Information Bulletin 91-2
NH-2

Waiver Guidelines - Admission Of Children

This Bulletin contains information needed to evaluate requests for the admission of persons under 16 years of age to a nursing home.

Minnesota's nursing home rules state that nursing facilities may not admit persons under 16 years of age. Nursing facilities that wish to admit children under 16 years of age must seek a waiver from the Minnesota Department of Health (MDH), Health Regulation Division. Historically, requests for admission of children to nursing homes have been infrequent. Waiver requests have been submitted on an individual basis, and typically involve the admission of only one child to the requesting facility. To date, all waivers for admission of a child have been granted.

The number of requests for admission of children to nursing homes has been increasing in recent months, including requests for multiple admissions to a single facility. Indications from the Minnesota Department of Health, Minnesota Children with Special Health Needs Program, the Department of Human Services, Children's Services Division, and community and professional organizations, are that the number of children needing skilled care will continue to increase. Because this is a relatively new and probable growth area in nursing facility care, it is important that the Department have information that the needs of this population will be met by the nursing facility. As a result, the Department has revised the information needed to evaluate waiver requests for the admission of children to nursing homes.

If you have questions about waiver guidelines, or need additional information, please call (651) 201-4200.

Authority

A nursing home for adults shall not receive either sick children or well children for care. Children are defined as persons under 16 years of age. MN Rule 4655.0400. 4655.0400 TYPES OF PATIENTS OR RESIDENTS NOT TO BE RECEIVED

Department Approval

A nursing home may request that the Department grant a variance or waiver from the provisions of Chapter 4655. All requests for a variance or waiver shall be submitted to the Department in writing. Each request shall contain the following information.(MN Rule 4655.1000) 4655.1000 VARIANCE AND WAIVERS.

The specific rule or rules for which the variance or waiver is requested;

1. The reasons for the request;
2. The alternative measures that will be taken if a variance or waiver is granted;
3. The length of time for which the variance or waiver is requested; and
4. Such other relevant information necessary to properly evaluate the request for the variance or waiver.

Note: A waiver request must be submitted for each individual child a nursing home wishes to admit, and is required for long-term and respite care admissions.

Program Policies

1. A patient shall be admitted to a nursing home only upon the recommendation of a physician. (MN Rule 4658.0710 Subpart 2.) 4658.0710 ADMISSION ORDERS AND PHYSICIAN EVALUATIONS.
2. Residents shall not be accepted or retained for whom care cannot be provided in keeping with their known physical, mental, or behavioral condition., MN Rule 4658.0140 Subpart 2.) 4658.0140 TYPE OF ADMISSIONS.

   Note: If the child is mentally retarded or has a related condition they must also be screened according to federal OBRA regulations before admission to a nursing home. This applies both to permanent admissions and respite admissions.

   On or after January1, 1989, section 1919 (b) (3) (F) (ii) of OBRA 1987 prohibited a Medicaid certified facility from admitting any new resident who has a diagnosis of mental illness, or mental retardation or related condition, unless the state mental health authority or the state developmental disabilities authority has determined that the individual requires the level of care provided by the nursing facility.

   The procedure for this screening is outlined in the Department of Human Services Instructional Bulletins # 01-56-20.

   County case managers are responsible for assuring that the screening is completed before the admission of the child to a nursing facility. This procedure should be done prior to requesting a Department of Health waiver.

   Once the screening is completed, the state developmental disabilities authority must approve the request. These screenings and any questions regarding this procedure should be directed to:

   Minnesota Department of Human Services
   Community Supports for Minnesotans with Disabilities (CSMD)
   444 Lafayette Road
   St. Paul, Minnesota 55155
   Telephone: (651) 296-2160

3. A nursing home must conduct a comprehensive assessment of each resident's needs, which describes the resident's capability to perform daily life functions and significant impairments in functional capacity. A nursing assessment conducted according to Minnesota Statutes, section 148.171 , subdivision 15, may be used as part of the comprehensive resident assessment. The results of the comprehensive resident assessment must be used to develop, review, and revise the resident's comprehensive plan of care as defined in part 4658.0405 . MN Rule 4658.0400 Subpart 1. 4658.0400 COMPREHENSIVE RESIDENT ASSESSMENT.

