WSR 07-12-039

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed May 30, 2007, 3:45 p.m. , effective August 1, 2007 ]


Effective Date of Rule: August 1, 2007.

Purpose: The department is amending these rules to update and clarify existing language for the acute physical medical and rehabilitation (acute PM&R) program, change verbiage from "medical assistance administration (MAA)" to "the department," change verbiage from "facility" to "hospital," and delete definitions for terms that are no longer applicable or that are defined in other sections. In addition, the department is adding verbiage that states on and after August 1, 2007, an instate bordering city, or critical border hospital may apply to become a department-approved acute PM&R hospital.

Citation of Existing Rules Affected by this Order: Amending WAC 388-550-2501, 388-550-2511, 388-550-2521, 388-550-2531, 388-550-2541, and 388-550-2561.

Statutory Authority for Adoption: RCW 74.08.090 and 74.09.500.

Adopted under notice filed as WSR 07-08-106 on April 4, 2007.

A final cost-benefit analysis is available by contacting Larry Linn, P.O. Box 45510, Olympia, WA 98504-5510, phone (360) 725-1856, fax (360) 753-9152, e-mail linnld@dshs.wa.gov.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 6, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 6, Repealed 0.

Date Adopted: May 30, 2007.

Robin Arnold-Williams

Secretary

3842.2
AMENDATORY SECTION(Amending WSR 03-06-047, filed 2/28/03, effective 3/31/03)

WAC 388-550-2501   Acute physical medicine and rehabilitation (acute PM&R) program -- General.   Acute physical medicine and rehabilitation (acute PM&R) is a twenty-four-hour inpatient comprehensive program of integrated medical and rehabilitative services provided during the acute phase of a client's rehabilitation. The ((medical assistance administration (MAA))) department requires prior authorization for acute PM&R services. (See WAC 388-550-2561 for prior authorization requirements.)

(1) An interdisciplinary team coordinates individualized acute PM&R services at ((an MAA)) a department-approved rehabilitation ((facility)) hospital to achieve the following for a client:

(a) Improved health and welfare; and

(b) Maximum physical, social, psychological and educational or vocational potential.

(2) ((MAA)) The department determines and authorizes a length of stay based on:

(a) The client's acute PM&R needs; and

(b) Community standards of care for acute PM&R services.

(3) When ((MAA's)) the department's authorized acute period of rehabilitation ends, the hospital provider ((transfers the client to a more)) discharges the client to the client's residence, or to an appropriate level of care. Therapies may continue to help the client achieve maximum potential through other ((MAA)) department programs such as:

(a) Home health services;

(b) Nursing facilities;

(c) Outpatient physical, occupational, and speech therapies; or

(d) Neurodevelopmental centers.

[Statutory Authority: RCW 74.08.090, 74.09.520 and 42 C.F.R. 482.56. 03-06-047, 388-550-2501, filed 2/28/03, effective 3/31/03. Statutory Authority: RCW 74.08.090 and 74.09.520. 99-17-111, 388-550-2501, filed 8/18/99, effective 9/18/99.]


AMENDATORY SECTION(Amending WSR 03-06-047, filed 2/28/03, effective 3/31/03)

WAC 388-550-2511   Acute PM&R definitions.   The following definitions and abbreviations and those found in WAC 388-500-0005 and 388-550-1050 apply to the acute PM&R program. If conflicts occur, this section prevails for this subchapter.

"Accredit" (or "Accreditation") means a term used by nationally recognized health organizations, such as CARF, to state a facility meets community standards of medical care.

"Acute" means an intense medical episode, not longer than three months.

(("Acute physical medicine and rehabilitation (acute PM&R)" means a comprehensive inpatient rehabilitative program coordinated by an interdisciplinary team at an MAA-approved rehabilitation facility. The program provides twenty-four-hour specialized nursing services and an intense level of therapy for specific medical conditions for which the client shows significant potential for functional improvement.

"Administrative day" means a day of a hospital stay in which an acute inpatient level of care is no longer necessary, and noninpatient hospital placement is appropriate.

"Administrative day rate" means the statewide Medicaid average daily nursing facility rate as determined by the department.

