1.Short title; table of
contents
(a)This Act may be cited
as the Long-Term Care Hospital
Improvement Act of 2011
.
(b)The table of contents of this Act is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Specification of criteria for patient preadmission,
admission, and continuing stay assessments.
Sec. 3. Specification of core services and patient care
requirements.
Sec. 4. Additional long-term care hospital payment
classification criteria.
Sec. 5. Application of criteria for certain
hospitals.
2.Specification of
criteria for patient preadmission, admission, and continuing stay
assessments
(a)Section 1861(ccc) of the Social Security Act (42 U.S.C.
1395x(ccc)) is amended—
(1)in paragraph
(4)(A)—
(A)by inserting
in accordance with paragraph (2)
after screens patients
prior to admission for appropriateness of admission to a long-term care
hospital
;
(B)by striking
validates within 48 hours of admission
and inserting
validates, in accordance with paragraph (3), within 24 hours of
admission
;
(C)by inserting
in accordance with paragraph (4)
after regularly
evaluates
; and
(D)by inserting
in accordance with paragraph (5)
after assesses the
available discharge options
;
(2)in paragraph (4),
by redesignating subparagraphs (A), (B), and (C) as clauses (i), (ii), and
(iii), respectively;
(3)by redesignating
paragraphs (1), (2), (3), and (4) as subparagraphs (A), (B), (C), and (D),
respectively;
(4)by inserting
(1)
after (ccc)
; and
(5)by adding at the
end the following new paragraphs:
(2)An institution provides for screening
of patients prior to admission in accordance with this paragraph by using a
standardized preadmission patient screening process that meets the following
criteria:
(A)(i)Preadmission patient
screening shall be conducted by a clinical health care professional (as defined
in clause (ii)) who is licensed or certified by the State in which the
institution is located and permitted to conduct preadmission patient screening
(as defined in subparagraph (C)) within the scope of practice of the
professional under such State law.
(ii)For purposes of clause (i), the term
clinical health care professional
means a physician, a
registered professional nurse, a licensed practical or licensed vocational
nurse, a physician assistant, a respiratory therapist, and such other clinical
health care professionals as the Secretary may specify.
(B)(i)Except as provided in
clause (ii), preadmission patient screening shall be conducted during the
36-hour period preceding admission of the patient to the institution.
(ii)In the case of preadmission patient
screening that takes place before the 36-hour period described in clause (i),
such screening shall be updated by telephone or otherwise during such 36-hour
period.
(C)In this paragraph, the term
preadmission patient screening
means a process, with respect to
a patient, for the determination whether admission to a long-term care hospital
for care is medically reasonable and necessary for the patient based on the
following:
(i)The medical status of the
patient.
(ii)The planned level of improvement
in the condition of the patient if admitted to the institution.
(iii)Estimation of the expected length
of stay of the patient in the institution to achieve health care goals with
respect to the patient.
(iv)Evaluation of risk for clinical
complications of the patient.
(v)The primary and secondary diagnoses
of the patient for which treatment in the institution is appropriate.
(vi)Identification of the primary
treatments the patient will need in the institution.
(vii)Evaluation of whether there is a
more appropriate treatment setting for the patient at a lower level of care
instead of in the institution.
(viii)The anticipated
post-institutional discharge settings and available treatments.
(ix)Such other clinical rationale for
the admission of the patient that the clinical health care professional
determines to be appropriate.
(D)A patient may not be admitted to the
institution unless a physician (as defined in subsection (r)(1)) reviews and
concurs with the most current results of the preadmission patient screening
with respect to the patient and approves, in advance, the admission of the
patient to the institution.
(3)An institution validates patients meeting
admission criteria in accordance with this paragraph if, not later than 24
hours from the time of admission of a patient to the institution, the
institution provides for a face-to-face evaluation of the patient by a
physician (as defined in subsection (r)(1)) and, with respect to patients who
are identified as medically appropriate for admission to the institution based
on such evaluation, the physician attests that the patient meets the following
patient admission criteria and provides in the medical record of the patient
for the documentation of such attestation as well as any additional clinical
rationale that the physician determines to be appropriate that establishes the
medical reasonableness and necessity of furnishing care to the patient in the
institution based on such admission criteria:
(A)The patient has two or more active
secondary diagnoses.
(B)It is reasonable to expect that the
patient will—
(i)require the level of care furnished
to an inpatient of a hospital;
(ii)benefit from a medically necessary
program of care furnished by the institution; and
(iii)require an extended stay for care
in a hospital that is typical of the extended stays for care provided by
long-term care hospitals.
