ARTICLE 67:54

MEDICAL PROGRAMS ADMINISTERED BY DEPARTMENT OF HUMAN SERVICES

Chapter

67:54:01            Reserved.

67:54:02            Reserved.

67:54:03                   Intermediate care for individuals with intellectual or developmental disabilities.

67:54:04              Home and community-based services.

67:54:05            Nursing facility for individuals with a mental disease.

67:54:06            Assistive daily living services for individuals with quadriplegia.

67:54:07            Traumatic brain injury services.

67:54:08            Treatment for chemical dependency and substance abuse, Repealed.

67:54:09            Family support waiver services.

CHAPTER 67:54:01

RESERVED

CHAPTER 67:54:02

RESERVED

CHAPTER 67:54:03

INTERMEDIATE CARE FOR INDIVIDUALS WITH INTELLECTUAL OR DEVELOPMENTAL DISABILITIES

Section

67:54:03:01                                Definitions.

67:54:03:02                                Eligibility for ICF-IID services.

67:54:03:03                                Criteria for determining developmental disability -- Facility to maintain documentation.

67:54:03:04                                Determination of need for ICF-IID services -- Initial level of care and annual redetermination.

67:54:03:05 and 67:54:03:06     Repealed.

67:54:03:07                                Utilization review.

67:54:03:08                                Payment limits.

67:54:03:09                                Payments for reserved bed days.

67:54:03:10                                Application of other rules.

67:54:03:11 and 67:54:03:12     Repealed.

Appendix A  Criteria for Inventory for Client and Agency Planning (ICAP).

DEPARTMENT OF SOCIAL SERVICES

MEDICAL PROGRAMS ADMINISTERED BY DEPARTMENT OF HUMAN SERVICES

(ICF-MR/DD)

CRITERIA FOR INVENTORY FOR CLIENT AND AGENCY PLANNING (ICAP)

Chapter 67:54:03

APPENDIX A

SEE: §§ 67:54:03:05 and 67:54:04:06

          Source: 21 SDR 34, effective August 29, 1994.

APPENDIX A

CRITERIA FOR INVENTORY FOR CLIENT AND AGENCY PLANNING (ICAP)

          67:54:03:10.  Application of other rules. Unless otherwise specified, the following chapters apply to this chapter:

          (1)  Chapter 67:16:26 -- Third-party liability;

          (2)  Chapter 67:16:33 -- Provider enrollment;

          (3)  Chapter 67:16:34 -- Records; and

          (4)  Chapter 67:16:35 -- Claims.

          Source: 18 SDR 224, effective July 13, 1992.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

CHAPTER 67:54:04

HOME AND COMMUNITY-BASED SERVICES

Section

67:54:04:01                                Definitions.

67:54:04:02                                Long-term care requirements apply to HCBS.

67:54:04:03                                Financial eligibility requirements.

67:54:04:03.01                           Notification of eligibility.

67:54:04:04                                General eligibility -- Ineligible if SSI disability benefits denied.

67:54:04:05                                Criteria for determining developmental disabilities -- Documentation required.

67:54:04:06                                Preplacement assessment.

67:54:04:07 and 67:54:04:08     Repealed.

67:54:04:09                                Residential limitations on eligibility.

67:54:04:10                                Individual service plan.

67:54:04:11                                Parent's income and resources.

67:54:04:12                                Determining amount of HCBS assistance.

67:54:04:13                                Repealed.

67:54:04:14                                Covered services.

67:54:04:15 to 67:54:04:17       Repealed.

67:54:04:18                                Initial level of care.

67:54:04:18.01                           Redetermination of level of care.

67:54:04:19                                Conditions of provider participation -- Certification -- Agreement.

67:54:04:20 and 67:54:04:21     Repealed.

67:54:04:22                                Extent of payment.

67:54:04:23                                Payments during temporary absences.

67:54:04:24                                Basis of payment.

67:54:04:25                                Utilization review.

67:54:04:26                                Application of other chapters.

67:54:04:27                                Right to request a fair hearing.

          67:54:04:02.  Long-term care requirements apply to HCBS. All provisions of chapters 67:16:01 and 67:46:02 to 67:46:06, inclusive, and 67:46:08 apply to HCBS unless otherwise specified in this chapter.

          Source: 10 SDR 79, effective February 1, 1984; transferred from § 67:16:27:02, effective August 23, 1992.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

    67:54:04:06.  Preplacement assessment. Before home and community-based services (HCBS) are approved for an individual, the proposed HCBS provider shall complete an Integrated Case-Based Applied Pathology (ICAP). The ICAP must indicate a substantial functional limitation, in at least three of the seven areas listed in § 67:54:03:04. The proposed HCBS provider shall submit the ICAP to the Division of Developmental Disabilities, Department of Human Services, using the ICAP Compuscore software. The provider shall submit this data to the division upon the initiation of HCBS annually on January 15^th, and as changes occur. For an individual's record to be valid, the evaluation date may not be more than 13 months old.

    No deficit exists if the following criteria are met:

    (1)  Self care: The personal living skills domain score exceeds the age-related criterion in Appendix A at the end of chapter 67:54:03 and, in the case of an individual who is four years of age or older, there are no arm or hand limitations in daily activities;

    (2)  Language: The social and communication skills domain score exceeds the age-related criterion in Appendix A at the end of chapter 67:54:03 and, in the case of an individual who is four years or age or older, the individual is able to speak;

    (3)  Learning/cognition: The individual does not have an intellectual disability;

    (4)  Mobility: The individual is able to walk and, in the case of an individual who is four years of age or older, no mobility assistance is needed;

    (5)  Self-direction: The general maladaptive index is in the normal range , the individual's community living skills domain score exceeds the age-related criterion in Appendix A at the end of chapter 67:54:03, and there is no psychiatric diagnosis;

    (6)  Independent living: The individual's community living skills domain score exceeds the age-related criterion in Appendix A at the end of chapter 67:54:03 and, in the case of an individual who is 18 years of age or older, the recommended residential placement is "independent in own home or rental unit"; and

    (7)  Economic self-sufficiency: The individual's recommended daytime program is "competitive employment."

    A substantial functional limitation is present if the preceding criteria are not met.

    Source: 10 SDR 79, effective February 1, 1984; 15 SDR 154, effective April 9, 1989; transferred from § 67:16:27:06, effective August 23, 1992; 21 SDR 34, effective August 29, 1994; 22 SDR 188, effective July 8, 1996; 26 SDR 150, effective May 21, 2000; SL 2013, ch 128, § 4, effective July 1, 2013; 40 SDR 122, effective January 8, 2014; 45 SDR 82, effective December 10, 2018; 49 SDR 21, effective September 12, 2022.

    General Authority: SDCL 28-6-1.

    Law Implemented: SDCL 28-6-1(1)(4)(6).

    Reference: Inventory for Client and Agency Planning (ICAP), 1986, published by Riverside Publishing Company, 425 Spring Lake, Itasca, Illinois 60134-2079; 25 response booklets $45.

          67:54:04:11.  Parent's income and resources. The income and resources of the parents or guardians of children receiving assistance from school districts or the state section for special education may not be considered when determining the child's eligibility or when budgeting for HCBS.

          Source: 10 SDR 79, effective February 1, 1984; transferred from § 67:16:27:11, effective August 23, 1992.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          Cross-References:

          Long-term care eligibility, ch 67:46:03.

          Long-term care income requirements, ch 67:46:04.

          Determining amount of HCBS assistance, § 67:54:04:12.

          67:54:04:19.  Conditions of provider participation -- Certification -- Agreement. To participate in the delivery of HCBS, providers shall be approved by the Department of Human Services according to article 46:11. Providers shall have a signed provider agreement with the Department of Human Services and the Department of Social Services. These agreements must be renewed annually.

