471 Neb. Admin. Code, ch. 12, § 002

Current through June 17, 2024

Section 471-12-002 - DEFINITIONS

The following definitions apply:

002.01ACUTE MEDICAL HOSPITAL. An institution which:

(A) Is licensed or formally approved as a hospital by an officially designated authority for State standard-setting;

(B) Meets the requirements for participation in Medicare as a hospital; and

(C) Has in effect a utilization review plan, applicable to all Medicaid patients, that meets the requirements of 42 Code of Federal Regulations (CFR) 482.30.

002.02ADMISSION. An admission applies to an individual who:

(A) Has never resided in the nursing facility (NF);

(B) Has been formally discharged from one nursing facility (NF) and is being admitted to a different facility; or

(C) Has been formally discharged, return not anticipated from a previous stay, by the admitting facility.

002.03ADVANCE DIRECTIVE. A written instruction, such as a living will or power of attorney for health care, recognized under State law, or as recognized by the courts of the State, that relates to the provision of medical care if the individual becomes incapacitated.

002.04ALLOWABLE COST. Those facility costs which are included in the computation of the facility's per diem. The facility's reported costs may be reduced because they are not allowable under Medicaid or Medicare regulation, or because they are limited under this chapter.

002.05ALTERNATIVE SERVICES. Living arrangements providing less care than nursing facility (NF), intermediate care facility for individuals with developmental disabilities (ICF/DD), institution for mental diseases (IMD), or inpatient psychiatric hospital, and more than independent living, such as adult family home, room and board, or assisted living.

002.06APPROPRIATE. That which best meets the client's needs in the least restrictive setting.

002.07ASSISTED LIVING RATES. Standard rates, single occupancy, rural or urban, per day equivalent, paid under the home and community-based waiver services for aged persons or adults or children with disabilities.

002.08BED HOLDING. Reimbursement made to a facility to hold a bed when a client is hospitalized and return is anticipated or on therapeutic leave.

002.09BEHAVIORAL HEALTH REGIONS (BHR). Community mental health programs divided geographically into mental health regions to organize and facilitate the delivery of community mental health services.

002.10BRAIN INJURY. Any level of injury to the brain often caused by an impact with the skull. Mild symptoms include persistent headaches, mood changes, dizziness, and memory difficulties. Severe head injury symptoms are more obvious: loss of consciousness; loss of physical coordination, speech, and many thinking skills; and substantial changes in personality. A brain injury can be acute, meaning that the injury or insult occurred two years or less from the date of admission to the current extended brain injury rehabilitation program. A brain injury can also be chronic, meaning that the insult or injury that occurred more than two years before admission to the current extended brain injury rehabilitation program as described.

(A)Acquired Brain Injury (ABI): An injury to the brain that has occurred after birth and which may result in mild, moderate, or severe impairments in cognition, speech language communication, memory, attention and concentration, reasoning, abstract thinking, physical functions, psychosocial behavior, or information processing.

(B)Traumatic Brain Injury (TBI): An injury to the brain caused by external physical force and which may produce a diminished or altered state of consciousness resulting in an impairment of cognitive abilities or physical functioning. These impairments may be either temporary or permanent and cause partial or total functional disability or psychological maladjustment.

002.11CATEGORICAL DETERMINATIONS. Advance group determinations under preadmission screening and resident review (PASRR) that take into account that certain situations, diagnoses, or levels of severity of illness clearly indicate that admission to or residence in a nursing facility (NF) is needed, exempting the client from a Level II evaluation for a specified period of time. These determinations must be based on current documentation, such as hospital or physician report.

002.12CENTER FOR PERSONS WITH DEVELOPMENTAL DISABILITIES (CDD). A facility where shelter, food, and care, including habilitation, advice, counseling, diagnosis, treatment, or related services are provided for a period of more than twenty-four consecutive hours to four or more persons residing at such facility who have developmental disabilities.

002.13CERTIFIED FACILITY. A facility which participates in the Medicaid program, whether that entity comprises all or a distinct part of a larger institution.

002.14CIVIL MONEY PENALTY (CMP). A per day or per instance fine imposed against a nursing facility (NF) as a result of a survey deficiency(ies) identified by the Department of Public Health or Centers for Medicare and Medicaid Services (CMS).

002.15COMMUNITY-BASED MENTAL HEALTH SERVICES (CBMHS). An array of mental health services, including residential, day rehabilitation, vocational support, and service coordination.