(C)(i)The furnishing of
intensive therapy (as defined in clause (ii)) to the patient is not the primary
medical justification for the admission of the patient to the
institution.
(ii)For purposes of clause (i), the term
intensive therapy
means a program of physical or occupational
therapy or speech-language pathology services furnished three hours per day,
five days per week in such an institution or similar institution such as a
rehabilitation facility (as described in section 1886(j)).
(4)An institution regularly evaluates
patients in accordance with this paragraph if—
(A)not later than 7 days after the date
of admission of the patient to the institution, and weekly thereafter until
discharge, the institution provides for a face-to-face evaluation of the
patient by a physician (as defined in subsection (r)(1)) to assess whether the
continuation of the furnishing of inpatient hospital services to the patient is
medically reasonable and necessary;
(B)such an assessment is based on the
medical reasonableness and necessity of the continuation of the furnishing of
inpatient hospital services to the patient and is not based on the admission
criteria described in paragraph (3) applicable to the patient; and
(C)the physician performing the evaluation
provides in the medical record of the patient for the documentation of the
evaluation as well as any additional clinical rationale that the physician
determines to be appropriate that establishes the medical reasonableness and
necessity of the continuation of inpatient hospital services for the patient in
the institution based on the outcome of each such evaluation.
(5)(A)Subject to subparagraph
(B), an institution assesses available discharge options in accordance with
this paragraph if, upon a determination by a physician (as defined in
subsection (r)(1)) that a patient admitted to the institution no longer
requires the furnishing of hospital inpatient care, the patient is discharged
from the institution when a safe and appropriate discharge option is available
to the patient.
(B)(i)In the case of a patient
for whom a determination described in subparagraph (A) has been made but for
whom a safe and appropriate discharge option is unavailable, such patient may
continue as an inpatient of the institution for such period of days until a
safe and appropriate discharge option is available to the patient.
(ii)Clause (i) shall only apply if the
institution—
(I)notifies the patient that a
determination described in subparagraph (A) has been made with respect to that
patient; and
(II)actively seeks to identify a safe and
appropriate discharge option that is available to the patient for the
furnishing of post long-term care hospital care.
(iii)Subject to clause (ii), the period
of days described in clause (i) shall be included for purposes of paragraph
(1)(B) (relating to determination of average inpatient length of stay) but, for
purposes of section 1886(m) (relating to prospective payment for inpatient
hospital services furnished by long-term care hospitals), such days shall be
paid at the lesser of such prospective payment amount or
cost.
.
(b)The amendments made by subsection (a) shall—
(1)take effect on
the day that is six months after the date of the enactment of this Act;
and
(2)apply with
respect to cost reporting periods beginning on or after the effective date
described in paragraph (1).
3.Specification of
core services and patient care requirements
(a)Section 1861(ccc) of the Social Security Act (42 U.S.C.
1395x(ccc)), as amended by section 2, is amended—
(1)in paragraph
(1)(D)(ii), by inserting , and meets the requirements of paragraph
(6)
before the semicolon; and
(2)by adding at the
end the following new paragraph:
(6)The following are the requirements of this
paragraph applicable to an institution:
(A)The types of items and services
furnished to inpatients of the institution include at least the following items
and services furnished by clinicians who are licensed or certified by the State
in which the services are furnished to furnish such services:
(i)Complex respiratory services,
including the availability on site of respiratory therapists 24 hours a day, 7
days a week and access to consultation by pulmonologists 24 hours a day, 7 days
a week.
(ii)Complex wound services, including
provision of wound care by registered nurses and access to consultations by
physicians (as defined in subsection (r)(1)) for infectious disease.
(iii)Care for patients with medically
complex conditions.
(iv)The availability on site 24 hours
a day, 7 days a week of advanced cardiac life support furnished by health care
personnel trained in advanced cardiac life support.
(B)The institution develops a plan of
care for each patient admitted to the institution which includes the
following:
(i)Not later than 24 hours after the
time of admission of a patient to the institution, a physician (as defined in
subsection (r)(1)) conducts an in-person evaluation of the patient; begins to
develop a plan of care for the patient; and documents the clinical status of
the patient.
(ii)Not later than 7 days after the
date of admission of the patient to the institution, and weekly thereafter
until discharge, a physician-directed interdisciplinary team establishes and
updates, as appropriate, an individualized plan of care for the patient.