          Source: 10 SDR 79, effective February 1, 1984; 12 SDR 151, effective March 16, 1986; transferred from § 67:16:27:16, effective August 23, 1992; 26 SDR 150, effective May 21, 2000.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:04:20.  Agreement to provide services -- Limit on number of clients. Repealed.

          Source: 10 SDR 79, effective February 1, 1984; repealed, 12 SDR 151, March 16, 1986; readopted, 15 SDR 154, effective April 9, 1989; transferred from § 67:16:27:17, effective August 23, 1992; repealed, 26 SDR 150, effective May 21, 2000.

          67:54:04:21.  Required financial reports. Repealed.

          Source: 10 SDR 79, effective February 1, 1984; transferred from § 67:16:27:18, effective August 23, 1992; repealed, 26 SDR 150, effective May 21, 2000.

          67:54:04:26.  Application of other chapters. In addition to the rules contained in this chapter, providers and recipients must meet the requirements of chapters 67:16:01, 67:16:26, 67:16:33, 67:16:34, and 67:16:35.

          Source: 17 SDR 184, effective June 6, 1991; transferred from § 67:16:27:23, effective August 23, 1992.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

CHAPTER 67:54:05

NURSING FACILITY FOR INDIVIDUALS WITH A MENTAL DISEASE

Section

67:54:05:01        Definitions.

67:54:05:02        Eligibility for medical assistance.

67:54:05:03        Criteria used to determine existence of mental disease.

67:54:05:04        Determination of need for nursing facility care.

67:54:05:05        Determination of need for specialized psychiatric services.

67:54:05:06        Services not covered in nursing facility for individual with mental disease.

67:54:05:07        Utilization review.

67:54:05:08        Payment limits.

67:54:05:09        Application of other rules.

67:54:05:10        Claim requirements.

          67:54:05:01.  Definitions. Terms used in this chapter mean:

          (1)  "Interdisciplinary team," a team under the auspices of a nursing home or the Department of Human Services which consists of a physician who is either a psychiatrist or is supervised by a psychiatrist, a qualified mental health professional, and other professionals, as appropriate, which prepares a plan of care for an individual admitted to a nursing facility for individuals with a mental disease;

          (2)  "Mental disease," the verifiable existence and manifested persistence of a severe mental illness as defined in SDCL 27A-1-1, which requires specialized psychiatric services beyond monitoring of psychotropic medication;

          (3)  "Nursing facility for individuals with mental disease," a facility licensed as a nursing home by the Department of Health which is maintained and operated for the express or implied purpose of providing care for individuals with mental disease who require specialized psychiatric services and professional nursing care under the direction of a physician 24 hours a day;

          (4)  "Plan of care," the individual treatment plan developed and supervised by an interdisciplinary team which is designed to obtain improvement in the individual's functioning and alleviate the need for specialized psychiatric services at the earliest possible time;

          (5)  "Specialized psychiatric services," continuous and aggressive therapies and activities which direct and reduce behavior symptoms, improve an individual's level of functioning, are contained in an individual's plan of care, and require supervision of a psychiatrist for the treatment of an acute episode of a severe mental illness;

          (6)  "Utilization control team," a team under the auspices of the Department of Human Services which consists of a qualified mental health professional as defined in SDCL 27A-1-3 and a registered nurse.

          Source: 20 SDR 170, effective April 18, 1994.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:05:02.  Eligibility for medical assistance. An individual with a mental disease is eligible for medical assistance if the following criteria are met:

          (1)  The individual is eligible for Medicaid under article 67:46;

          (2)  The service is a covered Medicaid service under article 67:16;

          (3)  The utilization control team has determined that the individual has a severe mental illness and requires care in a nursing facility for individuals with a mental disease;

          (4)  The annual redetermination of the need for continued care, if applicable, is current; and

          (5)  The facility meets the individual's needs.

          Source: 20 SDR 170, effective April 18, 1994.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:05:03.  Criteria used to determine existence of mental disease. The utilization control team shall determine an individual's need for specialized psychiatric services based on a psychiatric evaluation that verifies the existence and manifested persistence of a severe mental illness which requires specialized psychiatric treatment beyond monitoring of psychotropic medication.

          Source: 20 SDR 170, effective April 18, 1994.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          Cross-Reference: Definition of "severe mental illness," SDCL 27A-1-1.

          67:54:05:04.  Determination of need for nursing facility care. The utilization control team shall establish an individual's need for nursing facility care by reviewing the individual's medical, nursing, social, and mental health needs. The individual must require professional nursing services in addition to the provision of or assistance with personal care activities or medications.

          The utilization control team shall, at least annually, redetermine whether or not the individual continues to need nursing facility care for a mental disease.

          Source: 20 SDR 170, effective April 18, 1994.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:05:05.  Determination of need for specialized psychiatric services. The utilization control team shall determine the individual's need for specialized psychiatric services. The determination must be based on the following criteria:

          (1)  A comprehensive history and physical examination of the person, including a complete medical history, a review of all body systems, and a specific evaluation of the person's neurological system in the areas of motor function, sensory functioning, gait, deep tendon reflexes, cranial nerves, and abnormal reflexes and, in the case of abnormal findings which are the basis for the determination of the need for nursing facility placement, additional evaluations conducted by appropriate specialists;

          (2)  A comprehensive drug history including current or immediate past use of medications that could mask symptoms or mimic mental illness;

          (3)  A psychosocial evaluation of the person, including current living arrangements and medical and support systems;

          (4)  A comprehensive psychiatric evaluation including a complete psychiatric history; evaluation of intellectual and memory functioning; orientation; description of current attitudes and affect; overt behaviors; suicidal or homicidal ideation; paranoia, degree of reality testing, presence and content of delusions, and hallucinations; and

          (5)  A functional assessment of the individual's ability to engage in activities of daily living and the level of support that would be needed to assist the individual to perform these activities while living in the community. The assessment shall indicate whether this level of support can be provided to the individual in an alternative community setting or whether the level of support needed is such that nursing facility placement is required. The functional assessment must address self-monitoring of health status, self-administering and scheduling of medical treatment, including medication compliance, self-monitoring of nutritional status, handling money, dressing appropriately, and grooming.

          Source: 20 SDR 170, effective April 18, 1994.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:05:06.  Services not covered in nursing facility for individual with mental disease. The following services are not covered in a nursing facility for an individual with a mental disease:

          (1)  Rehabilitation treatment for alcoholism or drug addiction;

          (2)  Counseling for alcoholism or drug addition;

          (3)  Detoxification for alcoholism or drug addiction;

          (4)  Alcohol or drug abuse prevention programs; and

          (5)  Initial psychiatric evaluation.

          Source: 20 SDR 170, effective April 18, 1994.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:05:07.  Utilization review. Services provided under this chapter are subject to utilization review on the following four levels:

          (1)  At the time of the admission;

          (2)  During claims processing;

          (3)  At the annual redetermination review; and

          (4)  After payment.

          Source: 20 SDR 170, effective April 18, 1994.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:05:08.  Payment limits. Payment to a facility is made for resident days only. Resident days include the day of admission but exclude the day of discharge.

          No payment may be made to a facility owned by the state for reserving a bed during a resident's absence.

          No payment may be made to a facility until the psychiatric evaluation required in § 67:54:05:03 has been completed.

          Source: 20 SDR 170, effective April 18, 1994.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:05:09.  Application of other rules. Unless otherwise specified, the following chapters apply to this chapter:

          (1)  Chapter 67:16:01 -- General provisions;

          (2)  Chapter 67:16:26 -- Third-party liability;

          (3)  Chapter 67:16:33 -- Provider enrollment;

          (4)  Chapter 67:16:34 -- Records; and

          (5)  Chapter 67:16:35 -- Claims.