4. A nursing home must have on duty at all times a sufficient number of qualified nursing personnel, including registered nurses, licensed practical nurses, and nursing assistants to meet the needs of the residents at all nurses' stations, on all floors, and in all buildings if more than one building is involved. This includes relief duty, weekends, and vacation replacements. MN Rule 4658.0510 Subpart 1. 4658.0510 NURSING PERSONNEL.

5. A nursing home must provide an organized activity and recreation program. The program must be based on each individual resident's interests, strengths, and needs, and must be designed to meet the physical, mental, and psychological well-being of each resident, as determined by the comprehensive resident assessment and comprehensive plan of care. MN Rule 4658.0900 Subpart 1. 4658.0900 ACTIVITY AND RECREATION PROGRAM.

6. A nursing home must arrange for the provision of Pharmacy Services. MN Rule 4658.1325 Subpart 1. 4658.1325 ADMINISTRATION OF MEDICATIONS. Pharmacy Services means services to ensure the accurate acquiring, receiving, and administering of all drugs to meet the needs of each resident. (MN Rule 4658.1300 Subp. 3.) 4658.1300 MEDICATIONS AND PHARMACY SERVICES; DEFINITIONS.
7. Furnishings and equipment for resident care must be provided. MN Rule 4658.1405. 4658.1405 RESIDENT UNITS.

8. The nursing home must ensure that a resident is offered a diet which supplies the caloric and nutrient needs as determined by the comprehensive resident assessment. MN Rule 4658.0600 Subpart 2. 4658.0600 DIETARY SERVICE.

Waiver Information

MDH requests that the following information be submitted with each waiver request. This is necessary to properly evaluate the request for the waiver of the rule prohibiting admission of children to nursing homes (MN Rule.4655.1000). This information will be used to provide MDH, the payers of the care, and the guardians of the child, a reasonable assurance that individual children's needs are being met in the nursing home. The requested information corresponds to the rule requirements listed in the previous section, Program Policies. Please provide the following in the order enumerated below: 4655.1000 VARIANCE AND WAIVERS.

1. A letter from the attending physician indicating diagnosis and that a nursing home is the appropriate placement, including a brief description of whether alternative service settings were explored, and the reasons why alternative service settings were rejected (refer to Program Policies, 1.);
2. A listing of the child's age and needs, including physical, social and rehabilitation potential (refer to Program Policies, 2.);
3. A description of how the facility will meet the child's needs in the nursing home setting, including a description of how the facility will adequately staff to meet the child's needs (refer to Program Policies, 3.);
4. For uninterrupted stays of longer than 30 days, a quarterly report to include information about ongoing discharge planning (refer to Program Policies, 3.);
5. A description of how staff will be oriented, monitored and supervised to deliver cares to the child (refer to Program Policies, 4.);
6. If the child will be in the facility longer than 15 days, some verification that education needs of the child will be met. (The process is to contact the host school district to notify personnel of the child's admission. Federal and state law require the provision of an education to all children with handicaps (MN Statutes, section 125A.03) (Refer to Program Policies, 5.);
7. Evidence that staff is trained in the appropriate dose levels of any medications given to the child, including information on side effects and monitoring, and that this is part of the physician's orders (Refer to Program Policies, 6.);
8. A brief description of where the child will be housed, including assurance that the child will be placed with a compatible roommate and in a safe environment which is age appropriate (eg. proper size bed, bright colors, pictures) (Refer to Program Policies, 7.); and
9. Assurance that dietary staff will review the child's nutritional needs and adjust the menus accordingly (Refer to Program Policies, 8.);
10. If the information submitted is for a child you have already admitted, please indicate date of admission (Refer to Program Policies, 2.).

Other

Briefly describe what criteria will be used in determining appropriate activities and level of integration into the environment (eg. social and recreational activities, dining); and notify the Minnesota Department of Health, Health Regulation Division, in writing, when a child is discharged.