002.16DEINSTITUTIONALIZATION. The release of institutionalized individuals from institutional care to care in the community.

002.17DEPARTMENT. The Nebraska Department of Health and Human Services.

002.18DEVELOPMENTAL DISABILITY (DD). A severe chronic disability of an individual five years of age or older that is:

(A) Attributable to a mental or physical impairment or combination of mental and physical impairments.

(B) Likely to continue indefinitely.

(C) Manifested before the individual attains age 22.

(D) Is likely to continue indefinitely; results in substantial functional limitations in three or more of the following major life activities:

(i) Self-care;

(ii) Receptive and expressive language;

(iii) Learning;

(iv) Mobility;

(v) Self-direction;

(vi) Capacity for independent living; and

(vii) Economic self-sufficiency.

(E) Reflects the individual's need for a combination and sequence of special, interdisciplinary, or generic services, supports, or other assistance that is lifelong or extended duration and is individually planned and coordinated, except that such term, when applied to infants and young children means individuals from birth to age five, inclusive, who have substantial developmental delay or congenital or acquired conditions with a high probability of resulting in developmental disabilities if services are not provided.

002.19DISCHARGE PLAN. A plan developed by the interdisciplinary team at the time of admission which identifies:

(A) The rationale for the client's current level of care;

(B) The types of services the client would require in an alternate living environment; and (C) The steps to be taken for movement to a less restrictive living environment.

002.20DIVISION. The Division of Medicaid and Long-Term Care.

002.21DUAL DIAGNOSIS. For preadmission screening and resident review (PASRR) purposes, an individual is considered to have a dual diagnosis of serious mental illness and intellectual disability if they have a primary or secondary diagnosis in each category according to the definitions found in this chapter.

002.22FAIR MARKET VALUE. The price that the asset would bring by bona fide bargaining between well-informed buyers and sellers at the date of acquisition.

002.23HOME AND COMMUNITY-BASED WAIVER SERVICES FOR AGED PERSONS OR ADULTS OR CHILDREN WITH DISABILITIES. An array of community-based services available to individuals who are eligible for nursing facility (NF) services under Medicaid but choose to receive services at home. The purpose of the waiver services is to offer options to Medicaid clients who would otherwise require nursing facility (NF) services.

002.24HOSPICE. Hospice or hospice services shall meet the definition in 471 Nebraska Administrative Code (NAC) 36.

002.25IHS NURSING FACILITY (NF) PROVIDER. An Indian Health Services Nursing Facility (NF) or a Tribal Nursing Facility (NF) designated as an Indian Health Services (IHS) provider and funded by the Title I or III of the Indian Self-Determination and Education Assistance Act, Public Law 93-638.

002.26INPATIENT PSYCHIATRIC HOSPITAL. A psychiatric hospital or an inpatient program in a psychiatric facility, either of which is accredited by the Joint Commission on Accreditation of Healthcare Organizations.

002.27INSTITUTION FOR MENTAL DISEASES (IMD). A hospital, nursing facility (NF), or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.

002.28INTELLECTUAL DISABILITY (ID). Significantly sub-average general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period.

002.29SPECIALIZED ADD-ON SERVICES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITY OR A RELATED CONDITION. A continuous program for each individual, which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services, and related services that is directed towards:

(1) The acquisition of the skills necessary for the individual to function with as much self-determination and independence as possible; and

(2) The prevention or deceleration of regression or loss of current optimal functional status.

002.29(A)SPECIALIZED ADD-ON SERVICES. Specialized add-on services do not include services to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous specialized add-on services program. Specialized add-on services may include services provided in an intermediate care facility for individuals with developmental disabilities (ICF/DD) setting or in a community-based developmental disability services (CBDDS) program and are provided for: residents determined to have medical needs which are secondary to developmental or habilitative needs. Specialized add-on service options include:

(i) Assessment or evaluation for alternative communication devices;

(ii) Behavior management program;

(iii) Day program;

(iv) Vocational evaluation;

(v) Psychological or psychiatric evaluation; and

(vi) Stimulation or environmental enhancements or use of assistive devices.

002.30SPECIALIZED ADD-ON SERVICES FOR INDIVIDUALS WITH SERIOUS MENTAL ILLNESS. Services which result in the continuous and aggressive implementation of an individualized plan of care that:

(A) Is developed and supervised by an interdisciplinary team, which includes a physician, qualified mental health professionals, and, as appropriate, other professionals;

(B) Prescribes specific therapies and activities for the treatment of persons experiencing an acute episode of serious mental illness, which necessitates supervision by trained mental health personnel; and

(C) Is directed toward diagnosing and reducing the resident's behavioral symptoms that necessitated institutionalization, improving their level of independent functioning, and achieving a functioning level that permits reduction in the intensity of mental health services to below the level of specialized add-on services at the earliest possible time.

