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R-15-98E

CRITERIA CHAPTER 7.0

CRITERIA FOR LONG-TERM CARE SERVICES

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R-15-98E

CRITERIA FOR LONG-TERM CARE SERVICES

SKILLED NURSING FACILITY SERVICES

I. Criteria for Determining Admission to SNFs

Criteria for admission to SNFs are contained in state regulations (Title 22, CCR, Section 51335) and are applied on a statewide basis. Those criteria for admission and extension of stay (continuing care) are as follows:
A. Need for patient observation, evaluation of treatment plans, and updating of medical orders by the responsible physician
B. Need for constantly available skilled nursing services. A patient may qualify for SNF services if the patient's care involves one or more of the following conditions:
1. Conditions such as the following weigh in favor of SNF Placement:
a. Dressing of postsurgical wounds, decubitus ulcers, leg ulcers, etc. The seventy of the lesions and the frequency of dressings will be determining factors in evaluating whether they require SNF care.
b. Tracheostomy care, nasal catheter maintenance.
c. Indwelling catheter in conjunction with other conditions. Its presence without a requirement for other skilled nursing care is not a sufficient criterion for SNF placement.
d. Gastrostromy feeding or other tube feeding,
e. Colostomy care for initial or debilitated patients. Facilities shall be required to instruct in self-care where such is feasible for the patient. Colostomy care alone should not be a reason for continuing SNF placement.
f. Bladder and bowel training for incontinent patients.

2. Patients whose medical condition requires continuous skilled nursing observation of the following may be in a SNF depending on the severity of the condition. Observation must, however, be needed at frequent intervals throughout the 24 hours to warrant care in an SNF.
a. Regular observation of blood pressure, pulse, and respiration as indicated by the diagnosis or medication and ordered by the attending physician.
b. Regular observation of skin for conditions such as decubitus ulcers, edema, color, and turgor.
c. Careful measurement of intake and output as indicated by the diagnosis or medication and ordered by the attending physician.

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3. If the patient needs medications which cannot be self-administered and requires skilled nursing services for administration of the medications, SNF placement may be appropriate for reasons such as the following:

a. Injections administered during the evening or night shift. If this is the only reason for SNF placement, consideration should be given to other therapeutic approaches or to the possibility of teaching the patient or a family member to give the injections.
b. Medications prescribed on an as needed basis. This will depend on the nature of the drug and the condition being treated and frequency of need as documented.
c. Use of restricted or dangerous drugs if required more than during the daytime, requiring close nursing supervision.
d. Use of new medications requiring close observation during initial stabilization for selected patients. Depending upon the circumstances, such patients may also be candidates for intermediate care facilities (ICFs).

4. A physical or mental functional limitation.
a. Physical limitations. The physical functional incapacity of certain patients may exceed the patient care capability of ICFs.
(1) Bedfast patients.
(2) Quadriplegics or other severe paralysis cases. Severe quadriplegics may require such demanding attention (skin care, personal assistance, respiratory embarrassment) as to justify placement in SNF.
(3) Patients who are unable to feed themselves.
(4) Patients who require extensive assistance with personal care such as bathing and dressing

. b. Mental limitations. Persons with a primary diagnosis of mental illness (including mental retardation) when such patients are severely incapacitated by mental illness or mental retardation. The following criteria are used when considering the type of facility most suitable for the mentally ill and mentally retarded person where care is related to the patient's mental condition.
(1) The severity or unpredictability of the patient's behavior or emotional state.
(2) The intensity of care, treatment. services, or skilled observation that the patient's condition requires and
(3) The physical environment of the facility, its equipment, and the qualifications of staff and
(4) The impact of the particular patient on other patients under care in the facility.

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c. The general criteria identified above are not intended to be either all-inclusive or mutually exclusive. In practice, they should be applied as a total package in evaluation of an approved admission.

II. Continuing Care Determinations
A. Regular Extensions
Extensions of stay in SNFs require reauthorization by the Medi-Cal consultant every four months except for those patients who have been identified as "prolonged care" patients (see B, below). Regular extensions are based on the same criteria as initial authorizations:

B. Prolonged Care Determinations
The "prolonged care" classification recognizes that the medical condition of selected patients requires a prolonged period of skilled nursing care. The prolonged care classification is intended only to eliminate unnecessary, costly paper work for both the State and providers of service. Reauthorizations for prolonged care at the SNF level of care are approvable for up to one year. Therefore. all patients are considered regular or nonprolonged care unless the patient meets the criteria for prolonged care.

