CHAPTER He-Hea 2100  LONG-TERM ACUTE CARE HOSPITAL SERVICES

 

PART He-Hea 2101  DEFINITIONS

 

          He-Hea 2101.01  Definitions.

 

          (a)  Acute care hospital” means a facility licensed as a general hospital under RSA 151.

 

          (b)  Applicant” means “applicant” as defined in RSA 151-C:2, II.

 

          (c)  Board” means “board” as defined in RSA 151-C:2, IV.

 

          (d)  “Board-certified” means the confirmation given by a national or regional association to a physician as having passed special examinations for his or her medical specialty.

 

          (e)  “Centers for Medicare and Medicaid Services (CMS)” means the federal agency responsible for the management of the Medicare and Medicaid programs, 2 national health insurance programs for the economically disadvantaged and persons aged 65 and over.

 

          (f)  “Certificate of need (CON)” means “certificate of need” as defined in RSA 151-C:2, VIII.

 

          (g)  “Deeming authority” means the authority granted by CMS to an accrediting organization to enforce CMS standards relating to Medicare and Medicaid participation.

 

          (h)  Department” means the N.H. department of health and human services.

 

          (i)  “Detrimental” means an adverse impact on the ability to maintain the accessibility, quality and cost of health care services in the area.

 

          (j)  “Diagnosis Related Groups code (DRG)” means the statistical symbol used to categorize major diagnosis and procedures, age, sex and the presence of complications or co morbidities, of hospitalized patients for medical records and reimbursement purposes.

 

          (k)  “Free-standing long-term acute care hospital (free-standing LTACH)” means a long-term acute care hospital that is owned, operated and located distinctly apart from any existing licensed facility.

 

          (l)  Hospital within a Hospital (HwH)” means a long-term acute care hospital that:

 

(1)  Is licensed pursuant to RSA 151;

 

(2)  Occupies space in a building or on the same campus also used by an existing licensed acute care hospital; and

 

(3)  Can certify that it will comply with CMS requirements to meet conditions of participation for an HwH.

 

          (m)  “Joint Commission on Accreditation of Healthcare Organizations (JCAHO)” means a not-for-profit-accrediting organization that provides healthcare and accrediting performance standards to healthcare organizations.  It includes the term “The Joint Commission (TJC).”

 

          (n)  “Long-term acute care bed” means a bed in an LTACH reserved for patients receiving long-term acute care services.

 

          (o)  “Long-term acute care hospital (LTACH)” means a facility that is certified by CMS as a long-term acute care hospital and licensed pursuant to RSA 151, and provides a broad spectrum of clinical services to acutely ill and medically complex patients requiring, on average, a length of stay of 25 days or greater. 

 

          (p)  “Marshall Valuation Service” means an appraisal guide for the development and reporting of replacement building and equipment costs used to determine construction/renovation costs of commercial buildings.

 

          (q)  “Quality improvement program” means a comprehensive, ongoing facility-wide program designed to:

 

(1)  Assess the provision of long-term acute care services;

 

(2)  Identify quality improvement opportunities and system failures; and

 

(3)  Assure that remedial action is implemented and evaluated.

 

          (r)  “Satellite long-term acute care hospital (satellite LTACH)” means an extension of an existing long-term acute care hospital that:

 

(1)  Is licensed pursuant to RSA 151;

 

(2)  Provides long term acute inpatient services to patients in the same building or on the same campus as an acute care hospital but is not operated under common ownership or control with the host acute care hospital; and

 

(3)  Can certify that it will comply with CMS requirements to meet conditions of participation for a satellite LTACH.

 

          (s)  “Story height multiplier” means the number by which the base cost of a building is multiplied to adjust for any variation in average story height from the base of 12 feet.

 

Source.  #9110, eff 3-25-08

 

PART He-Hea 2102  STANDARDS FOR DETERMINING THE NEED FOR LONG-TERM ACUTE CARE HOSPITALS IN THE STATE OF NEW HAMPSHIRE

 

          He-Hea 2102.01  Bed Minimum Requirement.  To promote the efficient use of resources, promote quality and ensure financial viability, minimum bed counts shall be as follows:

 

          (a)  Minimum size for a freestanding LTACH shall be 60 licensed beds;

 

          (b)  Minimum size for an HwH or satellite LTACH shall be 20 licensed beds; and

 

          (c)  Notwithstanding paragraph (b) above, the minimum size for an HwH or satellite LTACH within the service area of a critical access hospital shall be 10 licensed beds.

