Inspection of Care and Rate Setting Appeal Process

Section 146.1010  Inspection of Care and Rate Setting Appeal Process a)         Inspection of Care Appeal Process 1)         Resident Assessment – A facility may request an appeal of the resident assessment conducted by the Inspection of Care (IOC) team.  Examples of conditions which may be appealed include level of functioning (IQ, results of functional assessments and existence of related conditions), medical add-ons, behavioral add-ons, major life area limitations, special transportation needs, special care nursing and information on the developmental training agency attended.  Differences between the facility and the IOC team regarding the conditions of the residents will be addressed using a three-step approach: A)        exit conference discussion between the facility and the IOC team; B)        informal review involving the Department of Public Health (DPH) regional supervisor and/or central office staff upon request by the facility; and C)        formal review to be heard by the Department of Healthcare and Family Services, Bureau of Long Term Care (BLTC) management. 2)         Incomplete Assessments – In order for an assessment to be appealable, the assessment must be completed prior to the exit conference to be included in the IOC. b)         Examples of Appealable Situations 1)         If the facility believes the surveyor has misinterpreted the regulations, or the facility disagrees with the surveyor's recommendations pertinent to the resident's condition (examples are included in subsection (a)(1)), the facility may request an appeal. 2)         If the facility believes that all assessment data pertinent to the individual's status/condition have not been reviewed, the facility may bring that data to the attention of the surveyor through the appeal process.  Such information must have been part of the resident's record at the time of the assessment to be considered. 3)         The facility has been surveyed because of a 25 percent Medicaid eligible population change, a State Developmental Center admission or because it is a new facility, and there is disagreement with the findings. c)         Process and Time Frames 1)         Exit Conference – At the exit conference, the facility may state the service needs that it disputes.  The facility is responsible for providing supporting data to the IOC team at the exit conference.  When the differences are not reconciled through discussion, the facility may request an appeal.  The facility shall submit the written appeal request stating the service needs in dispute.  The appeal request and the supporting documentation provided by the facility shall be submitted to the IOC regional supervisor (with a copy of the appeal request to DPH's Division of Long Term Care (DLTC) Field Operations) within 14 calendar days after the IOC exit date. 2)         Informal Review – Within 30 calendar days after receipt of the IOC appeal request and supporting documentation, the IOC regional supervisor, the DPH central office staff, or both will review the documentation and either uphold or overturn the surveyor's findings and shall provide written notification of the decision to the facility. 3)         Formal Review – The facility may request a formal review of the informal review decision.  Within ten calendar days after receipt of the decision from the regional supervisor, the facility shall submit a written request for a formal review to the Department of Healthcare and Family Services, Bureau of Long Term Care with a copy to the DLTC Field Operations within DPH. A)        The formal review shall be conducted not more than 30 days after the facility's request for such a review.  Not fewer than 14 days prior to the scheduled review date, the Department of Healthcare and Family Services, Bureau of Long Term Care will notify the facility in writing of the review date, with necessary instructions for the facility to request rescheduling if the date is not feasible for the facility. B)        The Department of Healthcare and Family Services, Bureau of Long Term Care will preside over the formal review.  During the review, DPH representatives shall present the basis for the decision reached at the informal level of the review.  The facility shall present its documentation and BLTC shall apply policy as it relates to the findings under dispute.  BLTC shall send to the facility a written decision rendered as a result of the formal review within ten calendar days after the conclusion of the formal review with a copy to DPH. The decision of BLTC is final. 4)         Continuation of an appeal is contingent upon following the steps and timeframes established in this Section.