          Source: 20 SDR 170, effective April 18, 1994.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:05:10.  Claim requirements. Each month the Department of Social Services shall send a two-part claim form (nursing home request for payment) to the provider. The first part contains a list of the recipients who were present at the provider's facility during the last billing period. The provider must complete the second part by correcting any errors or changes in the list in the first part and adding information on the new residents.

          The provider or the provider's authorized agent must sign and date the form even if there are no changes or additions and return the form to the Department of Social Services. The completed form must contain each recipient's full name, recipient's identification number, date of service, credit amount, level of care, and status. The provider must use one of the following codes to indicate the individual's status:

          (1)  0 - reserved bed days;

          (2)  1 - transferred to a hospital;

          (3)  2 - transferred to another nursing facility;

          (4)  4 - reserved bed days - individual died;

          (5)  5 - discharged to home for self-care;

          (6)  6 - discharged to home under home health agency care;

          (7)  7 - left against advice;

          (8)  8 - died;

          (9)  9 - individual on therapeutic leave; or

          (10)  Blank - individual remains in care.

          If the claim is being submitted to adjust or void a previously submitted claim, the provider must include the reference number of the claim being adjusted or voided.

          Source: 20 SDR 170, effective April 18, 1994.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

CHAPTER 67:54:06

ASSISTIVE DAILY LIVING SERVICES FOR INDIVIDUALS WITH QUADRIPLEGIA

Section

67:54:06:01        Definitions.

67:54:06:02        Eligibility -- Individual.

67:54:06:03        Individual to select provider agency.

67:54:06:04        Eligibility -- Provider agency.

67:54:06:05        Provider agency to assign case manager -- Preparation of assessment and case service plan.

67:54:06:06        Qualifications of case manager.

67:54:06:07        Covered services -- Case management.

67:54:06:08        Qualifications of personal attendant.

67:54:06:09        Covered services -- Personal attendant.

67:54:06:09.01   Services not covered.

67:54:06:10        Qualifications and duties of consumer preparation specialist.

67:54:06:11        Covered services -- Consumer preparation specialist.

67:54:06:11.01   Ancillary services.

67:54:06:11.02   Ancillary services -- Private duty nursing -- Limits.

67:54:06:12        Department of Human Services to determine level of care.

67:54:06:13        Payment, procedure codes, and limits for covered services.

67:54:06:14        Basis of payment.

67:54:06:15        Billing requirements.

67:54:06:16        Claim requirements.

67:54:06:17        Cost of service not to exceed cost of institutional care.

67:54:06:18        Provider agency may terminate services.

67:54:06:18.01   Provider agency may terminate services -- Notice -- Exception.

67:54:06:19        Notice of adverse action.

67:54:06:19.01   Conference with staff from Department of Human Services or Department of Social Services.

67:54:06:20        Record retention.

67:54:06:21        Access to records.

67:54:06:22        Annual review.

          67:54:06:01.  Definitions. Terms used in this chapter mean:

          (1)  "Ancillary services," services or equipment that supplement the direct care services provided under this chapter;

          (2)  "Assistive daily living services," services of a personal attendant, case management and consumer preparation services, and ancillary services performed on behalf of and at the request of an individual with quadriplegia to allow the individual to remain in the individual's own home;

          (3)  "Case management," services designed to monitor and assist a consumer gain access to services contained in the case service plan;

          (4)  "Client" or "consumer," an individual with quadriplegia who is receiving assistance under the provisions of this chapter;

          (5)  "Consumer preparation," services designed to train the consumer in areas such as medical self-care, activities of daily living, time management, and management of a personal attendant;

          (6)  "Emergency response device," a device that links an individual living at home to an individual who will respond in the event of an emergency;

          (7)  "Independently direct and manage," the ability to recruit, screen, interview, select, schedule, train, supervise, arrange for emergency coverage, determine the attendant's competency to perform the needed services, direct the attendant to do the task, resolve conflict, and, if necessary, terminate the attendant if the conflict cannot be resolved, all with only a minimal amount of assistance or direction from or collaboration with the provider agency;

          (8)  "Personal attendant," an individual who completes tasks on behalf of an individual with quadriplegia or assists an individual with quadriplegia in the completion of a task when the individual with quadriplegia is unable to do the task or to do the task would take an exceptionally long time to complete alone;

          (9)  "Private duty nursing," temporary nursing services prescribed by a physician and provided by a nurse who holds a current license under the provisions of SDCL chapter 36-9;

          (10)  "Unit," a 15-minute measurement of time or fraction thereof; and

          (11)  "Utilization review team" or "URT," a team employed by the Department of Human Services that consists of a registered nurse, a physician, and an employee of the Department of Human Services.

          Source: 21 SDR 230, effective July 13, 1995; 26 SDR 99, effective January 30, 2000.

          General Authority: SDCL 28-6-1(4).

          Law Implemented: SDCL 28-6-1(4).

          67:54:06:02.  Eligibility -- Individual. An individual must meet the following requirements to be eligible to receive services under this chapter:

          (1)  Must be receiving personal attendant, case management, consumer preparation, or ancillary services;

          (2)  Must be at least 18 years old;

          (3)  Must have quadriplegia due to or resulting from ataxia, cerebral palsy, rheumatoid arthritis, muscular dystrophy, multiple sclerosis, traumatic brain injury, a congenital condition, an accident or injury to the spinal cord, or another neuromuscular or cerebral condition or disease other than traumatic brain injury; or the individual has four limbs absent due to disease, trauma, or congenital conditions;

          (4)  Must require a nursing facility level of care;

          (5)  Must have a service plan prepared under the provisions of § 67:54:06:05 that requires one or more of the services provided under this chapter;

          (6)  Must be a recipient of SSI or must qualify for Medicaid as determined by the Department of Social Services under article 67:46 except for residing in a long-term care facility;

          (7)  If receiving personal attendant services, must be able to independently direct and manage the needed personal attendant services;

          (8)  Must be medically stable and free from life-threatening conditions as determined by the individual's personal physician.

          Source: 21 SDR 230, effective July 13, 1995; 26 SDR 99, effective January 30, 2000.

          General Authority: SDCL 28-6-1(6).

          Law Implemented: SDCL 28-6-1(6).

          Cross-References:

          Medical review team -- Level of care, ch 67:45:01.

          Agency to assign case manager -- Preparation of assessment and case service plan, § 67:54:06:05.

          Ineligibility when income exceeds 300 percent of the maximum SSI standard, § 67:46:04:14.

          Eligibility starting date, § 67:46:01:03.

          67:54:06:03.  Individual to select provider agency. The Department of Human Services shall provide an individual desiring assistive daily living services with a list of provider agencies. The individual must select a service provider agency from the list and must apply directly to the selected agency for services.

          For purposes of service delivery, each provider agency must maintain the following directories:

          (1)  Attendants who meet the requirements of § 67:54:06:08, are available to provide services, and have requested to have their names placed into the directory;

          (2)  Home health agencies available in the consumer's area that have an agreement with the Department of Social Services to provide private duty nursing services under the provisions of chapter 67:16:05;

          (3)  Companies that have an agreement with the Department of Social Services to supply an emergency response device that meets the consumer's needs.

          The consumer must independently select a personal attendant from the agency's list of available attendants. If the agency has no attendants available to provide the needed services, the consumer may need to independently recruit, interview, and select a personal attendant. The consumer must submit the name of the selected attendant to the provider agency for review and approval.

          The provider agency must reimburse the consumer for the consumer's actual out-of-pocket expenses incurred while recruiting, interviewing, and selecting a personal attendant who is placed on the provider agency's attendant list. The consumer must have approval from the provider agency before incurring the expenditure.

          Source: 21 SDR 230, effective July 13, 1995; 26 SDR 99, effective January 30, 2000.

          General Authority: SDCL 28-6-1(4).

          Law Implemented: SDCL 28-6-1(4).

