Regulation .05 Covered Services.
Regulation .05 Covered Services.LinkCopy Citation
A.
Chronic hospitals shall provide the following services:
(1)
Complex respiratory care services;
(2)
Complex wound care services;
(3)
Services for participants with multiple co-morbidities, including but not limited to services necessary to care for:
(a)
Ventilator-assisted individuals who have been ventilator dependent for less than 6 months and who need further medical stabilization or are candidates for weaning from ventilator assistance;
(b)
Tracheostomy participants who require suctioning more frequently than every 2 hours or are candidates for decannulation;
(c)
More than two extensive stage IV decubiti which require daily intensive treatment that is not available in a nursing facility; or
(d)
Extensive post-operative or post-traumatic care with multiple drains or extensive dressing change or therapies beyond the capabilities of a nursing facility;
(4)
For participants admitted for medically necessary rehabilitation services, physical therapy, occupational therapy, or speech therapy, directed by an interdisciplinary team; and
(5)
Ancillary services.
B.
Treatment Plan.
(1)
Within 24 hours of a participant’s admission, a physician shall perform a documented face-to-face evaluation of the participant and begin developing an individualized treatment plan designed to meet the participant’s assessed needs.
(2)
By the 7th day of a participant’s admission, an interdisciplinary team shall establish a written, individualized treatment plan for the participant, which shall include, at a minimum:
(a)
Diagnoses;
(b)
Treatment goals;
(c)
Frequency of interventions for each type of service ordered;
(d)
Duration of treatment of each type of service ordered; and
(e)
Prognosis.
(3)
The physician-led interdisciplinary team shall update the individualized treatment plan weekly until discharge.
C.
The Program covers outpatient hospital services provided by a chronic hospital when the services are:
(1)
Medically necessary; and
(2)
Provided to individuals who are eligible for Medical Assistance and who are not current inpatients at the chronic hospital, except when payment for certain outpatient services provided to a participant on the date of inpatient admission or within 3 calendar days before the date of an inpatient admission are bundled, in accordance with 42 CFR §412.2(c)(5).
D.
The program covers the following brain injury community integration program services:
(1)
Neuro-behavioral management programming, which includes, but is not limited to:
(a)
Assessment of maladaptive behaviors using valid and reliable behavioral measurement tools;
(b)
Pharmacologic intervention provided to manage maladaptive behaviors related to brain injury;
(c)
Neuro-behavioral programming created, implemented, overseen, and revised as needed;
(d)
Incorporation of neuro-behavioral programming into therapy and care for participants in the community integration program; and
(e)
Referral to a neuro-psychiatrist, as needed, if a neuro-psychiatrist is not a member of the facility staff;
(2)
Cognitive skills adaptation and compensation programming, including:
(a)
Specific programming dedicated to cognitive skills adaptation and compensation; and
(b)
Incorporation of cognitive compensatory strategies into community integration program participant’s interdisciplinary team treatment;
(3)
Community re-entry programming, including specific programming dedicated to social or pragmatic skills, leisure skills, and life skills; and
(4)
According to the participant’s needs:
(a)
The services of a psychiatrist or psychiatric nurse;
(b)
Services and supports related to substance use disorders and other addictions;
(c)
Speech therapy, which includes but is not limited to:
(i)
Cognitive skills;
(ii)
Communication skills;
(iii)
Swallowing ability; and
(iv)
Linguistic programming that assists the patient to connect the meaning of words to their context;
(d)
Occupational therapy, which includes but is not limited to:
(i)
Instrumental activities of daily living; and
(ii)
Community re-entry activities;
(e)
Physical therapy, which includes but is not limited to:
(i)
Ambulation; and
(ii)
Motor planning and coordination;
(f)
Dietary services, which includes but is not limited to nutritional needs assessment and monitoring; and
(g)
Case management, which includes but is not limited to:
(i)
Treatment planning; and
(ii)
Discharge planning.
E.
The Program covers administrative days approved by the Department or its designee according to the conditions set forth in Regulation .08C of this chapter.