Medical functional factors of the patient must support a sound professional judgment that a prolonged period of care will be required. The following medical/functional factors shall be used to reach the decision on prolonged care status:

1. Highest indications of need for prolonged care.
a. Total or severe incontinence which despite bowel and bladder training has failed to improve.
b. Bedridden and/or comatose or semicomatose states.
c. Conditions which have resulted in quadriplegia, hemiplegia, spasticity, rigidity, and uncontrolled movements, tremors, or deformity dependent upon severity or intensity
d. Conditions which require a high degree of prolonged medical nursing support and supervision (depending upon the patient's ability to participate responsibly in the patient's own care). These include complex regiments of oral and/or parenteral medications and diet to control diabetes, cardiac conditions, seizure disorders. hypertension, tumor conditions, obstructive pulmonary conditions, infectious conditions, and pain.
e. Conditions which require a high degree of prolonged mechanical nursing support and supervision (depending upon the patient's ability to participate responsibly in the patient's own care). These include tracheostomies, gastrostomies, colostomies. catheters, NIG tubes, IPPB machines, irrigation procedures, medicinal installation procedures, dressing changes, and conditions requiring sterile technique.

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f. Conditions requiring medical/psychiatric/developmental nursing support and supervision (dependent upon severity and the patient's ability to participate responsibly in the patient's own care). These include extreme confusion and disorientation, inability to communicate, unacceptable physical, sexual, or verbally aggressive behavior, and anxiety or depression which is secondary to the medical/physical condition (e.g.. terminal cancer). Note: Conditions which are psychogenic as opposed to organic are generally considered transitory in nature They constitute poor justification for authorizing prolonged care.

2. Important indications of need for prolonged care. (Usually requiring two or more of the following factors.)

a. Conditions outlined in c, d, e, and f above, but of lesser seventy. intensity, or degree than alluded to in section 1. above.
b. Occasional incontinence-on bowel and bladder retraining programs.
c. Debilitating conditions including extreme age which indicate a need for preventive nursing care and supervision to avoid skin breakdown, fractured bones. nutritional deficiency, or infectious conditions.
d. Cases in which the documented history gives clear indication that changes in the "status quo" will likely lead to levels of care which are more costly to the Medi-Cal program.

3. Supporting indications.

(The relative importance of factors in this category is determined by the relationship with factors from a and b of 1 above. Any one factor in this category standing alone is not sufficient to establish prolonged care status. However, items in this category will add to the weight of facts to support a finding of prolonged care status.)

a. Conditions outlined in a and b of 1 above but of lesser seventy, intensity, or degree than alluded to in those sections.
b. Cases in which the documented history and/or diagnosis gives clear indication of progressive incapacitation.
c. Dependence for activities of dally living-dependent upon degree.
d. Sensory impairment.
e. Generalized weakness or feebleness.
f. Behavioral management problems.

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III. Subacute Level of Care-Criteria for Determining Admission or Extension of Stay (Continuing Care).

Subacute level of care is defined in Title 22. California Code of Regulations (CCR), Section 51 124.5. Authorization shall be based on medical necessity and the lowest cost service in accordance with Title 22. CCR. Sections 51003 and 51303.

An initial Treatment Authorization Request shall be required for each admission. Extensions of stay require reauthorization by the Medical Consultant every two months. Prolonged care may be authorized for up to a maximum of four months. Extensions are based on the same criteria as initial authorizations.

Minimal standards of medical necessity for this level of care include:

A. Physician visits medically required at least twice weekly during the first month and a minimum of at least once every week thereafter.

B. Twenty-four hour access to services available in a general acute care hospital.

C. The need for special medical equipment and supplies such as ventilators which are in addition to those listed in Title 22, CCR, Section 5151l(b).

D. Twenty-four hour nursing care by a registered nurse.

E. Any one of the following three items:
(1) A tracheostomy with continuous mechanical ventilation for at least 50 percent of the day; or
(2) Tracheostomy care with suctioning and room air mist or oxygen as needed and one of the six treatment procedures listed in Section F: or
(3) Administration of any three of the six treatment procedures listed in Section F.

F. Treatment Procedures
1. Total parenteral nutrition (TPN).
2. Inpatient physical, occupational, and/or speech therapy, at least two hours per day five days per week.
3. Tube feeding (NG or gastrostomy).
4 Inhalation therapy treatments during every shift and a minimum of 4 times per 24-hour period.
5. Continuous IV therapy involving administration of therapeutic agents or IV therapy necessary for hydration or frequent IV drug administration via a peripheral and/or central line without continuous infusion such as via Heparin lock.
6. Debridement, packing, and medicated irrigation with or without whirlpool treatment.

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Manual of Criteria, Chapter 7.0, Criteria for Long Term Care Services