          67:54:06:04.  Eligibility -- Provider agency. To be eligible to receive reimbursements for services provided under this chapter, a provider agency must meet the following requirements:

          (1)  Must have experience in delivering services to individuals with severe disabilities;

          (2)  Must have a process for gathering consumer input;

          (3)  Must have a contract with the Department of Human Services to provide assistive daily living services;

          (4)  Must be a Medicaid provider and have a signed provider agreement with the Department of Social Services;

          (5)  Must have available the following array of services:

               (a)  Personal attendant services;

               (b)  Case management services;

               (c)  Consumer preparation services; and

               (d)  Ancillary services;

          (6)  Must ensure a choice of providers by either employing individuals who are qualified to provide the assistive daily living services contained in a consumer's case service plan or maintaining directories of qualified service providers; and

          (7)  Must have a grievance procedure in place under which a consumer may appeal to the provider agency any decision or action by the service provider or the provider agency that adversely affects the consumer. The procedure must be in writing and the provider agency must provide the consumer with a copy of the grievance procedure at the time services begin and must assist the consumer in submitting a grievance, if requested. If a written document of the procedure is not an appropriate format for the consumer involved, the provider agency must also provide the information to the consumer in a format that is appropriate for the consumer. For purposes of this subdivision, a provider agency may limit its assistance to referral of the consumer to another agency, organization, or individual that can advocate for or represent the consumer during the grievance process.

          Source: 21 SDR 230, effective July 13, 1995; 26 SDR 99, effective January 30, 2000; 30 SDR 135, effective March 16, 2004.

          General Authority: SDCL 28-6-1(2).

          Law Implemented: SDCL 28-6-1(2).

          Cross-Reference: Provider requirements, ch 67:16:33.

          67:54:06:05.  Provider agency to assign case manager -- Preparation of assessment and case service plan. Within 10 days after the individual requests services from a provider agency, the agency must assign a case manager. The case manager must assess the individual's cognitive, mental, and physical functioning capabilities within 45 days to determine whether the individual is appropriate for assistive daily living services.

          If determined appropriate, the case manager together with the client shall prepare the assessment and service plan. At a minimum, the service plan must contain the types of services to be furnished; the amount, frequency, and duration of each service; and the type of provider to furnish each service. The case service plan must be reviewed and approved by the client's personal physician. As evidence of approval, the client's physician must sign and date the client assessment and service plan. The case manager must forward copies of the completed client assessment and service plan to the Department of Human Services.

          The case manager is responsible for ongoing monitoring of the services included in the client's assessment and service plan. Additionally, case managers must initiate and oversee the process of assessment and reassessment of the client's level of care. The case manager must prepare a new assessment and service plan at least annually.

          Source: 21 SDR 230, effective July 13, 1995.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:06:06.  Qualifications of case manager. A provider agency's case manager must meet the following qualifications:

          (1)  Must be employed by a provider agency;

          (2)  Must have a minimum of one year experience working with individuals having severe disabilities, with experience working with individuals with quadriplegia preferred;

          (3)  Must be trained by the provider agency in case management; and

          (4)  Must be able to provide the services listed in § 67:54:06:07.

          Source: 21 SDR 230, effective July 13, 1995; 30 SDR 135, effective March 16, 2004.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:06:07.  Covered services -- Case management. Covered case management services include the following:

          (1)  Determining the consumer's level of functioning, including an assessment of the consumer's knowledge of service needs, appropriate procedures and practices needed to address those needs, the ability to effectively communicate those needs, and the ability to effectively and independently direct and manage the services of a personal attendant on a daily basis;

          (2)  Determining whether the consumer is in need of personal attendant, consumer preparation, or ancillary services;

          (3)  Identifying resources currently being utilized to meet the consumer's identified needs and locate and facilitate the use of community resources needed to meet the identified needs;

          (4)  Informing the consumer about how the provider agency documents the consumer's competency to independently direct and manage a personal attendant;

          (5)  Working directly with the consumer to develop and implement an individual service plan;

          (6)  Estimating the cost of the planned services;

          (7)  Monitoring the provision of services and reviewing the consumer's service plan following the initial six-month period and at least once every 12 months thereafter unless more frequent contact is indicated or if requested by the consumer. The case manager must monitor the consumer's assessment and service plan for continuity of services, changes in the consumer's functioning, appropriateness of care, and quality of the services provided; and

          (8)  Monitoring the service costs to assure continued cost effectiveness is maintained.

          Source: 21 SDR 230, effective July 13, 1995; 26 SDR 99, effective January 30, 2000; 30 SDR 135, effective March 16, 2004.

          General Authority: SDCL 28-6-1(1).

          Law Implemented: SDCL 28-6-1(1).

          67:54:06:08.  Qualifications of personal attendant. A personal attendant must have completed a basic nurse aide or home health aide training course, as evidenced by a certificate of completion signed by the director of the training program, provided the trainee also received training in disability awareness and in the philosophy of consumer direction; a personal attendant training program supervised by a registered nurse at an approved agency, as evidenced by a certificate of completion signed by the director of the training program; or a personal attendant competency assessment as evidenced by a certificate of competency signed by a licensed nurse, a physician, or the consumer.

          The provider agency must maintain a copy of the signed certificate in the personal attendant's personnel file. If the personal attendant is certified through a personal attendant competency assessment and provides services for more than one individual, there must be a separate certification for each individual served. In addition, the personal attendant must meet the following qualifications:

          (1)  Must be employed by a provider agency that has a contract with the Department of Human Services  to provide assistive daily living services;

          (2)  Must produce proof of having a social security number;

          (3)  Must be able to read, write, and communicate;

          (4)  During the last three years, may not have on record a conviction for an offense that would directly affect the individual's fitness to be a personal attendant. For purposes of this subdivision, the provider agency must develop and use a system for screening each applicant and for including the consumer in the screening process;

          (5)  May not have an infectious or contagious disease or condition which results in a medical condition that is prolonged or potentially life-threatening;

          (6)  Must be capable of performing the needed services;

          (7)  Must be capable of maintaining confidentiality; and

          (8)  Must have demonstrated competency to perform the duties contained in § 67:54:06:09.

          A consumer's spouse, parent, or adult child may receive reimbursement for providing personal attendant services if the requirements of this chapter are met.

          Source: 21 SDR 230, effective July 13, 1995; 26 SDR 99, effective January 30, 2000.

          General Authority: SDCL 28-6-1(4).

          Law Implemented: SDCL 28-6-1(4).

          67:54:06:09.  Covered services -- Personal attendant. Covered services of a personal attendant are those services listed in the case service plan which include services such as the following:

          (1)  Practicing infection control methods;

          (2)  Handling and disposing of body fluids;

          (3)  Bathing techniques including bed, tub, and shower;

          (4)  Caring for hair, including shaving;

          (5)  Maintaining oral hygiene, including brushing teeth and cleaning dentures;

          (6)  Dressing and undressing a consumer;

          (7)  Assisting with toileting;

          (8)  Caring for a consumer who is incontinent;

          (9)  Feeding or assisting a consumer with eating, unless there is another person in the home who is able to perform the task;

          (10)  Planning and preparing meals including shopping for and purchasing food, unless there is another person in the home who is able to perform the task;

          (11)  Performing routine eye care;

          (12)  Taking a consumer's temperature;

          (13)  Caring of nails and feet;

          (14)  Applying an ace wrap and anti-embolic stockings;

          (15)  Assisting the consumer apply or remove a prosthesis or orthotic;

          (16)  Assisting a consumer with self-administration of medications;

          (17)  Changing dressings on noninfected sores;

          (18)  Caring for skin including giving back rubs;

          (19)  Turning and positioning the consumer in bed;

          (20)  Transferring the consumer;

          (21)  Maintaining the consumer's home in a clean and safe condition, unless there is another person in the home who is able to perform the task;

          (22)  Making a wrinkle-free bed, unless there is another person in the home who is able to perform the task;

          (23)  Laundering and mending clothes, unless there is another person in the home who is able to perform the task;

          (24)  Assisting the consumer with paying bills, balancing a checkbook, and managing a home budget, unless there is another person in the home who is able to perform the task;

          (25)  Performing range of motion exercises designed for the specific consumer;

          (26)  Performing routine ostomy care;

          (27)  Assisting with a bladder and bowel program;

          (28)  Assisting the consumer into and out of a vehicle;

          (29)  Providing ventilator management if the personal attendant is a family member. A consumer who was receiving ventilator management by someone other than a family member before the effective date of this rule change is not affected by this change;

          (30)  Performing tracheostomy care if the personal attendant is a family member. A consumer who was receiving tracheostomy care by someone other than a family member before the effective date of this rule change is not affected by this change;

          (31)  Providing chest physiotherapy;

          (32)  Providing nebulizer therapy; and

          (33)  Applying topical medications.

