(1) "Active treatment," the implementation of a program of specialized and generic training, treatment, health services, and related services, which lead to the acquisition of the behaviors necessary for the individual to function with as much self-determination and independence as possible, and to prevent regression or loss of current optimal functional status;

(2) "Dementia," disorders characterized by the development of multiple cognitive deficits, including memory impairment, which are due to the direct physiological effects of a general medical condition, to the persisting effects of a substance, or to multiple etiologies ;

(3) "Nursing facility," a facility licensed as a nursing facility by the Department of Health and maintained and operated for the express or implied purpose of providing care to one or more persons, whether for consideration or not, who are not acutely ill but require nursing care and related medical services of such complexity as to require professional nursing care under the direction of a physician twenty-four hours a day;

(4) "Preadmission screening and resident review," a process made up of a Level I screening completed by the department, and a Level II review completed by the department, to determine eligibility when an individual with a mental disorder, as defined in § 67:62:01:01, applies to reside in a Medicaid certified swing bed or nursing facility;

(5) "Specialized mental health services," psychiatric services that result in the continuous and aggressive implementation of an individualized plan of care developed by an interdisciplinary team consisting of a physician, a qualified mental health professional, and other professionals, which prescribes specific therapies and activities for the treatment of individuals experiencing an acute episode of serious mental illness. requiring supervision by trained mental health professionals, to obtain improvement in function thereby permitting a reduction in the level of intensity to less than the level of specialized services at the earliest possible time; and

(6) "Swing bed," a licensed hospital bed approved by the Department of Health to provide short-term nursing facility care pending the availability of a nursing facility bed.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25.

Law Implemented: SDCL 1-36-25.

Rule 67:62:15:02 Level I screening.

67:62:15:02. Level I screening. The department shall conduct a Level I screening that identifies each individual who is seeking Medicaid certified swing bed or nursing facility services who may have a mental illness.

Source: 43 SDR 80, effective December 5, 2016.

General Authority: SDCL 1-36-25.

Law Implemented: SDCL 1-36-25(4).

67:62:15:03. Level II review exemptions. An individual is exempt from a Level II review if:

(1) The diagnosis of mental illness is unsubstantiated;

(2) The individual is readmitted to a Medicaid certified swing bed or nursing facility from a hospital to which the individual was transferred for the purpose of receiving care;

(3) The individual is transferred from one Medicaid certified swing bed or nursing facility to another, and a preadmission screening and resident review has previously been completed;

(4) The physician identifies the need for convalescent care following hospitalization for a duration of less than one hundred days;

(5) The physician orders a respite stay of thirty days or less;

(6) The individual has a diagnosis of situational depression that:

(a) Is of short duration;

(b) Is in direct relation to an occurrence in an individual's life; and

(7) The individual is using psychotropic medication in the absence of a major mental illness diagnosis; or

(8) The individual has a diagnosis of an anxiety disorder that is not identified as severe and does not appear to be leading to a chronic disability.

The department shall complete a Level I screening form to notify appropriate parties of the determination of the exemption.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25.

Law Implemented: SDCL 1-36-25.

67:62:15:04. Exempt hospital discharge. An individual is exempt from a preadmission screening and resident review (PASRR) following a hospital discharge if:

(1) The individual is admitted to a Medicaid certified swing bed or nursing facility, directly from a hospital, after receiving acute inpatient care at the hospital;

(2) The individual requires Medicaid certified swing bed or nursing facility services for the condition that required care in the hospital; and

(3) The individual's attending physician has certified, before admission to the Medicaid certified swing bed or nursing facility, that the individual is likely to require less than thirty calendar days of Medicaid certified swing bed or nursing facility services.

If an individual enters a Medicaid certified swing bed or nursing facility as an exempt hospital discharge and is later found to require more than thirty days of nursing care, the facility must request a PASRR prior to the expiration of that thirty days.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25.

Law Implemented: SDCL 1-36-25.

Rule 67:62:15:05 Categorical determinations for Level I.

67:62:15:05 Categorical determinations for Level I. The department shall make a categorical determination in one of the following situations:

(1) A terminal illness diagnosis, determined by a physician or hospice involvement that includes a life expectancy of 6 months or less;

(2) A severe physical illness that has resulted in coma or ventilator dependence;

(3) The age of an individual is 75 years or older; or

(4) A primary diagnosis of dementia, including Alzheimer's disease or a related disorder or a non-primary diagnosis of dementia without a primary diagnosis that is a serious mental illness.

