50-24.4-01.1. Nursing home resident payment classifications - Procedures for reconsideration

50-24.4-01.1. Nursing home resident payment classifications - Procedures for

reconsideration.

1. For purposes of this section, "resident's representative" includes the resident's

guardian or conservator, a person authorized or required to pay the nursing home

expenses of the resident, or any other person designated by the resident in writing.

2. The department shall establish resident payment classifications for the care of

residents of nursing homes.

3. The department shall assign nursing home residents to the appropriate payment

classification based upon assessments of the residents.

4. The department shall notify each resident, and the nursing home in which the resident

resides, of the payment classification established under subsection 3. The notice must

inform the resident of the classification that was assigned, the opportunity to review

the documentation supporting the classification, the opportunity to obtain clarification

from the department, and the opportunity to appeal the classification. The notice of

resident classification must be sent by first-class mail. The individual resident notices

may be sent to the resident's nursing home for distribution to the resident in which

event the nursing home is responsible for the distribution of the notice to the resident

and to the resident's representative, if any. This notice must be distributed to the

resident and sent first-class mail or hand-delivered to the resident's representative

within three working days after the nursing home's receipt of the notice from the

department.

5. The resident or the nursing home may appeal the assigned payment classification to

the department. The appeal must be submitted in writing to the department within thirty

days of the receipt of the notice of resident classification. For appeals submitted by or

on behalf of the resident, the time period for submission of the request begins on the

date the classification notice is delivered to the resident, or mailed or delivered to the

resident's representative, whichever is latest. The appeal must be accompanied by the

name of the resident, the name and address of the nursing home in which the resident

resides, the reasons for the appeal, the requested classification changes, and

documentation supporting the requested classification. The documentation

accompanying the appeal is limited to documentation intended to establish that the

needs of the resident, at the time of the assessment resulting in the disputed

classification, justify a change of classification.

6. Upon written request, the nursing home shall give the resident or the resident's

representative a copy of the assessment form and the other documentation that was

given to the department to support the assessment findings. The nursing home shall

also provide access to and a copy of other information from the resident's record that

has been requested by or on behalf of the resident to support a resident's appeal. A

copy of any requested material must be provided within three working days of receipt

of a written request for the information. Upon request, the nursing home shall assist

the resident in preparing an appeal.

7. In addition to the information required in subsection 5, an appeal by a nursing home

must be accompanied by the following information: the date the resident payment

classification notices were received by the nursing home; the date the classification

notices were distributed to the resident or the resident's representative; and a copy of

a notice of appeal sent to the resident or to the resident's representative. This notice

must tell the resident or the resident's representative that the resident's classification is

being appealed, the reason for the appeal, that the resident's rate will change if the

appeal is approved by the department and the extent of the change, that copies of the

nursing home's appeal and supporting documentation are available for review, and

or to the resident's representative. This notice

must tell the resident or the resident's representative that the resident's classification is

being appealed, the reason for the appeal, that the resident's rate will change if the

appeal is approved by the department and the extent of the change, that copies of the

nursing home's appeal and supporting documentation are available for review, and

that the resident also has the right to appeal. If the nursing home fails to provide this

information with the appeal, the appeal must be denied, and the nursing home may not

make further appeals concerning that specific resident payment classification until

such time as the resident's payment classification is re-established by the department.

8. The appeal determination of the department must be made by individuals not involved

in reviewing the assessment that established the disputed classification. The appeal

determination must be based upon the initial assessment and upon the information

provided to the department under subsection 5. If the department determines that it is

necessary for the appeal determination, it may conduct onsite reviews. Within fifteen

working days of receiving the appeal, the department shall affirm or modify the original

resident classification. The original classification must be modified if the department

determines that the assessment resulting in the classification did not accurately reflect

the needs of the resident at the time of the assessment. The resident and the nursing

home must be notified within five working days after the decision is made.

9. The appeal determination under subsection 8 is the final administrative decision of the

agency. That decision is subject to appeal to the district court, and for that purpose, the

decision must be treated as a decision on a petition for rehearing made pursuant to

section 28-32-40. Appeal to the district court must be taken in the manner required by

section 28-32-42.