          Source: 21 SDR 230, effective July 13, 1995; 26 SDR 99, effective January 30, 2000; 30 SDR 135, effective March 16, 2004.

          General Authority: SDCL 28-6-1(1).

          Law Implemented: SDCL 28-6-1(1).

          67:54:06:10.  Qualifications and duties of consumer preparation specialist. A provider agency's consumer preparation specialist must meet the following qualifications:

          (1)  Must be employed by a provider agency;

          (2)  Must have a minimum of one year experience working with individuals having severe disabilities with experience working with individuals with quadriplegia preferred;

          (3)  Must be trained by the provider agency in consumer preparation; and

          (4)  Must be able to provide the services listed in § 67:54:06:11.

          Consumer preparation services are provided by staff from a provider agency. The services are contained in the consumer's service plan and are agreed to by the consumer and the consumer's case manager.

          Source: 21 SDR 230, effective July 13, 1995; 30 SDR 135, effective March 16, 2004.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:06:11.  Covered services -- Consumer preparation specialist. Covered consumer preparation specialist services include the following:

          (1)  Instructing clients in the methods of identifying personal needs and effectively communicating those needs to the personal attendant;

          (2)  Instructing the client in personal health maintenance tasks;

          (3)  Instructing the client in managing a personal attendant, including interviewing, selecting, training, supervising, and scheduling the attendant;

          (4)  Instructing the client on the appropriate personal and professional relationships to be maintained by the client and the client's personal attendant.

          Source: 21 SDR 230, effective July 13, 1995.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:06:11.01.  Ancillary services. Ancillary services provided under this chapter are limited to emergency response devices and private duty nursing services. The need for ancillary services must be determined by the client's case manager under the provisions of §§ 67:54:06:05 and 67:54:06:07.

          Source: 26 SDR 99, effective January 30, 2000.

          General Authority: SDCL 28-6-1(1).

          Law Implemented: SDCL 28-6-1(1).

          67:54:06:11.02.  Ancillary services -- Private duty nursing -- Limits. Private duty nursing services are limited to nursing services provided under the direction of the consumer's physician that cannot be provided by the consumer's personal attendant because the needed services are beyond the attendant's scope of practice as allowed under SDCL 36-9-28.

          Source: 26 SDR 99, effective January 30, 2000; 30 SDR 135, effective March 16, 2004.

          General Authority: SDCL 28-6-1(1).

          Law Implemented: SDCL 28-6-1(1).

          67:54:06:12.  Department of Human Services to determine level of care. Within 30 days after receiving the completed client assessment and service plan, the Department of Human Services' utilization review team must review the documents to determine whether placement into the program and the services required are appropriate. Within the same 30-day period, the URT must also determine whether the individual requires a nursing facility level of care. The determination of the need for care is based on information submitted by the client's personal physician and the provider agency which documents the client's medical status and the need for services.

          The URT must redetermine the individual's level of care at least annually.

          Source: 21 SDR 230, effective July 13, 1995.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:06:13.  Payment, procedure codes, and limits for covered services. Payment for assistive daily living services is limited to the following procedure codes:

          A provider may bill for no more than three units of services of a personal attendant if the actual service time is less than 45 minutes and the personal attendant did not provide services for another consumer immediately preceding or subsequent to the services provided to the consumer on whose behalf the services are being billed.

          The Department of Human Services shall establish the rate of payment in the provider agency's contract.

          Source: 21 SDR 230, effective July 13, 1995; 26 SDR 99, effective January 30, 2000; 30 SDR 135, effective March 16, 2004.

          General Authority: SDCL 28-6-1(2).

          Law Implemented: SDCL 28-6-1(2).

          67:54:06:14.  Basis of payment. Payment for assistive daily living services is based on the difference between the consumer's income, minus allowable deductions, and the consumer's monthly care costs.

          If the consumer meets the requirements of subdivision 67:54:04:03(1), none of the consumer's income is credited to the monthly care costs.

          If the consumer meets the requirements of subdivision 67:54:04:03(2), the department applies the following criteria to determine the amount of assistance a consumer is eligible to receive from the department to meet the consumer's monthly care costs:

          (1)  Apply the provisions of chapter 67:46:06, with the exception of § 67:46:06:05;

          (2)  If the consumer is married, apply the provisions of chapter 67:46:07, with the exception of subdivision 67:46:07:10(1);

          (3)  Allow a deduction equal to the SSI standard benefit amount plus $20 for the consumer's personal needs; and

          (4)  If the consumer is employed, allow a deduction of $400 from gross wages for work expenses.

          The Department of Social Services shall pay its share of the costs directly to the provider agency. The consumer is responsible for paying the consumer's share directly to the provider agency.

          Source: 21 SDR 230, effective July 13, 1995; 26 SDR 99, effective January 30, 2000.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          Cross-Reference: SSI standard benefit amount, § 67:46:04:13(2).

          67:54:06:15.  Billing requirements. A claim submitted for services provided under this chapter must be submitted at the provider's usual and customary charge and must contain the applicable procedure codes and units being billed.

          Source: 21 SDR 230, effective July 13, 1995.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          Cross-Reference: Eligibility starting date, § 67:46:01:03.

          67:54:06:16.  Claim requirements. A claim for services provided under this chapter must be submitted on a form which contains the following information:

          (1)  The recipient's full name;

          (2)  The recipient's medical assistance identification number from the recipient's medical identification card;

          (3)  The third-party liability information required under chapter 67:16:26;

          (4)  The date of service;

          (5)  The place of service;

          (6)  The provider's usual and customary charge. The provider may not subtract other third-party or cost-sharing payments from this charge;

          (7)  The units of service furnished, if more than one, for each procedure;

          (8)  The applicable procedure codes;

          (9)  The type of service; and

          (10)  The provider's name and medical assistance identification number.

          A separate claim form must be used for each client.

          Source: 21 SDR 230, effective July 13, 1995.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          Cross-Reference: Claims, ch 67:16:35.

          Note: The HFCA 1500 form substantially meets the requirements of this rule and its content and appearance are acceptable to the department. These forms are available for direct purchase through the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402. (202) 783-3238 - pricing desk.

          67:54:06:17.  Cost of service not to exceed cost of institutional care. The cost of services provided under this chapter may not exceed the cost of caring for the client in an institutional setting. The cost of caring for the client in an institutional setting is equal to the monthly statewide average nursing home rate for individuals classified in the special care case mix category payable under the provisions of chapter 67:16:04. If the assistive daily living service costs exceed the monthly statewide average nursing home rate for individuals classified in the special care case mix category, the client is no longer eligible for services under this chapter.

