Title 7 . Health and Social Services

Chapter 43 . Hearings

Section 210. Placement and level-of-care planning

7 AAC 43.210. Placement and level-of-care planning

(a) The following procedures apply only to those recipients in acute care (in a hospital or inpatient psychiatric facility) who appear to require placement in a long-term care facility:

(1) the attending physician should take an active part in planning for the proposed transfer through consultation with the medical director of the facility, specialists, the director of nursing at the facility, and the discharge coordinator at acute care;

(2) the discharge coordinator at acute care and the director of nursing at the facility should appraise the level-of-care needs of the recipient;

(3) if a decision is made to transfer the recipient from acute care to long-term care, a preliminary evaluation establishing the need for long-term care placement shall be made by the attending physician, the director of nursing and any therapist, specialist, or other professional involved in planning for the care of the recipient; that evaluation must be submitted to the division or the division's designee by the long-term care facility on an initial Request for Nursing Home Authorization form unless 7 AAC 43.205(b) applies; this request form must be mailed to the division or to a designee named by the division within one week of the recipient's admission to the long-term care facility; to ensure timely receipt by the medical practice review section, this initial Request for Nursing Home Authorization form should be sent by certified mail; failure to follow this procedure may result in denial of payment for care provided by the long-term care facility before receipt of a request form;

(4) the initial Request for Nursing Home Authorization must either confirm the recipient's need for continued placement at the current level of care or must provide a specific time frame for transfer or discharge;

(5) upon receipt of the initial Request for Nursing Home Authorization under (3) of this subsection, the medical practice review section will evaluate the request form and either concur in the placement or request that additional information be supplied by the facility to support the level-of-care decision; if upon submittal of the additional information the medical practice review section does not find sufficient justification for continued placement, the division will advise the facility that it has 10 days from the date of notification to either transfer or discharge the recipient; if the division approves the placement the division will notify the facility of the length of the certification and the date by which the placement must be reviewed by the utilization review committee.

(b) The following procedures apply only to those recipients who are already receiving care in an ICF or an SNF or who are in their home or other non-acute care setting who appear to require placement in a long-term care facility:

(1) except as provided in 7 AAC 43.205(b) , the long-term care facility shall complete a Request for Nursing Home Authorization form with all pertinent medical and social factors to justify the level-of-care request, including consideration of alternative placement for the recipient, the care prescribed by the attending physician, and physician notes, and submit the form to the utilization review committee; the utilization review committee at its next scheduled meeting will be responsible for reviewing the appropriateness of the level-of-care placement and the medical necessity for continued placement; the decision of the utilization review committee must be indicated on the Request for Nursing Home Authorization and submitted to the division or the division's designee by the long-term care facility;

(2) the medical practice review section of the division will evaluate the Request for Nursing Home Authorization and the recommendation of the utilization review committee and either concur in the placement or request that additional information be reviewed by the utilization review committee to support the level-of-care decision; upon resubmittal of the Request for Nursing Home Authorization, if the medical practice review section does not find that sufficient justification exists to continue the recipient's present level-of-care placement, the division will so advise the facility;

(3) the facility will have 30 days to arrange for discharge or alternative placement of a recipient who has been found by the medical practice review section to no longer be in need of care at his or her present level-of-care placement; at the end of that 30-day period, if the recipient has been recommended for transfer to an intermediate level-of-care placement and has not been transferred, payment to the facility will be made at the facility's ICF rate or the statewide weighted average ICF rate if the facility does not provide intermediate care; at the end of the 30-day period, if the beneficiary has been recommended for discharge and the facility has not yet discharged the beneficiary, the division will terminate payment.

(c) The following procedures apply to all recipients who are new or continuing long-term care facility placements:

(1) there must be a current, approved Request for Nursing Home Authorization in the division case file supporting each recipient's level-of-care placement; subsequent request forms must be submitted no less than semi-annually following admission to an ICF and no less than quarterly following admission to an SNF;

(2) the Request for Nursing Home Authorization form must be precise as to the medical reason for continued stay and, where appropriate, should indicate what alternative types of medical care have been considered; the facility must provide information on the Request for Nursing Home Authorization form supporting the level-of-care decision of the utilization review committee; the Request for Nursing Home Authorization must also explain the plan of care established for the treatment prescribed by the attending physician and documented in the facility's patient file by physician and nursing notes as well as the evaluation of social workers, therapists, and other health care professionals involved in the recipient's care; the Request for Nursing Home Authorization must include discussion of the following factors related to the recipient's care: diagnoses, symptoms, complaints, and complications indicating the need for admission or continued stay; a description of the functional level of the recipient; written objectives; orders (as appropriate) for medications, treatments, restorative and habilitative services, therapies, diet, activities, social services, and special procedures designed to meet these objectives; plans for continuing care (including provisions for review and necessary modifications of the plan); reasons why alternative placement is not feasible or appropriate; and plan for discharge;

(3) upon request, authorized representatives of the division must be given access to facility records pertaining to any recipient; "access" means the opportunity to personally read charts and records in order to document continuing eligibility for payment;

(4) a copy of all utilization review reports and Requests for Nursing Home Authorization must be entered in the recipient's record at the facility;

(5) the facility must have written policies which state that only those persons are accepted whose needs can be met by the facility directly or in cooperation with community resources or other providers of care with which it is affiliated or has a contract; it is the responsibility of the facility to monitor admissions carefully to insure that only recipients are admitted whom it has the capability to treat;

(6) a facility unable to provide appropriate care for a recipient must notify the division and assist in prompt transfer of that person to another facility that can provide the care needed;

(7) recipients whose level-of-care placement is found to be inappropriate have the hearing rights set out in 7 AAC 49;

(8) a facility that is denied payment under this section is entitled to appeal under 7 AAC 43.085.

History: Eff. 8/18/79, Register 71; readopt 8/7/96, Register 139; am 11/13/97, Register 144

Authority: AS 47.05.010

AS 47.07.040

Editor's note: Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.210 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department.