Sec. 10.09.93.05. Covered Services

A. Chronic hospitals shall provide the following services:

(1) Complex respiratory care services;

(2) Complex wound care services;

(3) Services for participants with multiple co-morbidities, including but not limited to services necessary to care for:

(a) Ventilator-assisted individuals who have been ventilator dependent for less than 6 months and who need further medical stabilization or are candidates for weaning from ventilator assistance;

(b) Tracheostomy participants who require suctioning more frequently than every 2 hours or are candidates for decannulation;

(c) More than two extensive stage IV decubiti which require daily intensive treatment that is not available in a nursing facility; or

(d) Extensive post-operative or post-traumatic care with multiple drains or extensive dressing change or therapies beyond the capabilities of a nursing facility;

(4) For participants admitted for medically necessary rehabilitation services, physical therapy, occupational therapy, or speech therapy, directed by an interdisciplinary team; and

(5) Ancillary services.

B. Treatment Plan.

(1) Within 24 hours of a participant’s admission, a physician shall perform a documented face-to-face evaluation of the participant and begin developing an individualized treatment plan designed to meet the participant’s assessed needs.

(2) By the 7th day of a participant’s admission, an interdisciplinary team shall establish a written, individualized treatment plan for the participant, which shall include, at a minimum:

(a) Diagnoses;

(b) Treatment goals;

(c) Frequency of interventions for each type of service ordered;

(d) Duration of treatment of each type of service ordered; and

(e) Prognosis.

(3) The physician-led interdisciplinary team shall update the individualized treatment plan weekly until discharge.

C. The Program covers outpatient hospital services provided by a chronic hospital when the services are:

(1) Medically necessary; and

(2) Provided to individuals who are eligible for Medical Assistance and who are not current inpatients at the chronic hospital, except when payment for certain outpatient services provided to a participant on the date of inpatient admission or within 3 calendar days before the date of an inpatient admission are bundled, in accordance with 42 CFR §412.2(c)(5).

D. The program covers the following brain injury community integration program services:

(1) Neuro-behavioral management programming, which includes, but is not limited to:

(a) Assessment of maladaptive behaviors using valid and reliable behavioral measurement tools;

(b) Pharmacologic intervention provided to manage maladaptive behaviors related to brain injury;

(c) Neuro-behavioral programming created, implemented, overseen, and revised as needed;

(d) Incorporation of neuro-behavioral programming into therapy and care for participants in the community integration program; and

(e) Referral to a neuro-psychiatrist, as needed, if a neuro-psychiatrist is not a member of the facility staff;

(2) Cognitive skills adaptation and compensation programming, including:

(a) Specific programming dedicated to cognitive skills adaptation and compensation; and

(b) Incorporation of cognitive compensatory strategies into community integration program participant’s interdisciplinary team treatment;

(3) Community re-entry programming, including specific programming dedicated to social or pragmatic skills, leisure skills, and life skills; and

(4) According to the participant’s needs:

(a) The services of a psychiatrist or psychiatric nurse;

(b) Services and supports related to substance use disorders and other addictions;

(c) Speech therapy, which includes but is not limited to:

(i) Cognitive skills;

(ii) Communication skills;

(iii) Swallowing ability; and

(iv) Linguistic programming that assists the patient to connect the meaning of words to their context;

(d) Occupational therapy, which includes but is not limited to:

(i) Instrumental activities of daily living; and

(ii) Community re-entry activities;

(e) Physical therapy, which includes but is not limited to:

(i) Ambulation; and

(ii) Motor planning and coordination;

(f) Dietary services, which includes but is not limited to nutritional needs assessment and monitoring; and

(g) Case management, which includes but is not limited to:

(i) Treatment planning; and

(ii) Discharge planning.

E. The Program covers administrative days approved by the Department or its designee according to the conditions set forth in Regulation .08C of this chapter.