Section 330. Traumatic brain injury diagnoses

Part IV. Traumatic Brain Injury Payment System

A. Consistent with the Nursing Home Payment System, DMAS shall provide a fixed per day payment for nursing facility residents with traumatic brain injury diagnoses. The residents and facilities must meet the criteria set out in this section.

B. Resident criteria. To meet the criteria for admission and continued stay for the TBI program, there shall be documented evidence in the resident's medical record of all of the following:

1. The resident shall meet the minimum nursing facility criteria, as well as meet the preadmission screening requirements for nursing facility level of care as specified in 12VAC30-60-300, Nursing facility criteria;

2. The resident has a physician's diagnosis of TBI which is also recorded on the Patient Intensity Rating System Review (DMAS-80) form by diagnosis code 85000 (trauma to the brain);

3. Abusive, aggressive, or disruptive behavior has been documented within 30 days prior to admission and also recorded on the Patient Intensity Rating System Review (DMAS-80) form by coding of behavior pattern 3 or 4. Behavior coding on the Patient Intensity Rating System Review form must also be supported by documentation in the medical record;

4. The resident is at least 14 years old; and

5. The resident must be appropriate for nursing facility placement and the facility must be able to safeguard him such that the resident will not be a physical or emotional danger to himself or other residents on the unit.

C. Provider criteria. Nursing facilities which may be approved to provide this service shall operate a dedicated unit of 20 beds or more and provide additional professional services to support the special needs of these individuals. These criteria shall concentrate individuals with TBI into specially dedicated facilities thereby satisfying safety concerns and achieving economies of scale necessary for the nursing facilities. At a minimum, the provider shall meet all of the criteria outlined below to receive the add-on reimbursement for the TBI program for residents who meet the TBI program resident criteria.

1. Provide all services that are available to the general nursing facility population in accordance with established standards and regulations for nursing facilities to include programming that is individualized and geared toward the needs and interests of the unit's population;

2. Provide a dedicated unit of at least 20 beds that is physically separated by a doorway that shall be either locked or maintained with an alarm system that sounds at the unit nursing station when opened;

3. Certify all beds on this dedicated unit for licensed nursing facility care. To receive payment the resident must reside in a Medicaid certified bed;

4. Locate at least one nursing station on the unit and that nursing station must serve the dedicated unit only;

5. Maintain a contractual agreement with a physiatrist and a neuropsychologist to serve the resident population as needed;

6. Provide a registered nurse to function in a charge nurse capacity on the unit whose sole responsibility is for the care and oversight of the designated unit. This registered nurse cannot have other responsibilities outside of the unit during the period for which she is designated as the charge nurse for the dedicated unit. The registered nurse working in a charge nurse capacity must have sufficient experience working with the population with head injuries before serving in this capacity. Temporary agency nurses cannot be used to fulfill the charge nurse requirement;

7. Ensure that each resident on the unit is evaluated on an annual basis by a licensed clinical psychologist with expertise in neuropsychology or a neurologist. If a resident is admitted and has not been evaluated by a neuropsychologist or neurologist in the past calendar year, an evaluation must be completed within the first 30 days of the resident's stay in the TBI program; and

8. Coordinate educational services for the resident with the appropriate public school system if the resident has not completed all educational requirements for high school education as specified by the State Board of Education. Coordination is defined as making the necessary contacts and providing necessary information to the appropriate school division. The facility shall keep records of such coordination contacts.

Historical Notes

Derived from Volume 14, Issue 22, eff. August 19, 1998.

Statutory Authority

§ 32.1-325 of the Code of Virginia.