(C)The institution provides that, 24
hours per day, 7 days per week, a physician (as defined in subsection (r)(1))
is on-site or is on call and immediately available by telephone or radio
contact and available on site within 30 minutes (or 60 minutes in the case of
an institution located in a rural area (as defined for purposes of section
1886(d))). If a physician (as so defined) is not on-site 24 hours per day, 7
days per week, the institution shall furnish each patient (or their
representative), at the beginning of their stay at the institution, notice of
such fact. Such notice shall contain such information as the Secretary
determines appropriate.
(D)The institution provides for on-site
registered nurses 24 hours per day, 7 days per
week.
.
(b)The amendments made by subsection (a) shall—
(1)take effect on
the day that is six months after the date of the enactment of this Act;
and
(2)apply with
respect to cost reporting periods beginning on or after the effective date
described in paragraph (1).
4.Additional
long-term care hospital payment classification criteria
(a)Section 1861(ccc) of the Social Security Act (42 U.S.C.
1395x(ccc)), as amended by sections 2 and 3, is amended—
(1)in paragraph
(1)—
(A)by striking
and
at the end of subparagraph (C);
(B)by striking the
period at the end of subparagraph (D) and inserting ; and
;
and
(C)by adding at the
end the following new subparagraph:
(E)meets the requirements of paragraph
(7)(A).
;
and
(2)by adding at the
end the following new paragraph:
(7)(A)With respect to a
12-month period specified by the Secretary (which may be a cost reporting
period) of a long-term care hospital for a fiscal year, the hospital meets the
requirements of this subparagraph if each of the discharges comprising not less
than the applicable percent (as defined in subparagraph (B)) of the total
discharges of Medicare fee-for-service beneficiaries (as defined in
subparagraph (C)) of such hospital for such period meets one or more of the
following criteria:
(i)The discharge has a length of stay of
25 days or greater.
(ii)(I)The discharge applies to
an inpatient who was a short-term acute care hospital outlier (as defined in
subclause (II)) immediately prior to admission to the long-term care
hospital.
(II)For purposes of subclause (I), the
term short-term acute care hospital outlier
means an inpatient
discharge of a subsection (d) hospital in which inpatient hospital services
were furnished for a diagnosis-related group or groups for which a payment
adjustment under section 1886(d)(5)(A) (relating to outlier payments for
subsection (d) hospitals) was made to such subsection (d) hospital for such
services furnished to such inpatient.
(iii)The discharge applies to an
inpatient who received ventilator services in the long-term care
hospital.
(iv)The discharge has three or more of
any Medicare-Severity-Long-Term-Care-Diagnosis-Related-Group complications and
comorbidities or major complications and comorbidities.
(B)For purposes of subparagraph (A), the
term applicable percentage
means—
(i)with respect to the first 12-month
period specified by the Secretary of a long-term care hospital, 50
percent;
(ii)with respect to the 12-month period
specified by the Secretary that begins after the 12-month period described in
clause (i), 60 percent;
(iii)with respect to the 12-month period
specified by the Secretary that begins after the 12-month period described in
clause (ii)—
(I)in the case of a long-term care
hospital that is government-owned and operated, 65 percent; and
(II)in the case of a long-term care
hospital other than such a hospital described in subclause (I), 70 percent;
and
(iv)with respect to the 12-month period
specified by the Secretary that begins after the 12-month period described in
clause (iii) and each succeeding 12-month period so specified, 70
percent.
(C)For purposes of subparagraph (A), the
term Medicare fee-for-service beneficiary
means an individual
who is entitled to benefits under part A and enrolled under part B who is not
enrolled in an Medicare Advantage plan under part C.
(D)(i)In the case of a
determination by the Secretary that a long-term care hospital does not meet the
criteria under subparagraph (A) with respect to a 12-month period or the
criteria under paragraph (1)(B) (relating to average inpatient length of stay
(as determined by the Secretary) of greater than 25 days) with respect to a
cost reporting period—
(I)the Secretary shall provide notice to
such long-term care hospital of such determination; and
(II)the Secretary shall provide such
long-term care hospital a cure period (as defined in clause (ii)) to comply
with such criteria for purposes of such 12-month period or cost reporting
period, as the case may be.
(ii)For purposes of clause (i)(II), the
term cure period
means a 6-month period, beginning on the first
day of the first month that begins after the date of a notice under clause
(i)(I) during which the hospital meets the criteria under subparagraph (A) or
paragraph (1)(B), as the case may be, for not less than 5 months.