For any of these situations, the department shall complete a Level I screening form. A copy of the form shall be sent to the appropriate facility. A categorical determination may warrant Medicaid certified swing bed or nursing facility services but does not warrant mental health services or specialized services.

Source: 43 SDR 80, effective December 5, 2016.

General Authority: SDCL 1-36-25.

Law Implemented: SDCL 1-36-25(4).

67:62:15:06. Level II review. The department shall conduct a Level II review that consists of determining the appropriateness of a Medicaid certified swing bed or nursing facility, and possible mental health services, including specialized mental health services for individuals identified in the Level I screening.

Each individual is reviewed for appropriateness of placement, regardless of the source of payment for the swing bed or nursing facility services. A determination whether or not an individual requires the level of services provided by the facility and whether or not an individual can benefit from mental health services is made.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25.

Law Implemented: SDCL 1-36-25.

Rule 67:62:15:07 Level II determination -- Data requirements.

67:62:15:07. Level II determination -- Data requirements. The data used for a Level II determination includes:

(1) A comprehensive social and developmental history and physical, including:

(a) Medical history;

(b) Review of body systems;

(c) Evaluation of the individual's neurological system in the areas of motor functioning, sensory functioning, gait, deep tendon reflexes, cranial nerves, and abnormal reflexes; and

(d) Additional evaluations conducted by appropriate specialists in case of abnormal findings;

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

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

(4) A comprehensive psychiatric or psychological evaluation including a complete psychiatric and development history; evaluation of intellectual functioning, memory functioning, and orientation; description of current attitudes and overt behaviors; affect, suicidal, or homicidal ideation, paranoia, and 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. This assessment shall conclude whether this level of support can be provided to the individual in an alternative community setting or if a nursing facility placement is warranted.

Source: 43 SDR 80, effective December 5, 2016.

General Authority: SDCL 1-36-25.

Law Implemented: SDCL 1-36-25(4).

67:62:15:08. Determination of services. The department shall determine if the individual requires the level of services provided by a Medicaid certified swing bed or nursing facility due to the individual's physical or mental condition. If the department determines that an individual requires a Medicaid certified swing bed or nursing facility services, the facility may admit or retain the individual. If the department determines that an individual does not require Medicaid certified swing bed or nursing facility services, the individual may not be admitted.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25.

Law Implemented: SDCL 1-36-25.

67:62:15:09. Determination of specialized mental health services. If the department determines that the individual requires Medicaid certified swing bed or nursing facility services, the department must also determine whether the individual may benefit from mental health services.

If the department determines that an individual requires both Medicaid certified swing bed or nursing facility services and specialized mental health services as defined in § 67:62:15:01, the facility may admit or retain the individual and the state shall provide or arrange for the provision of the specialized mental health services needed by the individual in the Medicaid certified swing bed or nursing facility.

If the department determines that the individual does not require Medicaid certified swing bed or nursing facility services, but may benefit from mental health services, the department shall provide the individual with information regarding service options.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25.

Law Implemented: SDCL 1-36-25.

67:62:15:10. Timeliness of determinations of Level II review. The department shall make each Level II determination within an annual average of seven-to-nine business days of receipt of the Level I screening and all of the data required in § 67:62:15:07.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25.

Law Implemented: SDCL 1-36-25.

67:62:15:11. Notification of Level II determination. The department shall issue a written notification of the Level II review determination. The notification must contain:

(1) The name of each professional who performed an evaluation used to make the Level II determination;

(2) The date each portion of the evaluation was administered; and

(3) Any other information used to make the Level II determination.

The department shall provide a copy of the notification to the individual on whom the Level II review was completed; the individual's legal representative, if applicable; the Medicaid certified swing bed or nursing facility; and any other party affected by the Level II determination.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25.

Law Implemented: SDCL 1-36-25.

67:62:15:12. Determination may not be countermanded. A Level II determination made by the division may not be countermanded by the department.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25.

Law Implemented: SDCL 1-36-25.

Rule 67:62:15:13 Appeal of ineligibility of Level II determination.

67:62:15:13. Appeal of ineligibility of Level II determination. The individual, or the individual's legal representative, may request a fair hearing within 30 calendar days of receipt of the notice of ineligibility pursuant to SDCL chapter 1-26 by notifying the department in writing. Upon request, the individual, or the individual's legal representative, will be provided with information in an accessible format. Any costs associated with legal counsel obtained to represent the individual are not the responsibility of the department.