          Source: 21 SDR 230, effective July 13, 1995.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:06:18.  Provider agency may terminate services. If a provider agency terminates services to a consumer, the termination must be for cause. Specific reasons for terminating services include circumstances such as the following:

          (1)  The consumer is refusing to take prescribed medication, which is adversely affecting the consumer's ability to independently direct and manage the needed services, is a threat to the health or safety of the provider, or is interfering with the delivery of the needed services;

          (2)  The consumer is sexually harassing, verbally abusive, threatening, or is combative towards the personal attendant, case manager, or any other person involved in the delivery of services;

          (3)  The consumer's living environment presents health and fire hazards or unsafe conditions for the person delivering services and attempts to alleviate the situation have been unsuccessful;

          (4)  The consumer is not in compliance with the assessment, service plan, or other agreement needed to deliver services;

          (5)  The consumer's cognitive ability is limited to the extent that the consumer is not oriented to person, place, or time;

          (6)  The consumer's condition has improved and no longer meets program eligibility;

          (7)  The consumer refuses to allow the service provider on the premises;

          (8)  The consumer or others in the household are under the influence of alcohol or illegal drugs, which is a threat to the health or safety of the provider or is interfering with the delivery of needed services;

          (9)  The consumer is failing to pay the consumer's share of the payment as required in § 67:54:06:14; or

          (10)  The consumer is no longer able to independently direct and manage the attendant.

          Source: 21 SDR 230, effective July 13, 1995; 26 SDR 99, effective January 30, 2000; 30 SDR 135, effective March 16, 2004.

          General Authority: SDCL 28-6-1(1)(4).

          Law Implemented: SDCL 28-6-1(1)(4).

          67:54:06:18.01.  Provider agency may terminate services -- Notice -- Exception. If a provider agency intends to terminate services to a consumer, the provider agency must notify the consumer in writing at least ten working days before the service is terminated. If a written notice is not an appropriate format for the consumer, the provider agency must also provide the notice in a format that is appropriate for the consumer involved.

          The notice must contain the reason for the termination and an explanation of the consumer's right to file a grievance with the provider agency.

          At the same time the provider agency sends notice to the consumer, it must also send a copy of the notice to each of the consumer's service providers, the Department of Social Services, and the Department of Human Services.

          If the provider agency's management staff determines that an abusive, dangerous, or unsafe situation exists, the provider agency may immediately terminate the services without serving the ten-day notice on the consumer. However, the provider agency shall immediately notify the consumer in writing of the reason for the termination and an explanation of the consumer's right to file a grievance with the provider agency. If a written notice is not an appropriate format for the consumer, the provider agency must also provide the notice in a format that is appropriate for the consumer involved.

          Source: 26 SDR 99, effective January 30, 2000.

          General Authority: SDCL 28-6-1(4)(6).

          Law Implemented: SDCL 28-6-1(4)(6).

          67:54:06:19.  Notice of adverse action. The Department of Social Services shall send a written notice if any of the following occurs:

          (1)  The Department of Social Services has determined that the individual is no longer eligible under the provisions of subdivision 67:54:06:02(6);

          (2)  The Department of Human Services has determined that the individual is not eligible for services because the individual does not meet the requirements of subdivision 67:54:06:02(1), (2), (3), (4), (5), (7), or (8); or

          (3)  The Department of Human Services has determined that services will be terminated because the individual no longer meets the requirements of subdivision 67:54:06:02(1), (3), (4), (5), (7), or (8).

          The notice shall state the specific regulations supporting the action taken and explain the individual's right to request a conference and to be represented by others at the conference, the right to and procedure for requesting a fair hearing, the right to be represented by others at the hearing, and the time in which a hearing may be requested. The Department of Social Services shall mail this notice at least ten days before the date of the intended action.

          If the consumer does not request a conference within the 15-day period established in § 67:54:06:19.01, the notice of adverse action shall constitute the final decision for purposes of a fair hearing.

          Source: 21 SDR 230, effective July 13, 1995; 26 SDR 99, effective January 30, 2000; 30 SDR 135, effective March 16, 2004.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          Cross Reference: Conference with staff from Department of Human Services or Department of Social Services, § 67:54:06:19.01.

          67:54:06:19.01.  Conference with staff from Department of Human Services or Department of Social Services. An individual may request a conference if any of the following occurs:

          (1)  The Department of Social Services determines that the individual no longer meets the requirements of subdivision 67:54:06:02(6). The individual must request a conference with the Department of Social Services;

          (2)  The Department of Human Services determines that the individual does not meet the requirements of subdivision 67:54:06:02(1), (2), (3), (4), (5), (7), or (8). The individual must request a conference with the Department of Human Services;

          (3)  The Department of Human Services determines that services will be terminated because the individual no longer meets the requirements of subdivision 67:54:06:02(1), (3), (4), (5), (7), or (8). The individual must request a conference with the Department of Human Services.

          In any case, the request for a conference must be made within 15 days after the date the notice of adverse action is sent. The conference may be held by telephone or in person. Within five days after receiving the request, the appropriate department shall make arrangements for the conference. At the end of the conference, the department shall inform the individual of the department's final decision. If a final decision cannot be made, the conference may be extended until a decision is reached and written notice of the decision delivered to the individual. Following receipt of the final decision, the individual has 30 days to request a hearing.

          Source: 26 SDR 99, effective January 30, 2000; 30 SDR 135, effective March 16, 2004.

          General Authority: SDCL 28-6-1(4)(6).

          Law Implemented: SDCL 28-6-1(4)(6).

          Cross-References: Notice of adverse action, § 67:54:06:19; Fair hearings, ch 67:17:02.

          67:54:06:20.  Record retention. The provider agency must maintain or supervise the maintenance of records necessary for the program's operation including records relating to applications, determinations of eligibility, the provision of services, administrative costs, and statistical, fiscal, and other records necessary for reporting and accountability. The provider agency must retain the records for a minimum of six years after final payment has been made. If an audit is pending, records needed for the audit must be maintained until the audit is complete.

          Source: 21 SDR 230, effective July 13, 1995.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:06:21.  Access to records. Within ten days after the Department of Human Services or the Department of Social Services notifies the provider agency, the provider agency must allow the State of South Dakota and federal agencies access to and copies of all information, data, reports, and records maintained by the agency and relating to the services provided.

          Source: 21 SDR 230, effective July 13, 1995.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:06:22.  Annual review. The URT must conduct an annual review of the consumer's record to determine the appropriateness and adequacy of the services being provided and to ensure that the services provided are consistent with the nature and severity of the consumer's disability.

          Source: 21 SDR 230, effective July 13, 1995; 30 SDR 135, effective March 16, 2004.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

CHAPTER 67:54:07

TRAUMATIC BRAIN INJURY SERVICES

Section

67:54:07:01        Definitions.

67:54:07:02        Eligibility for services.

67:54:07:03        Application for services.

67:54:07:04        Department approval of client services -- Notice.

67:54:07:05        TBI rehabilitation service plan.

67:54:07:06        Covered services.

67:54:07:07        Termination of services.

67:54:07:08        Notice of adverse action.

67:54:07:09        Participating provider.

67:54:07:10        Provider agreement with Department of Human Services.

67:54:07:11        Required cost reports.

67:54:07:12        Record retention.

67:54:07:13        Access to records.

67:54:07:14        Basis of payment -- Payment limits.

67:54:07:15        Billing requirements.

67:54:07:16        Claim requirements.

67:54:07:17        Utilization review.

67:54:07:18        Application of other chapters.

