02 — Capability · BC-1890.20
Skilled Nursing & Long-Term Care
Admit residents at the level of care they need, plan and deliver that care in the facility, and support long-stay residents and their families, including the path to Medicaid coverage of the stay. The standardized resident assessment and stay billing are separate capabilities.
- Skilled Nursing Facility Operations
- SNF Operations
- Nursing Home Operations
- Long-Term Care Operations
In scope
- Preadmission screening, admission agreements, level of care and discharge or transfer notices
- Baseline and comprehensive resident care plans and care plan conferences
- Therapy delivery tracking by discipline, minutes and mode for each resident
- Long-stay resident services, resident funds and Medicaid long-term care applications
Out of scope
- Hospital-run inpatient and outpatient rehabilitation services (see BC-1830.60)
- The MDS assessment and its submission (see BC-1890.40)
- State survey inspections and correcting cited deficiencies (see BC-1850.50)
- Coverage enrollment help for hospital patients (see BC-1810.50)
Realized by · 0
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Used in · 5
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Decomposes into · 6
- BC-1890.20.10Resident Admission & Level of CareScreen each referral before admission, including the federally required screening for serious mental illness and intellectual disability, confirm a skilled or custodial level of care, a bed and, for a Medicare-covered stay, a three-day qualifying inpatient hospital stay or a waiver of it, and admit the resident with consents and an admission agreement.
- BC-1890.20.20Resident Care PlanningWrite a baseline care plan within the first days of the stay and a comprehensive one from the resident's assessment, review it with the resident and family at care plan conferences, and keep it current as needs change.
- BC-1890.20.30Resident Therapy TrackingSchedule and record the physical, occupational and speech therapy each resident receives, by discipline, minutes and mode of delivery, so the record supports the care plan, the assessment and the claim.
- BC-1890.20.40Long-Stay Resident ServicesProvide the daily living support, activities, social services and dining long-stay residents rely on, hold and account for residents' personal funds when they ask, and resolve resident and family grievances.
- BC-1890.20.50Medicaid Long-Term Care EligibilityHelp residents and families apply for Medicaid coverage of the stay, follow pending applications and renewals to a decision, and apply each resident's monthly share of cost to the account.
- BC-1890.20.60Resident Discharge & TransferPlan each resident's return home or move to another setting, give the required transfer, discharge and bed-hold notices, and send the next provider what it needs to continue care.