Section 16.03.10.223 - NURSING FACILITY: CRITERIA FOR DETERMINING NEEDThe participant requires nursing facility level of care when an adult meets one (1) of the Resource Utilization Group (RUG III) classifications or when a child meets one (1) or more of the criteria described in Subsections 223.02, 223.03, 223.04 or 223.05 of this rule. A child is an individual from age zero (0) through eighteen (18) years; an adult is an individual more than eighteen (18) years of age.
01.Required Assessment for Adults. A standard assessment will be approved by the Department for all adults requesting services with requirements for nursing facility level of care. The Department will specify the instrument to be used.02.Supervision Required for Children. Where the inherent complexity of a service prescribed by the physician is such that it can be safely and effectively performed only by or under the supervision of a licensed nurse or licensed physical or occupational therapist.03.Preventing Deterioration for Children. Skilled care is needed to prevent, to the extent possible, deterioration of the child's condition or to sustain current capacities, regardless of the restoration potential of a child, even where full recovery or medical improvement is not possible.04.Specific Needs for Children. When the plan of care, risk factors, and aggregate of health care needs is such that the assessments, interventions, or supervision of the child necessitates the skills of a licensed nurse or a licensed physical therapist or licensed occupational therapist. In such cases, the specific needs or activities must be documented by the physician's orders, progress notes, plan of care, and nursing and therapy notes.05.Nursing Facility Level of Care for Children. Using the criteria found in Subsections 223.02, 223.03, and 223.04 of these rules, plus consideration of the developmental milestones, based on the age of the child, the Department's BLTC will determine nursing facility level of care.06.Conditions of Payment. a. As a condition of payment by the Department for long-term care on behalf of medical assistance participants, each fully licensed long-term care facility is to be under the supervision of an administrator who is currently licensed under the laws of the state of Idaho and in accordance with the rules of the Bureau of Occupational Licenses.b. Payment by the Department for the cost of long-term care excludes the date of the participant's discharge, unless the day of discharge occurs on the same day as admission; then, one (1) day of care is deemed to exist. When a Medicaid patient dies in a nursing home, the date of death is covered, regardless of the time of death.Idaho Admin. Code r. 16.03.10.223