"CARF" is the official name for The Rehabilitation Accreditation Commission' of Tucson, Arizona. CARF is a national private agency that develops and maintains current, "field-driven" (community) standards through surveys and accreditations of rehabilitation facilities.

"Rehabilitation Accreditation Commission, The" - See "CARF."))

"Survey" or "review" means an inspection conducted by a federal, state, or private agency to evaluate and monitor a facility's compliance with acute PM&R program requirements.

[Statutory Authority: RCW 74.08.090, 74.09.520 and 42 C.F.R. 482.56. 03-06-047, 388-550-2511, filed 2/28/03, effective 3/31/03. Statutory Authority: RCW 74.08.090 and 74.09.520. 99-17-111, 388-550-2511, filed 8/18/99, effective 9/18/99.]


AMENDATORY SECTION(Amending WSR 03-06-047, filed 2/28/03, effective 3/31/03)

WAC 388-550-2521   Client eligibility requirements for acute PM&R services.   (1) Only a client who is eligible for one of the following programs may receive acute PM&R services, subject to the restrictions and limitations in this section and WAC 388-550-2501, 388-550-2511, 388-550-2531, 388-550-2541, 388-550-2551, 388-550-2561, 388-550-3381, and other ((published)) rules:

(a) Categorically needy program (CNP);

(b) ((CNP -)) State children's health insurance program (((CNP-))SCHIP);

(c) Limited casualty program - Medically needy program (LCP-MNP);

(d) ((CNP -)) Alien emergency medical ((only))(AEM)(CNP);

(e) ((LCP-MNP -)) Alien emergency medical ((only)) (AEM)(LCP-MNP);

(f) General assistance unemployable (GA-U - No out-of-state care); or

(g) Alcoholism and drug addiction treatment and support act (ADATSA)((; and

(h) Medically indigent program (MIP) - Emergency hospital-based and emergency transportation services only when:

(i) The client is transferred directly from an acute hospital stay; and

(ii) The client's acute PM&R needs are directly related to the emergency medical condition that qualified the client for MIP)).

(2) If a client is enrolled in ((an MAA Healthy Options)) a department managed care organization (MCO) plan at the time of acute care admission, that plan pays for and coordinates acute PM&R services as appropriate.

[Statutory Authority: RCW 74.08.090, 74.09.520 and 42 C.F.R. 482.56. 03-06-047, 388-550-2521, filed 2/28/03, effective 3/31/03. Statutory Authority: RCW 74.08.090 and 74.09.520. 99-17-111, 388-550-2521, filed 8/18/99, effective 9/18/99.]


AMENDATORY SECTION(Amending WSR 03-06-047, filed 2/28/03, effective 3/31/03)

WAC 388-550-2531   Requirements for becoming an acute PM&R provider.   (1) Before August 1, 2007, only an in-state or ((border area)) bordering city hospital may apply to become a ((medical assistance administration (MAA))) department-approved acute PM&R ((facility)) hospital. On and after August 1, 2007 an instate, bordering city, or critical border hospital may apply to become a department-approved acute PM&R hospital. To apply, ((MAA)) the department requires the hospital provider to submit a letter of request to:

Acute PM&R Program Manager

Division of ((Medical Management - Medical Operations)) Healthcare Services

((Medical Assistance)) Health and Recovery Services Administration

P.O. Box 45506

Olympia, WA 98504-5506

(2) A hospital that applies to become ((an MAA)) a department-approved acute PM&R facility must provide ((MAA)) the department with documentation that confirms the facility is all of the following:

(a) A medicare-certified hospital;

(b) Accredited by the Joint Commission on Accreditation of ((Hospital)) Healthcare Organizations (JCAHO);

(c) Licensed by the department of health (DOH) as an acute care hospital as defined under WAC 246-310-010;

(d) Commission on Accreditation of Rehabilitation Facilities (CARF) accredited as a comprehensive integrated inpatient rehabilitation program or as a pediatric family centered rehabilitation program, unless subsection (3) of this section applies;

(e) For dates of admission before July 1, 2007, contracted under ((MAA's)) the department's selective contracting program, if in a selective contracting area, unless exempted from the requirements by ((MAA)) the department; and

(f) Operating per the standards set by DOH (excluding the certified rehabilitation registered nurse (CRRN) requirement) in either:

(i) WAC 246-976-830, Level I trauma rehabilitation designation; or

(ii) WAC 246-976-840, Level II trauma rehabilitation designation.

