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Library: Policy

340:100-15-3. Criteria for determining that an individual requires nursing facility services but not specialized services

Issued 6-21-94

(a) In order for the determination to be made that an individual with mental retardation and/or related conditions needs services only available in a nursing facility but does not need specialized services, the individual must:

  • (1) require licensed nursing interventions at least once daily and/or require licensed nursing monitoring and observation on a frequent basis daily for maintenance of health or basic life support; and
  • (2) meets one or more of the following:
    • (A) be in a comatose state;
    • (B) require convalescent care;
    • (C) have a terminal illness;
    • (D) be at least 65 years of age, unless similar aging process characteristics are evident at age 50 and/or;
    • (E) have a serious medical condition which requires on-going medical care and licensed nursing intervention services monitoring, or observation. These conditions include but are not limited to:
      • (i) neurological disorders or malformations which includes muscle wasting diseases that are progressive, dementias, hydrocephalus, meningomyelocele, brain damage secondary to birth trauma, anoxia, cardiac arrest or other causes of cerebral anoxia that are severe enough to induce a comatose state. Cerebral or peripheral nerve damage secondary to central nervous system infection or trauma or other disorders or malfunctions inconsistent with normal functioning.
      • (ii) pulmonary disorder, with either congenital or acquired pulmonary disorders that leave the individual unable to adequately oxygenate (i.e., requiring respiratory support).
      • (iii) cardiac dysfunction or malformation which includes individuals with either congenital or acquired heart disease (i.e., myocarditis) that are in persistent or intractable heart failure, have cardiac rhythms that are life threatening, are persistently cyanotic enough to require supplemental oxygen in order to survive or are otherwise liable to cardiac arrest, either primarily or secondarily. These individuals are identified by a physician as being unable to survive unless immediate skilled medical and nursing intervention is available.
      • (iv) circulatory dysfunction which includes individuals with either hypotension or hypertension with a central or unknown etiology that require frequent licensed nursing intervention and/or monitoring and medication and/or stimulation. It also includes individuals whose orthopedic or postural malformations require meticulous skin care.
      • (v) endocrine or metabolic disorder which includes individuals with hypothyroidism or hyperthyroidism, or diabetes with its associated problems (i.e., circulation, skin care, infection, etc.), aminoaciduria with secondary mental retardation, glycogen storage disease or other abnormalities of lipid metabolism, and other genetic disorders limiting normal metabolism.
      • (vi) gastrointestinal disorder or malfunction which includes individuals with primary or secondary disorders of absorption of normal nutrients and vitamins that will not allow adequate calorie sustenance without supplementation by artificial means, those with congenital malformations of the gastrointestinal tract that require, despite surgical intervention, continuing supplementation with special diets and those whose nutritional requirements cannot be met without intravenous supplementation.
      • (vii) renal and bladder dysfunction or malformation which includes individuals with severe polycystic kidney disease, hydronephrosis, those with kidney failure secondary to either cogenital malformation, trauma or infection requiring frequent intravenous supplementation, and those in whom kidney or bladder malformations require surgical externalization with need for significant nursing and other management.

(b) The individual must be determined by the State Mental Retardation Authority to be unable to benefit from specialized service for mental retardation and/or related conditions.

(c) It remains the responsibility of the nursing facility to provide services to improve the physical, mental, and psychosocial development of the individual.

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