002.31INTERDISCIPLINARY TEAM. A group of persons who meet to identify the needs of the client and develop an integrated comprehensive plan of care to accomplish these needs.

002.32INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD). A facility that:

(A) Meets the standards for licensure as established by the Nebraska Department of Health and Human Services, Division of Public Health (Public Health) and all related requirements for participation as prescribed in federal law and regulations governing medical assistance under Title XIX of the Social Security Act;

(B) Is certified as a Title XIX Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) under Medicaid; and

(C) Has a current provider agreement.

002.33INTERMEDIATE SPECIALIZED SERVICES (ISS) FOR INDIVIDUALS WITH SERIOUS MENTAL ILLNESS. Services necessary to prevent avoidable physical and mental deterioration and to assist clients in obtaining or maintaining their highest practicable level of functional and psycho-social well being. Services are characterized by the client's regular participation, in accordance with his/her comprehensive care plan, in professionally developed and supervised activities, experiences, and therapies and activities, experiences, and therapies that reduce the client's psychiatric and behavioral symptoms, improve the level of independent functioning, and achieve a functional level that permits reduction in the need for intensive mental health services.

002.34LEGAL REPRESENTATIVE. Any person who has been vested by law with the power to act on behalf of an individual. The term includes a guardian appointed by a court of competent jurisdiction in the case of an incompetent individual or minor, or a parent in the case of a minor, or a person acting under a valid power of attorney.

002.35LEVEL OF CARE (LOC) DETERMINATION. Medicaid's nursing facility (NF) screening for medical necessity.

002.36LEVEL I SCREEN. The initial preadmission screening and resident review (PASRR) for all admissions to a Medicaid certified nursing facility (NF). A Level I screen must be completed before an individual is admitted to a nursing facility (NF) to determine whether there is an indication or diagnosis of serious mental illness, intellectual disability or a related condition, or a dual diagnosis.

002.37LEVEL II EVALUATION. The preadmission screening and resident review (PASRR) assessment of any individual who has a diagnosis or indication of serious mental illness, intellectual disability or a related condition, or a dual diagnosis.

002.38MAINTENANCE THERAPY. Therapy to maintain the client at current level or to prevent loss or deterioration of present abilities.

002.39MEDICAID AGED AND DISABLED WAIVER. See 480 NAC 5.

002.40MEDICAID-ELIGIBLE. The status of a client who has been determined to meet established standards to receive benefits of Medicaid.

002.41MEDICARE. The federal health insurance program for persons who are aged or have disabilities under Title XVIII of the Social Security Act.

002.42MEDICARE DISTINCT PART FACILITY. Some facilities have a "distinct part" which participates only in the Medicaid program as a nursing facility (NF) and another "distinct part" which participates only in the Medicare program. In such cases the Medicaid distinct part is subject to the preadmission screening and resident review (PASRR) requirements and the Medicare part is not. If the beds are dually certified as both Medicaid and Medicare, preadmission screening and resident review (PASRR) screening processes are required because of the Medicaid participation. Likewise, a nursing facility (NF) participating solely in the Medicare program as a skilled nursing facility (SNF), with no Medicaid certification, is not subject to Level I or Level II screening through preadmission screening and resident review (PASRR).

002.43MENTAL HEALTH (MH) SERVICES. For purposes of preadmission screening and resident review (PASRR), an array of services that are less intensive than intensive services. Mental health (MH) services may include medication monitoring, counseling and therapy, consultations with a psychiatrist, or mental health interventions. The nursing facility (NF) is responsible for ensuring the provision of mental health services.

002.44MISAPPROPRIATION OF RESIDENT PROPERTY. The deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.

002.45NEBRASKA CASEMIX INTERNET SYSTEM (NCIS). A Nebraska Medicaid webnursing facility (NF) resident assessment and level of care information.