(3) A hospital not yet accredited by CARF:

(a) May apply for or be awarded a twelve-month conditional written approval by ((MAA)) the department if the facility:

(i) Provides ((MAA)) the department with documentation that it has started the process of obtaining full CARF accreditation; and

(ii) Is actively operating under CARF standards.

(b) Is required to obtain full CARF accreditation within twelve months of ((MAA's)) the department's conditional approval date. If this requirement is not met, ((MAA)) the department sends a letter of notification to revoke the conditional approval.

(4) A hospital qualifies as ((an MAA)) a department-approved acute PM&R ((facility)) hospital when:

(a) The ((facility)) hospital meets all the applicable requirements in this section;

(b) ((MAA's)) The department's clinical staff has conducted a facility site visit; and

(c) ((MAA)) The department provides written notification that the ((facility)) hospital qualifies to be ((reimbursed)) paid for providing acute PM&R services to eligible medical assistance clients.

(5) ((MAA)) The department-approved acute PM&R ((facilities)) hospitals must meet the general requirements in chapter 388-502 WAC, Administration of medical programs--Providers.

[Statutory Authority: RCW 74.08.090, 74.09.520 and 42 C.F.R. 482.56. 03-06-047, 388-550-2531, filed 2/28/03, effective 3/31/03. Statutory Authority: RCW 74.08.090 and 74.09.520. 99-17-111, 388-550-2531, filed 8/18/99, effective 9/18/99.]


AMENDATORY SECTION(Amending WSR 03-06-047, filed 2/28/03, effective 3/31/03)

WAC 388-550-2541   Quality of care--Department-approved acute PM&R hospital.   (1) To ensure quality of care, the ((medical assistance administration (MAA))) department may conduct reviews (e.g., post-pay, on-site) of any ((MAA)) department-approved acute PM&R ((facility)) hospital.

(2) A provider of acute PM&R services must act on any report of substandard care or violation of the ((facility's)) hospital's medical staff bylaws and CARF standards. The provider must have and follow written procedures that:

(a) Provide a resolution to either a complaint or grievance or both; and

(b) Comply with applicable CARF standards for adults or pediatrics as appropriate.

(3) A complaint or grievance regarding substandard conditions or care may be investigated by any one or more of the following:

(a) The department of health (DOH);

(b) The Joint Commission on Accreditation of Healthcare Organizations (JCAHO);

(c) CARF;

(d) ((MAA)) The department; or

(e) Other agencies with review authority for ((MAA)) the department's programs.

[Statutory Authority: RCW 74.08.090, 74.09.520 and 42 C.F.R. 482.56. 03-06-047, 388-550-2541, filed 2/28/03, effective 3/31/03. Statutory Authority: RCW 74.08.090 and 74.09.520. 99-17-111, 388-550-2541, filed 8/18/99, effective 9/18/99.]


AMENDATORY SECTION(Amending WSR 03-06-047, filed 2/28/03, effective 3/31/03)

WAC 388-550-2561   ((MAA's)) The department's prior authorization requirements for acute PM&R services.   (1) The ((medical assistance administration (MAA))) department requires prior authorization for acute PM&R services. The acute PM&R provider of services must obtain prior authorization:

(a) Before admitting a client to the rehabilitation unit; and

(b) For an extension of stay before the client's current authorized period of stay expires.

(2) For an initial admit:

(a) A client must:

(i) Be eligible under one of the programs listed in WAC 388-550-2521, subject to the restrictions and limitations listed in that section;

(ii) Require acute PM&R services as determined in WAC 388-550-2551;

(iii) Be medically stable and show evidence of physical and cognitive readiness to participate in the rehabilitation program; and

(iv) Be willing and capable to participate at least three hours per day, seven days per week, in acute PM&R activities.