(iii)In the case of a hospital for which
a determination is made under clause (i) and with respect to which the
Secretary finds, during the cure period, fails to meet the criteria under
subparagraph (A) or paragraph (1)(B), as the case may be, for not less than 5
months, the Secretary shall provide notice to such hospital of such finding.
Any change in the payment classification of such hospital under this title from
a long-term care hospital to a subsection (d) hospital (as defined in section
1886(d)(1)(B)) as a result of a finding under this clause or a determination
under clause (i), shall apply with respect to the next cost reporting beginning
after the date of such finding.
(iv)The provisions of section 1878
(relating to rights to a hearing before the Provider Reimbursement Review Board
and judicial review) shall apply in the case of a long-term care hospital with
respect to which the Secretary has made a determination under clause
(i).
.
(b)The amendments made by subsection (a) shall—
(1)take effect on
the day that is six months after the date of the enactment of this Act;
and
(2)apply with
respect to 12-month periods (as specified by the Secretary of Health and Human
Services under section 1861(ccc)(7)(A) of the Social Security Act) beginning on
or after the effective date described in paragraph (1).
(c)
(1)
(A)The Secretary of Health and Human Services (in this
section referred to as the Secretary
) shall promulgate
regulations to carry out the amendments made by this section by substituting
the criteria made applicable to long-term care hospitals and facilities by
reason of paragraph (7) of section 1861(ccc) of the Social Security Act (42
U.S.C. 1395x(ccc)), as added by subsection (a)(2) (in this subsection referred
to as the section 1861(ccc)(7) criteria
), for the payment
adjustments applicable to such hospitals under sections 412.534 and 412.536 of
title 42, Code of Federal Regulations (relating to 25 percent patient threshold
payment adjustments), and under any related section of such title. The
Secretary shall implement the substitution referred to in the preceding
sentence in a seamless manner such that payment adjustments applicable to
long-term care hospitals and facilities under such sections 412.534 and
412.536, and other related sections, shall have no force or effect in law with
respect to periods applicable to a long-term care hospital or facility that
begin after the substitution by the Secretary of the section 1861(ccc)(7)
criteria with respect to that hospital or facility.
(B)Application
prior to substitutionUntil such time as the Secretary implements
the substitution described in this subparagraph (A), the modifications to the
payment adjustments under such sections 412.534 and 412.536, and other related
sections, pursuant to Public Law 110–173 (42 U.S.C. 1395ww note), as amended,
shall continue to apply.
(2)Payment
adjustments applicable to long-term care hospitals and facilities under section
412.529(c)(3)(i) of title 42, Code of Federal Regulations, shall have no force
or effect in law on or after the date of the enactment of this Act.
(3)The
Secretary shall not promulgate any payment adjustment that is similar to the
payment adjustments referred to in paragraph (1) or (2).
(d)No application
of adjustment to standard amount
(1)Notwithstanding any other provision of law, the Secretary
shall not make a one-time prospective adjustment to long-term care hospital
prospective payment rates under section 412.523(d)(3) of title 42, Code of
Federal Regulations, or any similar provision.
(2)Section 114(c)(4) of the Medicare, Medicaid, and SCHIP
Extension Act of 2007 (42 U.S.C. 1395ww note), as amended by sections 3106(a)
and 10312(a) of the Patient Protection and Affordable Care Act (Public Law
111–148), is amended by striking , for the 5-year period beginning on
the date of the enactment of this Act,
.
5.Application of
criteria for certain hospitals
(a)Section
1814(b)(3) hospitals
(1)Section 1861(ccc) of the Social Security Act (42 U.S.C.
1395x(ccc)), as amended by sections 2, 3 and 4, is amended by adding at the end
the following new paragraph:
(8)This subsection (other than paragraph
(7)) shall apply to a long-term care hospital that is paid under section
1814(b)(3).
.
(2)The amendments made by paragraph (1) shall—
(A)take effect on
the day that is six months after the date of the enactment of this Act;
and
(B)apply with
respect to cost reporting periods beginning on or after the effective date
described in subparagraph (A).
(b)Exemption of
section
1886(d)(1)(B)(iv)(II)
hospitalsSection 1861(ccc) of the Social Security Act (42 U.S.C.
1395x(ccc)), as amended by sections 2, 3 and 4, and subsection (a) of this
section, is amended by adding at the end the following new paragraph:
(9)Paragraphs (2) through (8) of this
subsection shall not apply to a long-term care hospital described in section
1886(d)(1)(B)(iv)(II).
.