002.46NEUROLOGICAL EXAMINATION. For purposes of preadmission screening and resident review (PASRR), a neurological examination may consist of the following components:

(A) Mental status exam. A mental status exam usually contains the following components:

(i) Appearance - age, grooming, posture, motor activity, and stature, meaning height and weight;

(ii) General behavior - cooperative, withdrawn, apathetic, suspicious, aggressive, compliant, histrionic, anxious, relaxed, or hostile;

(iii) Affect and mood - appropriate, flat, labile, sad, elated, angry, or inappropriate;

(iv) Thought processes - logical, circumstantial, dissociated, obsessive, phobic, suicidal, flight of ideas, or ideas of reference;

(v) Perception - illusions, hallucinations, or delusions; and

(vi) Cognitive Functions - level of awareness, meaning orientation to time, place, and person, attention and concentration, memory both remote and recent, judgment, and insight;

(B) Client's muscle strength and movements;

(C) Pupillary reaction in terms of time and uniformity;

(D) Coordination and balance;

(E) Sensory abilities;

(F) Lumbar and cisternal punctures as needed to detect blockage or central nervous system infection - such as meningitis, syphilis, or multiple sclerosis;

(G) Myelography to diagnose a tumor, herniated disc, or other cause of nerve or spinal cord compression;

(H) Brain scans and computed tomography scans to discover causes of difficulties thought to be of cerebral origin;

(I) Angiography to determine cause of motor weakness, stroke, seizure or intractable headaches;

(J) Electroencephalogram to detect brain tumors, infections, dementias and information concerning the cause and type of seizure disorder; and

(K) Electromyography to assist in diagnosing muscular dystrophy and myasthenia gravis or polyneuropathy.

002.47NURSING FACILITY (NF). A facility, or a distinct part of a facility, that:

(A) Meets the standards for hospital, skilled nursing, or nursing facility (NF) licensure established by Public Health, and all related requirements for participation as prescribed in federal law and regulations governing medical assistance under Title XIX of the Social Security Act;

(B) Is certified as a Title XIX NF under Medicaid. May also be certified as a Title XVIII skilled nursing facility (NF) under Medicare;

(C) Provides 24-hour, seven-day week registered nurse (RN) or licensed practical nurse (LPN) services, meaning full-time registered nurse (RN) on day shift, unless Public Health has issued a staffing waiver; and

(D) Has a current Medicaid provider agreement and a proof of certification on file with the Department.

002.48NURSING FACILITY (NF) QUALITY ASSURANCE FUND. The fund created in Neb. Rev. Stat. § 68-1926 as the repository for provider tax payments remitted by nursing facilities and skilled nursing facilities.

002.49PHYSICIAN'S CERTIFICATION. The physician's determination that the client requires the nursing facility level of care (NF LOC).

002.50PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR). A federal assessment process required of all applicants to and residents of Medicaid certified nursing facilities.

002.51PRIOR AUTHORIZATION. Authorization of payment for certain nursing facility (NF) services based on determination of medical necessity.

002.52PRIVATE PAY. An individual who does not meet the Medicaid eligibility requirements.

002.53PROFESSIONAL SERVICES. Services provided by, or under the direct supervision of professional personnel, including physician services or nursing care by a registered nurse or licensed practical nurse.

002.54PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE). A program that provides comprehensive, coordinated health care and long-term services and supports for voluntarily-enrolled individuals. Program of All-inclusive Care for the Elderly (PACE) provides another alternative along the continuum of available long-term care services and supports to enable participants to continue to live in their homes and communities.

002.55QUALITY ASSURANCE ASSESSMENT. The assessment imposed under the Nursing Facility Quality Assurance Assessment Act in Neb. Rev. Stat. § 68-1917.

002.56RATE DETERMINATION. Per diem rates by the Department. These rates may differ from rates actually paid for nursing facility (NF) services for levels of care 101, 102, 103 and 104, adjusted to include the nursing facility (NF) quality assessment component.

002.57RATE PAYMENT. Per diem rates paid under provisions of this chapter. The payment rate for levels of care 101, 102, 103, 104 and 105 is the applicable rate in effect for assisted living services under the Home and Community-Based Waiver Services for Aged Persons or Adults or Children with Disabilities adjusted to include the nursing facility (NF) quality assurance assessment component.

002.58REHABILITATION. Provision of services to promote restoration of the client to their previous level of functioning.

002.59REHABILITATIVE SERVICES. Services provided by or under the supervision of licensed or certified medical personnel, physical therapist, occupational therapist, respiratory therapist, speech pathologist, and audiologist.