          67:54:07:01.  Definitions. Terms used in this chapter mean:

          (1)  "Case management services," services which are provided on behalf of a client; which are provided by professional staff, such as a case manager, psychologist, or nurse; and which are designed to move the client towards the goals specified in the client's TBI rehabilitation service plan;

          (2)  "Cognitive training," services provided in a face-to-face encounter with the client which provide instruction and training in perception, judgment, and language and physical, social-emotional, vocation, and independent living skills;

          (3)  "Interdisciplinary team," a team from the TBI service provider which is responsible for identifying a client's needs and establishing a TBI rehabilitation service plan;

          (4)  "Preplacement assessment," an evaluation of a client in the areas of cognition, perception, language, physical, social-emotional, vocational, and independent living functions to ensure that TBI services are necessary for the individual to develop the skills to live or work independently in the community;

          (5)  "Residential setting," the individual's place of residence, which does not include a hospital, penal institution, detention center, school, nursing facility, intermediate care facility for the mentally retarded, or an institution which treats individuals for mental diseases;

          (6)  "TBI rehabilitation service plan," a written plan which is based on the client's preplacement assessment and contains the specific goals, objectives, and services needed to rehabilitate and move the client into a community independent living or working situation;

          (7)  "TBI service provider" or "provider," a private organization or a special unit within a facility which provides TBI services under this chapter and is certified by the Department of Human Services as an adjustment training center;

          (8)  "Traumatic brain injury" or "TBI," damage to living brain tissue which is characterized by altered consciousness, amnesia, paralysis, coma, sensory loss, or cognitive deficits and which impairs an individual's mental or psychosocial abilities;

          (9)  "Traumatic brain injury services," comprehensive rehabilitation services which are provided in a residential setting or in a community rehabilitation program on a short-term basis, usually not more than 24 months, which are delivered to eligible individuals who no longer demonstrate the need for acute medical care or intensive rehabilitation and whose rehabilitation service plan substantiates the continuing benefit of and the need for specialized services, and which are designed to assist a client to acquire or improve cognition, perception, language, physical, social-emotional, vocational, and independent living skills necessary to function independently at home, on the job, and in the community; and

          (10)  "Utilization review team," a team consisting of at least two rehabilitation professionals who have experience or knowledge of head trauma such as a physician, a certified rehabilitation counselor from the Department of Human Services, a neuropsychologist, and occupational therapist, a physiatrist, or a psychologist.

          Source: 23 SDR 8, effective July 21, 1996.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:07:02.  Eligibility for services. An individual is eligible for TBI services if the individual meets the following requirements:

          (1)  The individual has medical documentation from a licensed physician which contains a diagnosis of TBI, information as to the client's current physical condition, and a statement that the individual is medically stable and does not require ongoing nursing services in order to participate in the program and that the disability is likely to continue indefinitely;

          (2)  The individual requires TBI services to develop the ability to live independently within the community;

          (3)  The Department of Social Services has confirmed that the individual is eligible for and receiving Medicaid;

          (4)  The TBI service provider has completed a preplacement assessment;

          (5)  The Department of Human Services has determined that TBI services are the most appropriate services needed to address the individual's needs; and

          (6)  The individual is not receiving HCBS.

          Source: 23 SDR 8, effective July 21, 1996.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:07:03.  Application for services. An individual desiring to obtain TBI services must apply to a TBI service provider. A list of approved TBI service providers is available from the Department of Human Services.

          Source: 23 SDR 8, effective July 21, 1996.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:07:04.  Department approval of client services -- Notice. After an individual requests services from a TBI provider, the TBI service provider must prepare a preplacement assessment and, within five working days after completing the assessment, send a copy of the assessment together with the medical documentation required in § 67:54:07:02 to the Department of Human Services for its review and approval. The Department of Human Services shall determine eligibility for TBI services within seven working days after receiving the documentation.

          The Department of Human Services shall notify the individual and the individual's parent, guardian, spouse, or authorized representative, as appropriate, and the service provider of the eligibility determination within seven working days. If the individual is determined ineligible, the notice shall include the reason for the determination of ineligibility, the specific regulations supporting the action, an explanation of the individual's right to request a fair hearing, the procedure for requesting a fair hearing, the right to be represented by others at the hearing, and the time within which a hearing may be requested.

          Source: 23 SDR 8, effective July 21, 1996.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 1-26-16, 28-6-1.

          67:54:07:05.  TBI rehabilitation service plan. After the Department of Human Services has approved the individual as a TBI client and the TBI service provider has accepted the individual as a TBI client, the interdisciplinary team must prepare a TBI rehabilitation service plan for the client. The plan must contain specific goals, objectives, and services related to the needs identified in the client's preplacement assessment.

          The interdisciplinary team must consist of a licensed psychologist, the client's case manager, a vocational rehabilitation counselor, if appropriate, and other professional staff providing direct services to the client. When developing the plan, the interdisciplinary team must include the client and the client's parent, guardian, spouse, or authorized representative, if appropriate. The plan must be approved by the interdisciplinary team; the client; the client's parent, guardian, spouse, or authorized representative, if appropriate; the client's physician; and the Department of Human Services. Those approving the plan must sign the plan as an indication of their approval. The interdisciplinary team must develop and approve a new service plan at least once every six months.

          The provider must review the plan at least monthly to ensure that the services continue to be appropriate for the client and update it as needed. The provider must document completion of the monthly reviews and must maintain copies of the plan, plan amendments, and the documentation of the monthly reviews in the client's record.

          The provider must submit a copy of the individual's rehabilitation service plan to the Department of Human Services within seven days after completion.

          Failure to meet the conditions of this section is cause to determine that the service provided is a noncovered service.

          Source: 23 SDR 8, effective July 21, 1996.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:07:06.  Covered services. Services payable under this chapter are limited to cognitive training and case management services.

          Source: 23 SDR 8, effective July 21, 1996.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:07:07.  Termination of services. The provider may terminate services provided under this chapter if any of the following occurs:

          (1)  The client can no longer benefit from the services provided;

          (2)  The client is physically threatening towards provider staff or others involved in the delivery of services, including other clients;

          (3)  The client no longer meets the criteria contained in § 67:54:07:02;

          (4)  The client's living environment presents health and fire hazards or unsafe conditions for the person delivering services;

          (5)  The client refuses to comply with the assessment and service plan, fails to make progress toward achieving the goals identified in the plan, or fails to take needed medications;

          (6)  The client's cognitive ability is limited to the extent that the client is not oriented to person, place, or time;

          (7)  The client is under the influence of illegal drugs or alcohol; or

          (8)  The client has an uncontrolled infectious disease.

          The provider must have approval from the Department of Human Services before terminating the services.

          Source: 23 SDR 8, effective July 21, 1996.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:07:08.  Notice of adverse action. If the client is no longer eligible for Medicaid, the Department of Social Services will send a written notice to the recipient. This notice shall inform the recipient that he or she is no longer eligible.

          If services are going to be terminated or reduced, the Department of Human Services shall send a written notice to the client and the client's parent, guardian, spouse, or authorized representative, as appropriate. This notice shall state the specific regulations supporting the action taken and explain the individual's right to request a conference and to be represented by others at the conference, the right to and procedure for requesting a fair hearing, the right to be represented by others at the hearing, and the time in which a hearing may be requested.

          In either case, the notices must be mailed at least ten days before the date of the intended action.

          Source: 23 SDR 8, effective July 21, 1996.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 1-26-16, 28-6-1.

          67:54:07:10.  Provider agreement with Department of Human Services. A provider agreement between the Department of Human Services and the TBI service provider shall specify the provider's service limits and the rate of reimbursement. The agreement shall cover a one-year period and, if both parties agree, may be revised during the year. Revisions made during the year must be in writing.

          Source: 23 SDR 8, effective July 21, 1996.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:07:11.  Required cost reports. Each year the TBI service provider must complete and submit a cost report to the Department of Human Services by November 15. The cost report must be on the cost reporting form available from the Department of Human Services. The reporting period must cover the 12-month period of July 1 through June 30.

          Source: 23 SDR 8, effective July 21, 1996.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:07:12.  Record retention. The TBI service provider must maintain or supervise the maintenance of records necessary for the program's operation including records relating to applications, determinations of eligibility, the provision of services, administrative costs, and statistical, fiscal, and other records necessary for reporting and accountability. The TBI service provider must retain the records for a minimum of six years after final payment has been made. If an audit is pending, records needed for the audit must be maintained until the audit is complete.