Source: 43 SDR 80, effective December 5, 2016.

General Authority: SDCL 1-36-25.

Law Implemented: SDCL 1-36-25(4).

Rule 67:62:15:14 Length of stay.

67:62:15:14. Length of stay. For the purposes of establishing length of stay in a Medicaid certified swing bed or nursing facility, the 30 months of continuous residence in a Medicaid certified facility may include temporary absences for hospitalization or therapeutic leave and may include consecutive residences in more than one Medicaid certified swing bed or nursing facility.

Source: 43 SDR 80, effective December 5, 2016.

General Authority: SDCL 1-36-25.

Law Implemented: SDCL 1-36-25(4).

Rule 67:62:15:15 Individuals not requiring swing bed or nursing facility services but requiring mental health services -- 30 month determination.

67:62:15:15. Individuals not requiring swing bed or nursing facility services but requiring mental health services -- 30 month determination. If the individual is determined not eligible for swing bed or nursing home services, but requires mental health services, the department, in consultation with the individual's family or legal representative and caregivers, shall:

(1) If the individual has continuously resided in a Medicaid certified swing bed or nursing facility at least 30 months prior to a determination of eligibility and determined not eligible for swing bed or nursing home services, but who require mental health services, the department, in consultation with the individual's family or legal representative and caregivers, shall:

(a) Offer the choice of remaining in the facility or receiving services in an alternative setting;

(b) Inform the individual of the institutional and non-institutional alternatives covered under the state Medicaid plan;

(c) Clarify the effect on the individual's eligibility for Medicaid services under the state plan if the individual chooses to leave the Medicaid certified swing bed or nursing facility, including the effect on readmission to the Medicaid certified swing bed or nursing facility; and

(d) Provide, or arrange the provision of, mental health services for the mental illness; or

(2) If the individual has been residing in the Medicaid certified swing bed or nursing facility less than 30 months prior to a determination of eligibility and determined not eligible for swing bed or nursing home services, but who requires mental health services, the department, in consultation with the individual's family or legal representative and caregivers, shall:

(a) Arrange for the safe and orderly discharge of the individual from the facility;

(b) Prepare and orient the individual for discharge; and

Source: 43 SDR 80, effective December 5, 2016.

General Authority: SDCL 1-36-25.

Law Implemented: SDCL 1-36-25(4).

67:62:15:16. Significant change. A significant change is a decline or improvement in an individual's status that:

(1) Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions;

(2) Impacts more than one area of the individual's health status; and

(3) Requires interdisciplinary review or revision of the care plan.

A self-limiting decline is not considered a significant change. If a significant change occurs for an individual known or suspected to have a mental illness, the Medicaid certified swing bed or nursing facility must make a referral to the department for a possible Level II review. This referral must occur as soon as evidence of the significant change is identified.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25.

Law Implemented: SDCL 1-36-25.

67:62:15:17. New admission and readmission. A new admission occurs if an individual is admitted to a Medicaid certified swing bed or nursing facility for the first time, or when an admission does not qualify as a readmission. Unless excepted under § 67:62:15:04, a new admission is subject to a preadmission screening and resident review (PASRR).

A readmission occurs when an individual is readmitted to a Medicaid certified swing bed or nursing facility, from a hospital to which the individual, who was in a facility, had been transferred, for the purpose of receiving medical care. A readmission that meets the criteria set forth in this section does not require a PASRR.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25.

Law Implemented: SDCL 1-36-25.

67:62:15:18. Interfacility transfers. An interfacility transfer occurs if the individual is transferred from one Medicaid certified swing bed or nursing facility to another, with or without an intervening hospital stay. An interfacility transfer is not subject to a preadmission screening and resident review. If an individual transfers from a Medicaid certified swing bed or nursing facility to a hospital, or to another Medicaid certified swing bed or nursing facility, the transferring facility must ensure that copies of the individual's preadmission screening and resident review findings accompany the individual.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25.

Law Implemented: SDCL 1-36-25.

67:62:15:19. Out of state placement. The required preadmission screening and resident review determination must be conducted by the state in which the individual:

(1) Resides; or

(2) Will reside at the time Medicaid eligibility is obtained.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.

General Authority: SDCL 1-36-25.

Law Implemented: SDCL 1-36-25.

Cross Reference: Out-of-State arrangements, 42 C.F.R. § 483.110.

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