to justify the HNF request is not required when reviewing and processing HNF requests that clearly meet LNF criteria. • A new LOC order specifying LNF LOC is not required on HNF to LNF modified LOC approvals. • LNF approval will be indicated on the authorization and will be faxed to the nursing facility. • A letter is sent to the resident for notification of the reduced/modified LOC approval. A copy of the resident’s letter is sent to the nursing facility.

35. Workflow

36. Length of Stay Determinations • Initial LNF LOC cannot exceed 90 days , however, a shorter length of stay can be assigned based on the needs of the resident - 8.312.2-UR A, 3 (b) NMAC. • Continuing LNF LOC cannot exceed 365 days based on the medical needs and stability of the resident - 8.312.2.2-UR B, 2, b (ii) NMAC. • Initial HNF LOC cannot exceed 30 days, however, a shorter length of stay can be assigned based on the needs of the resident - 8.312.2-UR 2 A, 3 (a) NMAC. • Continuing HNF LOC cannot exceed 90 days based on the medical needs and stability of the resident - 8.312.2.2- UR B, 2, b (i) NMAC.

37. Length of Stay Determinations Discharge Status • Initial Discharge Status is authorized at LNF for a maximum of 90 days, based upon a Medical Director’s determination. 8.312.2 I (1) NMAC • Continued Stay Discharge Status is authorized at LNF for not less than 180 days, and up to 365 days. 8.312. I (2) NMAC

38. Nursing Facility Level of Care Transfer / reintegration / Reconsideration

39. Transfer from one facility to another The nursing facility must notify the Centennial Care MCO when a transfer is to occur from one nursing facility to another. The receiving nursing facility will provide the Centennial Care MCO with the date of the transfer. • If there are more than thirty(30) days on the resident’s current Level of Care, The Centennial Care MCO will send an authorization with the days remaining on the current Level of Care. • If there are less than thirty (30) days remaining on the resident’s current Level of Care, the receiving NF will be requested to send a Continued Stay request with all other required documents for Continued Stay. The days remaining on the current Level of Care will be added to the Continued Stay. The request should indicate that a transfer has occurred.

40. Community Reintegration For eligible residents who choose to transition to the community, the care coordinator shall facilitate the development of a transition plan, which shall address the members: • Physical health needs; • Behavioral health needs • Selection of providers in the community; • Housing needs • Financial needs; • Interpersonal skills; and • Safety For residents who are interested in transition to the community with the Community Benefit but do not have full Medicaid eligibility or who are not otherwise Medicaid eligible may contact the State Aging and Disability Resource Center (ADRC) at (800) 432-2080 and request a waiver allocation. The resident will receive a letter from the ADRC with instructions on next steps to complete financial and medical eligibility. When the resident is allocated, the Centennial Care MCO will complete the medical eligibility assessment, determine NF LOC eligibility, and determine if the member has a full Medicaid category of eligibility. Medical and financial eligibility must be completed within 90 calendar days from the allocation date unless an extension is granted. • A resident must have a 90 day nursing facility stay before an allocation will be given.

41. NFLOC Denials • Technical Denial – there are no appeal rights with a Technical Denial • Medical Denial • Reconsiderations

42. Reconsiderations The Nursing Facility reconsideration request must be received by the Centennial Care MCO within 30 calendar days from the date of the denial. The request must have the following information: reference to the challenged decision or action, basis for the challenge, copies of any document(s) pertinent to the challenged decision or action, copies of claim form(s) if the challenge involves a claim for payment which is denied due to a utilization review decision, and statement that a reconsideration of the decision is requested. The reconsideration process is indicated in the Medical Assistance Program Policy Manual 8.350.2 NMAC.

43. Appeals • Members must file appeal and complete the appeal process with MCO prior to requesting a State Fair Hearing. • Members must file an appeal verbally or in writing within 30 days of the date of the Notice of Action (NOA) letter • Verbal appeals can be filed through MCO Customer Service • A verbal appeal must be followed within 13 calendar days by a written appeal, signed by the member. • Failure to file the written appeal within 13 calendar days constitutes a withdrawal. • The MCO has 30 days from the receipt of the appeal to resolve it. • Per NM Regulations, if a provider files an appeal on behalf of a member, the member must provide written consent to MCO Appeals Department to begin the process.

44. Fair Hearing Fair hearings are administered through the HSD Fair Hearings Bureau. The resident has 90 days to request a Fair Hearing after the final decision of the appeal. The resident may utilize the Fair Hearing process after the reconsideration and appeal process has been exhausted The resident has 13 calendar days from date of denial letter to notify the State of the request for continuation of benefits.

45. Role of Care Coordinator in Centennial Care • Assessment of Members for Re-integration into the community • Ability to review the resident’s chart and visit with the resident on an “as needed” basis • Participation in Care Planning Meeting of all MCO residents

46. Nursing Facility Level of Care Scenarios

47. Scenario 1 LNF vs. HNF? 66 year old resident who has been a resident for 3 years Diagnosis of Diabetes Mellitus II, and Osteoarthritis Alert and oriented x 3 Receiving routine, unchanging dose of subcutaneous insulin twice a day Needs one person assist with all ADLs, but does not require skilled attendance and method of such mobility is not highly specialized mandating skilled monitoring and/or intervention Developed a stage II ulcer on the coccyx

48. Scenario 1 - Results Resident does not meet HNF criteria. Resident does not need skilled attendance for transfers. Resident does not have two or more stage II decubitus ulcers at separate anatomic sites. In order to meet HNF, the resident must meet LNF and meet a minimum of 2 High NF requirements. LNF criteria is met as resident’s functional level is such that two or more ADLs cannot be accomplished without consistent, ongoing, daily provision or some or all of the following levels of services: skilled, intermediate and/or assistance.

49. Scenario 2 LNF vs. HNF? • 80 year old resident who has been a resident for 2 years as LNF and continues to need assistance with 2 ADLs. • Resident has slowly worsening dementia and heart failure. • Over the last 2 weeks, member has become increasing lethargic and short of breath with increasing edema. • Hospitalization suggested but family (POA) refuses. This is his home and they request treatment in NF, understanding risks. • Chest x-ray demonstrates worsening heart failure. • Physician orders oxygen. increased diuretics; as well as vital signs, weight and O2 saturation checks daily and BMP today and in 3 days time. • Further orders are to contact MD with lab results  and make adjustments for weight change (up or down) of 3 + pounds and sats dropping below 90%. • Nursing Facility requests 30 day HNF

50. Scenario 2 - Results Resident does meet HNF criteria. The resident continues to meet LNF. Resident meets HNF criteria by meeting 2 skilled needs: • OXYGEN    --------- daily skilled assessments • MEDICATIONS  --- daily assessments of VS & weight & lab reporting If, after 30 days, the resident’s condition has stabilized, then the resident would resume approval as a LNF.