(b) The acute PM&R provider of services must:

(i) Submit a request for prior authorization to the ((MAA)) department's clinical consultation team by fax, electronic mail, or telephone as published in ((MAA's)) the department's acute PM&R billing instructions; and

(ii) Include sufficient medical information to justify that:

(A) Acute PM&R treatment would effectively enable the client to obtain a greater degree of self-care and/or independence;

(B) The client's medical condition requires that intensive twenty-four-hour inpatient comprehensive acute PM&R services be provided in ((an MAA)) a department-approved acute PM&R facility; and

(C) The client suffers from severe disabilities including, but not limited to, neurological and/or cognitive deficits.

(3) For an extension of stay:

(a) A client must meet the conditions listed in subsection (2)(a) of this section and have observable and significant improvement; and

(b) The acute PM&R provider of services must:

(i) Submit a request for the extension of stay to the ((MAA)) department clinical consultation team by fax, electronic mail, or telephone as published in ((MAA's)) the department's acute PM&R billing instructions; and

(ii) Include sufficient medical information to justify the extension and include documentation that the client's condition has observably and significantly improved.

(4) If ((MAA)) the department denies the request for an extension of stay, the client must be transferred to an appropriate lower level of care as described in WAC 388-550-2501(3).

(5) The ((MAA)) department's clinical consultation team approves or denies authorization for acute PM&R services for initial stays or extensions of stay based on individual circumstances and the medical information received. ((MAA)) The department notifies the client and the acute PM&R provider of a decision.

(a) If ((MAA)) the department approves the request for authorization, the notification letter includes:

(i) The number of days requested;

(ii) The allowed dates of service;

(iii) ((An MAA)) A department-assigned authorization number;

(iv) Applicable limitations to the authorized services; and

(v) ((MAA's)) The department's process to request additional services.

(b) If ((MAA)) the department denies the request for authorization, the notification letter includes:

(i) The number of days requested;

(ii) The reason for the denial;

(iii) Alternative services available for the client; and

(iv) The client's right to request a fair hearing. (See subsection (7) of this section.)

(6) A hospital or other facility intending to transfer a client to ((an MAA)) a department-approved acute PM&R ((facility)) hospital, and/or ((an)) a department-approved acute PM&R ((facility)) hospital requesting an extension of stay for a client, must:

(a) Discuss ((MAA's)) the department's authorization decision with the client and/or the client's legal representative; and

(b) Document in the client's medical record that ((MAA's)) the department's decision was discussed with the client and/or the client's legal representative.

(7) A client who does not agree with a decision regarding acute PM&R services has a right to a fair hearing under chapter 388-02 WAC. After receiving a request for a fair hearing, ((MAA)) the department may request additional information from the client and the facility, or both. After ((MAA)) the department reviews the available information, the result may be:

(a) A reversal of the initial ((MAA)) department decision;

(b) Resolution of the client's issue(s); or

(c) A fair hearing conducted per chapter 388-02 WAC.

(8) ((MAA)) The department may authorize administrative day(s) for a client who:

(a) Does not meet requirements described in subsection (3) of this section; or

(b) ((Stays in the facility longer than the "community standards length of stay"; or

(c))) Is waiting for a discharge destination or a discharge plan.

(9) ((MAA)) The department does not authorize acute PM&R services for a client who:

(a) Is deconditioned by a medical illness or by surgery; or

(b) Has loss of function primarily as a result of a psychiatric condition(s); or

(c) Has had a recent surgery and has no complicating neurological deficits. Examples of surgeries that do not qualify a client for inpatient acute PM&R services without extenuating circumstances are:

(i) Single amputation;

(ii) Single extremity surgery; and

(iii) Spine surgery.

[Statutory Authority: RCW 74.08.090, 74.09.520 and 42 C.F.R. 482.56. 03-06-047, 388-550-2561, filed 2/28/03, effective 3/31/03. Statutory Authority: RCW 74.08.090 and 74.09.520. 99-17-111, 388-550-2561, filed 8/18/99, effective 9/18/99.]

Washington State Code Reviser's Office