400.10 Purpose of the DDPAS-4
The purpose of the DDPAS-4 is to provide a clear and concise summary of the individual's medical diagnoses that includes the date of onset of the individual's medical condition. From this summary, the ISC agency will determine whether the individual requires 24-hour nursing services.
400.20 Required Documentation
In order for the ISC agency to substantiate the determination, the DDPAS-4 must:
- provide a clear and concise justification for the determination as to whether the individual does or does not require 24-hour nursing care.
- An individual does not need nursing care if there is no need for a nurse to be available on a 24-hour basis, as evidenced by all of the following conditions:
- The individual's medical and physical condition are stable.
- The routine nature of the individual's medication, treatment, and care allows implementation by someone other than a nurse, possibly with the supervision of a nurse.
- The individual needs only periodic nursing assistance, monitoring, or treatment which can be provided outside a nursing facility.
- The individual is able to comply with routine physical and medical care.
- An individual with a developmental disability shall be determined (based upon the clinical judgment of the ISC agency) to need a nursing facility level of care if the availability of nursing assessment, monitoring, intervention, and supervision of his or her condition and needs is required on a 24-hour basis. Indicators of the need for nursing facility level of care are any of the following:
- The complexity or instability of the individual's physical and medical condition.
- The need for professional judgment in administering medications, treatment, and care. (Needing prompting for administration of medication would not be sufficient reason to indicate a need for nursing facility level of care).
- The inability to comply with medical care (complex catheter or ostomy care, or complex or non-routine posturing or suctioning).
- The individual could require this level of care if the judgement of a medical professional is required to assist and supervise in any of the following areas. It should not be presumed that the existence of any of the following conditions alone categorically determines the need for nursing facility level of care:
- Care of dressings, decubitus ulcers, complex catheter or ostomy, complex or non-routine posturing or suctioning.
- Monitoring of vital signs, blood chemistry, or urinalysis.
- Special feeding techniques, including tube feeding.
- Intense physical, occupational, or respiratory therapy.
- Administration of medication.
- Administration of intravenous care or other prescribed health care.
- Provide a summary of the individual's medical diagnoses. This summary should include the date of onset of the individual's medical conditions.
Describe what has been done in the past calendar year to address the individual's medical conditions. If necessary, attach supporting documentation to DDPAS-4.
The ISC QIDP's signature represents that the information and data sources are accurately described and the determination is substantiated in the individual's record. Determination and signature by anyone other than a ISC QIDP is invalid.
400.30 Convalescent Care
An individual who is being released from an acute care hospital for a medically prescribed period of recovery, not to exceed 120 days, and who is not a danger to self or others, may be determined to need 24-hour nursing convalescent care.
It is not necessary for the ISC agency to perform a Level II PAS screen on an individual who is transferring to a Nursing Facility (NF) for convalescent care prior to movement to the NF. This directive is based on the belief that the individual is precluded from participating in active treatment because of his/her current and temporary medical condition. The ISC agency must:
- Complete intake for the individual and sign the Interagency Certification of Screening Results (HFS 2536) form, for NF payment. Prior to signing this form, the ISC agency must ensure that the individual is transferring from an acute care hospital for a medically prescribed period of recovery. Clearly indicate on the HFS 2536 that the admission is for a period of convalescent care, not to exceed 120 days.
- Must then monitor the individual's situation at 30-day intervals, or more frequently, if necessary. If the individual is recovering and will return to his or her residence within the 120 days, the ISC need not take further action. If the individual is not recovering, or for any reason cannot return to his or her permanent residence, the ISC agency must initiate and complete a level II assessment in order to secure permanent services by the end of the 120 days.
- Must check the DDPAS-2, Part III, the convalescent care option, along with the date of entry into the nursing facility, until permanent services are arranged.
400.40 Categorical Need for Nursing Facility Level of Care
An individual who is comatose, functioning at the brain stem level, terminally ill with a life expectancy of six months or less (as certified by a physician), or who has a diagnosis of dementia (of any type) shall categorically be determined to need a nursing facility level of care and is considered appropriate for admission to a nursing facility. It is not necessary to consider the need for active treatment when individuals experiencing these conditions are seeking admission to nursing facilities. In such cases, ISC agencies must document the condition on the DDPAS-4. Be certain to include documentation from the physician in the individual's file. Indicate on the DDPAS-5 that active treatment is not needed due to the categorical need for a nursing facility level of care.