6509 VENTILATOR CARE

6509.1 In addition to the facility-specific base year per diem rate calculated in accordance with subsection 6508.1 (a) through (c), MAA shall pay an additional per diem amount for any day that a resident qualifies for and receives ventilator care pursuant to the requirements set forth in sections 6509 through 6511.

6509.2 Each resident receiving ventilator care shall meet all of the following requirements:

1. (a) Be ventilator dependent and not able to breathe without mechanical ventilation;
2. (b) Use the ventilator for life support, 16 hours per day, 7 days per week;
3. (c) Have a tracheostomy or endotracheal tube;
4. (d) At the time of placement the resident has been ventilator dependent during a single stay or continuous stay at a hospital, skilled nursing facility or intermediate care facility for the mentally retarded;
5. (e) Have a determination by the resident's physician and respiratory care team that the service is medically necessary, as well as documentation which describes the type of mechanical ventilation, technique and equipment;
6. (f) Be medically stable, without infections or extreme changes in ventilatory settings and/or duration (increase in respiratory rate by 5 breaths per minute, increase in F102 of 25% or more, and/or increase in tidal volume of 200 mls or more) at time of placement;
7. (g) Require services on a daily basis which cannot be provided at a lower level of care; and
8. (h) Require services be provided under the supervision of a licensed health care professional.

6509.3 Each nursing facility shall comply with all of the standards governing ventilator care services set forth in section 3215 of Title 22 DCMR.

6509.4 Ventilator care shall be prior-authorized by the Department of Health, Medical Assistance Administration (MAA). The following documents shall be required for each authorization:

1. (a) Level of Care determination;
2. (b) Pre-admission Screening and Annual Resident Review (PASARR) forms;

(c) Admission history;

(d) Physical examination reports;

(e) Surgical reports; and

(f) Consultation reports and ventilator dependent addendum.

6509.5 For purposes of this section the term "medically necessary" shall mean a service that is required to prevent, identify, or treat a resident's illness, injury or disability and meets the following standards:

(a) Consistency with the resident's symptoms, or with prevention, diagnosis, or treatment of the resident's illness or injury;

(b) Consistency with standards of acceptable quality of care applicable to the type of service, the type of provider, and the setting in which the service is provided;

(c) Appropriateness with regard to generally accepted standards of medical practice;

(d) Is not medically contraindicated with regard to the resident's diagnosis, symptoms, or other medically necessary services being provided to the resident;

(e) Is of proven medical value or usefulness, and is not experimental in nature;

(f) Is not duplicative with respect to other services being provided to the resident;

(g) Is not solely for the convenience of the resident;

(h) Is cost-effective compared to an alternative medically necessary service which is reasonably acceptable to the resident based on coverage determinations; and

(i) Is the most appropriate supply or level of service that can safely and effectively be provided to the resident.

SOURCE: Final Rulemaking published at 53 DCR 1370 (February 24, 2006).