THIS ARTICLE IS INTENDED TO SUPPORT THE READER’S AWARENESS AND UNDERSTANDING. IT IS NOT LEGAL ADVICE. IF THE READER SEEKS LEGAL ADVICE CONCERNING HIS OR HER PARTICULAR SITUATION, HE OR SHE SHOULD SEEK OUT AN ATTORNEY IN A LAWYER CLIENT RELATIONSHIP.
In Pennsylvania, To Be Considered Nursing Facility Clinically Eligible As Is Required For Both Nursing Facility Services And Home and Community Based Pennsylvania Department of Aging ( i.e. PDA HCB ) Waiver Services Payment Under Medical Assistance ( i.e. Medicaid), You Must Show That You Need At Least An Intermediate Level of Health Care And Related Services , Above The Level Of Room And Board , That Is Available On A Continuously 24-hour Basis And , Therefore, Can Only Be Made Available Through , Or Under Waiver Of , Institutional Facility Level Services .
In Pennsylvania, to be considered nursing facility clinically eligible as is required for both nursing facility services and home and community based Pennsylvania Department of Aging ( i.e. PDA HCB ) waiver services payment under Medical Assistance ( i.e. Medicaid), you must show that at least an intermediate level of care is medically needed by the recipient of those services . See (55 Pa. Code § 1181.22; see also 42 U.S.C. 1396n(c) (1) concerning PDA waiver services ( emphasis added) .
A “nursing facility” often is just an intermediate care level provider, as a “nursing facility “ institution need not be an “skilled nursing facility “ institution that is primary engaged in providing skilled nursing care and related services and/or rehabilitation services to a resident. Rather, a “nursing facility” need only provide “on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services (above the level of room and board) which can be made available to them only through institutional facilities, and is not primarily for the care and treatment of mental diseases “ ” See 42 U.S.C. 1396r (a) (1)(C).
Pennsylvania defines an intermediate level of care as “ A level of care provided by a facility that is licensed by the Department of Health to provide intermediate care. Intermediate care shall be ordered by, and provided under the direction of a physician. It is available on a continuous 24-hour basis to a person who does not require the degree of care and treatment provided in a hospital or skilled nursing facility. Because of a mental or physical disability, the person does, however, require nursing and related health and medical services in the context of a planned program of health care and management. ….. See 55 Pa Code 1181.2 Definitions. (emphasis added)
(a) ….the term “nursing facility “ . means an institution (or a distinct part of an institution) which—
(1) is primarily engaged in providing to residents –
(C) on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services (above the level of room and board) which can be made available to them only through institutional facilities, and is not primarily for the care and treatment of mental diseases; See 42 U.S.C. 1396r (a) (1)(C)
(a) Sufficient staff.
(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived …, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.
(b) Registered nurse.
(1) Except when waived …., the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. See 42 CFR § 483.35