          Source: 23 SDR 8, effective July 21, 1996.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:07:13.  Access to records The TBI service provider must allow the agencies of this state and federal agencies access to and copies of all information, data, reports, and records maintained by the provider and relating to the services provided.

          Source: 23 SDR 8, effective July 21, 1996.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:07:14.  Basis of payment -- Payment limits. The Department of Human Services shall establish the rate of payment by June 1 each year. The rate of payment is based on reasonable and allowable costs reported on the cost report.

          If the services provided in a 24-hour period are up to but do not exceed five hours, payment is limited to one unit of service for the 24-hour period. If the services provided in a 24-hour period are five hours or more, payment is limited to two units of service for the 24-hour period.

          Source: 23 SDR 8, effective July 21, 1996.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          Cross-Reference: Required cost reports, § 67:54:07:11.

          67:54:07:15.  Billing requirements. Claims must be submitted at the provider's usual and customary charge and must contain the Procedure Code W5100.

          Claims must be submitted to the Department of Human Services. The Department of Human Services shall review the claims and forward the approved claims to the Department of Social Services for processing.

          Source: 23 SDR 8, effective July 21, 1996.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:07:16.  Claim requirements. A claim for services provided under this chapter must be submitted on a form which contains the following information:

          (1)  The recipient's full name;

          (2)  The recipient's medical assistance identification number from the recipient's medical assistance identification card;

          (3)  Third-party liability information required under chapter 67:16:26;

          (4)  Date of service;

          (5)  Place of service;

          (6)  The provider's usual and customary charge. The provider may not subtract other third-party payments from this charge;

          (7)  The procedure code specified in § 67:54:07:15;

          (8)  The units of service furnished if more than one; and

          (9)  The provider's name and medical assistance identification number.

          A separate claim form must be used for each recipient.

          Source: 23 SDR 8, effective July 21, 1996.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          Cross-Reference: Claims, ch 67:16:35.

          Note: The HCFA 1500 form substantially meets the requirements of this rule and its content and appearance are acceptable to the department. These forms are available for direct purchase through the Superintendent of Documents, U. S. Government Printing Office, Washington D.C. 20402. (202) 783-3238 - pricing desk.

          67:54:07:17.  Utilization review. The utilization review team must conduct, at least annually, an on-site review to determine whether the TBI program is an appropriate placement; whether the services delivered are appropriate for the client, meet the client's needs, and have assisted the client to live independently in the community; whether the needed services have been provided in a timely and efficient manner; and whether the provider has the staff and facilities to carry out the services identified in the client's rehabilitation plan.

          The utilization review team must submit its written report of the review to the Department of Human Services and the service provider within 30 days after completing the review. The report must include the team's findings and recommendations for corrective action. The service provider has 15 days from receipt of this report to challenge in writing any of the team's findings or recommendations. The Department of Human Services shall issue its final report within 40 days following receipt of the initial report. The Department of Human Services shall specify in the final report the time within which the provider must institute any required corrective action.

          Source: 23 SDR 8, effective July 21, 1996.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

          67:54:07:18.  Application of other chapters. In addition to the rules contained in this chapter, providers and recipients must meet the requirements of chapters 67:16:01, 67:16:26, 67:16:33, 67:16:34, 67:16:35, and, if applicable, 67:16:39.

          Source: 23 SDR 8, effective July 21, 1996.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.

CHAPTER 67:54:08

TREATMENT FOR CHEMICAL DEPENDENCY AND SUBSTANCE ABUSE

(Repealed. 43 SDR 80, effective December 5, 2016)

Section

67:54:08:01       Repealed.

67:54:08:02       Repealed.

67:54:08:03       Repealed.

67:54:08:04       Repealed.

67:54:08:05       Repealed.

67:54:08:06       Repealed.

67:54:08:07       Repealed.

67:54:08:08       Repealed.

67:54:08:09       Repealed.

67:54:08:10       Repealed.

67:54:08:11       Repealed.

67:54:08:12       Repealed.

67:54:08:13       Repealed.

CHAPTER 67:54:09

FAMILY SUPPORT WAIVER SERVICES

Section

67:54:09:01        Definitions.

67:54:09:02        Covered family support services.

67:54:09:03        Specialized medical and adaptive equipment and supplies.

67:54:09:04        Service coordination.

67:54:09:05        Respite care services.

67:54:09:06        Nutritional supplements.

67:54:09:07        Personal care services.

67:54:09:08        Companion services.

67:54:09:09        Environmental accessibility adaptations.

67:54:09:10        Supported employment services.

67:54:09:11        Vehicle modification -- Exclusions.

67:54:09:11.01    Specialized therapy.

67:54:09:12        Eligibility for family support services.

67:54:09:13        Service restrictions.

67:54:09:14        Repealed.

67:54:09:15        Service coordinator to coordinate development of ISP.

67:54:09:16        Provider requirements.

67:54:09:17        Rate of payment.

67:54:09:18        Billing requirements.

67:54:09:19        Claim requirements.

67:54:09:20        Record retention.

67:54:09:21        Access to records.

67:54:09:22        Application of other rules.

67:54:09:23        Utilization review.

67:54:09:24        Right to request a fair hearing.

    67:54:09:02.  Covered family support services. For a participant who meets the requirements of §§ 67:54:09:12 and 67:54:09:13, the following family support services are covered under this chapter:

    (1)  Specialized medical and adaptive equipment and supplies;

    (2)  Service coordination;

    (3)  Respite care services;

    (4)  Nutritional supplements;

    (5)  Personal care services;

    (6)  Companion services;

    (7)  Environmental accessibility adaptations;

    (8)  Supported employment;

    (9)  Vehicle modifications; and

    10)  Specialized therapies.

    Source: 34 SDR 271, effective May 7, 2008; SL 2013, ch 128, § 22, effective July 1, 2013; 50 SDR 63, effective November 27, 2023.

    General Authority: SDCL 28-6-1.

    Law Implemented: SDCL 28-6-1.

    67:54:09:11.01.  Specialized therapy. Specialized therapy means:

    (1)  Art therapy used to:

        (a)  Increase awareness of self and others;

        (b)  Cope with symptoms, stress, or traumatic experiences; and

        (c)  Enhance cognitive abilities;

    (2)  Music therapy, provided individually or in groups, used to help participants improve their:

        (a)  Cognitive functioning;

        (b)  Motor skills;

        (c)  Emotional development;

        (d)  Affective development;

        (e)  Behavior;

        (f)  Social skills; and

        (g)  Quality of life; and

    (3)  Hippotherapy or therapeutic horseback riding used to promote the use of the movement of the horse as a treatment strategy in physical, occupational, and speech-language therapy sessions.

    Only state- or national board-certified therapists may provide specialized therapy services.

Source: 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 28-6-01.

Law Implemented: SDCL 28-6-01.

    67:54:09:16.  Provider requirements. A provider of services under this chapter must be certified by the division under the applicable requirements contained in chapter 46:11:02 and must have a signed provider agreement with the department.

    Source: 34 SDR 271, effective May 7, 2008; 50 SDR 63, effective November 27, 2023.

    General Authority: SDCL 28-6-1.

    Law Implemented: SDCL 28-6-1.

    67:54:09:18.  Billing requirements. A claim submitted for payment under this chapter must contain the following Health Care Common Procedure Coding System procedure codes, as applicable.

    Source: 34 SDR 271, effective May 7, 2008; SL 2013, ch 128, § 37, effective July 1, 2013; 50 SDR 63, effective November 27, 2023.

    General Authority: SDCL 28-6-1.

    Law Implemented: SDCL 28-6-1.

    Cross-Reference: Use of Health Care Common Procedure Coding System, § 67:16:01:27.