002.60RELATED CONDITION. An individual is considered to have a related condition when the individual has a severe, chronic disability that meets all of the following conditions:

(A) It is attributable to:

(i) Cerebral palsy or epilepsy; or

(ii) Any other condition, other than serious mental illness, found to be closely related to intellectual disability because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with intellectual disability and requires treatment or services similar to those required for these persons.

(B) It is manifested before the person reaches age 22;

(C) It is likely to continue indefinitely;

(D) It results in substantial functional limitations in three or more of the following areas of major life activity:

(i) Self-care;

(ii) Understanding and use of language;

(iii) Learning;

(iv) Mobility;

(v) Self-direction; and

(vi) Capacity for independent living.

002.61REVISIT FEES. Fees charged to health care facilities by the Secretary of Health and Human Services to cover the costs incurred under Department of Health and Human Services, Centers for Medicare and Medicaid Services, Program Management for conducting revisit surveys on health care facilities cited for deficiencies during initial certification, recertification or substantiated complaint surveys.

002.62SIGNIFICANT CHANGE. A significant change is a decline or improvement in a resident's status that:

(A) Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting;

(B) Impacts more than one area of the residents health status; and

(C) Requires interdisciplinary review or revision of the care plan.

002.63SKILLED NURSING FACILITY (SNF), MEDICARE. A facility, or distinct part, that:

(A) Meets the standards for hospital or skilled nursing licensure established by Public Health and all related requirements for participation as prescribed in federal law and regulations governing medical assistance under Title XIX of the Social Security Act;

(B) Is certified as a Title XVIII skilled nursing facility (SNF) under Medicare, may also be certified as a Title XIX nursing facility (NF) under Medicaid.

002.64SPECIALIZED ADD-ON SERVICES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITY OR A RELATED CONDITION. Specialized add-on services are services which result in a continuous, aggressive individualized plan of care and recommended and monitored by the individual's interdisciplinary team (IDT). Specialized add-on services include habilitative services and are not provided by the nursing facility (NF). Habilitative services are medically necessary services intended to assist the individual in obtaining, maintaining, or improving developmental-age appropriate skills not fully acquired as a result of congenital, genetic, or early acquired health condition.

002.65STRAIGHT-LINE METHOD. A depreciation method in which the cost or other basis of the asset, less its estimated salvage value, if any, is determined and the balance of the cost is distributed in equal amounts over the assigned useful life of the asset class.

002.66SUMMARY OF FINDINGS REPORT. The summary and recommendation for services that addresses:

(1) The individual's diagnoses, medical, physical, functional, and psychosocial strengths or needs;

(2) The individual's need for any further evaluation;

(3) Recommendations for treatment or specialized add-on service needs and any referrals determined to be appropriate; and

(4) A summary of the findings.

002.66(A)SUMMARY OF FINDINGS REPORT INFORMATION. The Summary of Findings Report must be based on a compilation of supportive information provided by the facility, physician, mental health reviewer, and qualified intellectual disability professional (QIDP) through the preadmission screening and resident review process (PASRR).

002.67SWING BED. Post-hospital skilled nursing and rehabilitation extended-care services, which must be provided by or under the direct supervision of professional or technical personnel and require skilled knowledge, judgment, observation, and assessment.

002.68SWING BED FACILITY. A rural acute hospital which is certified to provide a skilled nursing facility level of care (NF LOC).

002.69TERMINALLY ILL OR TERMINAL ILLNESS. The client is diagnosed with a medical prognosis that his or her life expectancy is six months or less if the illness runs its normal course.

002.7030-MONTH CHOICE. A choice provided to an individual based on 30 months of continuous residence in a NF from time of admission to nursing facility (NF) care to the date of the Level II evaluation. The resident does not necessarily have to reside in the same nursing facility (NF) to meet the 30-month continuous residency requirement, but must reside in a nursing facility (NF) bed. Temporary absences from a nursing facility (NF) for inpatient hospital treatment for less than six months are not considered a break in residence.

002.71URBAN. Douglas, Lancaster, Sarpy, and Washington Counties.

002.72WAIVERED FACILITY. Facilities for which the State Certification Agency has waived professional nurse staffing requirements are classified as waivered if the total number of waivered days exceeds 90 calendar days at any time during the reporting period.

002.73WEIGHTED RESIDENT DAYS. A facility's inpatient days, as adjusted for the acuity level of the residents in that facility.

471 Neb. Admin. Code, ch. 12, § 002

Amended effective 12/19/2018

Amended effective 6/28/2020

Amended effective 12/23/2020

Amended effective 6/26/2021

Amended effective 6/6/2022