A1. Introduction
A facility evaluation process requires that you ask questions of a facility that provides claim department personal with the information needed to determine if the facility meets their policy’s definition of a Nursing Home. As part of developing a sample of potential questions, we did an analysis of the criteria required to meet the Nursing Home definition of 27 policies from 11 different companies. That analysis revealed that there were eight (8) commonly required criteria. While no policy required that a facility meet all 8 criteria, most required 4-5 of the following criteria:
1. Licensed as a Nursing Home or to provide Nursing Services.
2. Maintain Clinical Records (with or without a frequency requirement).
3. Operate under a set of Polices and Procedures Developed by an MD and/or RN.
“on duty or on call at all times”.
5. Require the facility to have a Plan of Care or Service Plan for all residents.
6. Require an MD to be “available” or “on call” for Emergency Care.
7. Require some minimum number of residents (usually 3-10) in the facility.
8. Provide Administration of Drugs and Biological.
Other considerations noted by insurers for licensed nursing facilities or nursing home included the following language:
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Provides on an inpatient basis skilled nursing care, intermediate nursing care or custodial care rendered by an R.N or by an LPN under the direction of an R.N
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Charges patients for services it provides.
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Services are supervised full-time by a Physician or R.N.
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Provides nursing services by licensed nurses [7 days a week on the day shift], under the direction of a full-time R.N.
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Keeps a complete medical record on each patient.
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It is not mainly a place for; rest, the aged, drug addicts, alcoholics, mental retardates, educational care, or care of mental disorders.
There were many other criteria that were unique to some insurers that might necessitate adding unique items to their questionnaire that would address specific policy language. The following samples contain questions that would help assess the most common criteria.
A2.
Facility Questionnaire
The facility questionnaire often serves a dual purpose for LTC insurers. This allows the facility to complete one form thereby facilitating the insurer’s ability to gather needed information to process the claim form and make a benefit determination as quickly as possible. Such a questionnaire obtains information to determine eligibility of the facility and supportive information to assess the policyholder’s benefit eligibility. For discussion purposes the sample questionnaires include an array of documentation that could be obtained for facility eligibility only or for facility and policyholder eligibility. Some of the documents you would consider obtaining are:
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Copies of all Facility Licenses
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MD signed Completed Plan of Care
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Pre-Screening
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Initial
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Physician’s Admission Orders signed by MD
• assessments and treatment plans o FIM o Inpatient Rehabilitation Facility–Patient Assessment Instrument
(IRF-PAI scores)
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Resident Assessment Instrument (RAI) o Minimum Data Set (MDS) o Resident Assessment Protocols (RAP/triggers) o Utilization Guidelines
A3. Sample Facility Questionnaires
Included here are sample questionnaires that demonstrate the variety of ways eligibility information can be obtained.
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Sample (obtains documentation related to facility
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• and policyholder eligibility, completed by the facility)
Sample
Sample
(completed by the facility)
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North Dakota Facility Inquiry Tool (completed by an independent assessor)
General Facility Questionnaire (completed by an independent assessor)
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