Sec. 10.09.10.26. Selected Costs — Allowable

A. Recreational Services. The allowable costs of recreational services of a facility shall be based on an hourly or salary rate, not on a fee-for-service basis.

B. Over-the-Counter Drugs. The cost of over-the-counter drugs is not to exceed the average wholesale price plus 50 percent, or the usual selling price, whichever is lower.

C. Leave of Absence. The Department shall pay the sum of the rates identified in Regulations .09-.11 of this chapter, less patient resources for the cost of reserving beds for recipients for therapeutic home visits or participation in State-approved therapeutic or rehabilitative programs, subject to the following conditions:

(1) The recipient's plan of care provides for the absence;

(2) The leave of absence does not exceed 18 days during any calendar year;

(3) The recipient's attending physician shall complete the physician's authorization form not more than 30 days before the recipient's anticipated leave of absence; and

(4) The facility submits the physician's authorization form to the Department with the facility's invoice, which covers the month in which the leave of absence occurred.

D. Administrative Days. The Department shall pay the sum of the rates identified in Regulations .09-.11 of this chapter, and 50 percent of the rate identified in Regulation .12 of this chapter, less patient resources for administrative days, documented on forms designated by the Department, which satisfy the following conditions:

(1) The recipient’s required level of care has changed, and the following conditions are met:

(a) The Department or its designee has determined that the recipient’s level of care is provided by an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID);

(b) The provider has implemented a predischarge planning program and initiated placement activities for the recipient at the earliest appropriate time;

(c) The provider has actively pursued placement of the recipient at the required level of care in an appropriate facility during the entire period of administrative days;

(d) The provider has submitted documentation to the Department or its designee that it has complied with the requirements of §D(1)(a)-(c) of this regulation for the entire period of the administrative stay claimed for reimbursement; and

(e) The recipient is transferred promptly to the first available appropriate facility licensed and certified for the required level of care;

(2) When institutional care is no longer appropriate, and the following conditions are met:

(a) The Department or its designee has determined that the recipient no longer requires the level of care, which is provided by a nursing facility or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID);

(b) The provider has implemented a predischarge planning program and initiated placement activities for the recipient at the earliest appropriate time;

(c) The provider has actively pursued placement of the recipient at the required level of care at home or in an appropriate setting during the entire period of administrative days;

(d) The provider has submitted documentation to the Department or its designee that it has complied with the requirements of §D(2)(a)-(c) of this regulation for the entire period of the administrative stay claimed for reimbursement; and

(e) The recipient is transferred promptly after appropriate placement has been found; and

(3) When the recipient is at an inappropriate level of care but cannot be moved, and the following conditions are met:

(a) The attending physician has declared that, because of physical or emotional problems, the recipient is unable to be moved;

(b) The reason the recipient cannot be moved is adequately documented by the attending physician in the recipient's record; and

(c) Reevaluation by the attending physician of the recipient's inability to be moved and appropriate documentation of it in the recipient's record have been made at least every 60 days.

E. Bed Occupancy. The Statewide average occupancy, defined in Regulation .09B(4) of this chapter, shall be calculated after the exclusion of all providers which operated under a waiver of the occupancy standard during any part of the cost report period.

F. A waiver of the occupancy standards defined in Regulation .09B(4) of this chapter may be made by the Department under the following conditions:

(1) During a period not to exceed the first 12 months of operation for a newly constructed facility or for a newly constructed portion of an existing facility;

(2) During periods throughout which the occupancy standard could not be attained due to labor strike, fire, flood, or act of God, when this event is reported to the State licensing authority within 10 days of the event and request for waiver is submitted to the Program within 30 days of the event;

(3) For a period not to exceed 12 months when a voluntary reduction in licensed nursing facility bed capacity has been granted by the Department and the provider has received prior approval from the Program to reduce available beds while renovations are being completed;

(4) For a period not to exceed 12 months after a new provider acquires an existing facility which has been operated by the previous provider below the occupancy standard due to a ban on admissions, and when prior approval for the waiver has been granted by the Program;

(5) For a period not to exceed 12 months after a new provider acquires an existing facility which was in bankruptcy and operated below the occupancy standard at the time of purchase; or

(6) For a period not to exceed 12 months after a new provider has acquired or leased a building that was not licensed as a nursing facility immediately before the provider's acquisition or lease.

G. When a waiver is granted under the provisions of §F(3) of this regulation, the occupancy standards shall be applied to the reduced licensed capacity.

H. A waiver of the occupancy standards defined in Regulation .09B(4) of this chapter may not be allowed due to a ban on admissions or under any circumstances other than those described in §F of this regulation.

I. Rates that are determined in accordance with the provisions of §F of this regulation are effective only for the period during which the waiver of the occupancy standard is in effect.