 

Source.  #9110, eff 3-25-08

 

          He-Hea 2102.02  Statewide Standard.  The number of long-term acute care beds statewide shall be .5 for each 10,000 persons.

 

Source.  #9110, eff 3-25-08

 

          He-Hea 2102.03  Determination of Need for Long-Term Acute Care Hospitals.

 

          (a)  POP” means the current population of NH as determined by NH Office of Energy and Planning.

 

          (b)  5” means .5 beds per 10,000 population.

 

          (c)  Need for long-term acute care beds shall be determined by dividing state population by 10,000, and multiplying the quotient by .5, as in the formula below:

 

(POP/10,000)(.5)

 

Source.  #9110, eff 3-25-08

 

          He-Hea 2102.04  Determination of Unmet Need.

 

          (a)  The board shall make a determination of unmet need for LTACH beds no later than 45 days from the initial effective date of this chapter, and either:

 

(1)  Two years after license and operation of any LTACH awarded a CON; or

 

(2)  Every three years thereafter on July 1.

 

          (b)  Unmet need shall be determined by subtracting the number of licensed or approved LTACH beds from that number calculated to be needed under He-Hea 2102.03.

 

          (c)  The unmet need shall be the difference between the calculated need and the number of licensed or approved beds.

 

Source.  #9110, eff 3-25-08

 

          He-Hea 2102.05  Access to Care.  Applicants shall ensure that no resident of the state of New Hampshire will be refused LTACH services by them on the basis of:

 

          (a)  Race;

 

          (b)  Color;

 

          (c)  Creed;

 

          (d)  Age;

 

          (e)  Gender;

 

          (f)  Sexual orientation;

 

          (g)  Disability; or

 

          (h)  Ability to pay.

 

Source.  #9110, eff 3-25-08

 

          He-Hea 2102.06  Location of Services.  LTACH services shall only be offered at a:

 

          (a)  Free-standing LTACH;

 

          (b)  Satellite LTACH; or

 

          (c)  HwH.

 

Source.  #9110, eff 3-25-08

 

          He-Hea 2102.07  Transfer of Long-Term Acute Care Beds.

 

          (a)  Any LTACH holding a CON for long-term acute care beds in the state may transfer all or a portion of those beds to another licensed LTACH within the state provided notice is made to the board.

 

          (b)  Notice of transfer shall be made jointly in writing, by the facility intending to transfer beds and the facility receiving the beds identifying the name, address and location of the transferring and receiving facility, and be signed and authorized by both parties.

 

          (c)  No such transfer shall be permitted if it causes the bed count of the transferring facility to fall below that identified in He-Hea 2102.04.

 

          (d)  Any purchase price paid by the transferee for the transfer of long term acute care beds shall not be considered in the total project cost that is compared to the threshold amount set by RSA 151-C:5, II.

 

Source.  #9110, eff 3-25-08

 

          He-Hea 2102.08  Administrative Requirements.  Applicants for a CON shall develop treatment policies which, at minimum, address:

 

          (a)  Intake screenings;

 

          (b)  Admissions;

 

          (c)  Transfers;

 

          (d)  Patient discharges, including a plan for continuity of patient care;

 

          (e)  Individual treatment plan(s) for each patient;

 

          (f)  Medical records; and

 

          (g)  Availability of services provided by the hospital to its inpatients, directly or through contractual agreements, or both, which shall include, at minimum:

 

(1)  Physician services;

 

(2)  Nursing services;

 

(3)  Diagnostic radiology services;

 

(4)  Social work and case management services;

 

(5)  Nutritional services;

 

(6)  Pharmacy services;

 

(7)  Laboratory services;

 

(8)  Rehabilitation services;

 

(9)  Cardiopulmonary/respiratory services; and

 

(10)  Such diagnostic, therapeutic, surgical and medical services as are necessary to treat medically complex patients in an LTACH setting, including but not limited to:

 

a.  Excisional debridement;

 

b.  Percutaneous tracheotomies,

 

c.  Central venous access;

 

d.  Telemetry; and

 

e.  IV therapy.

 

Source.  #9110, eff 3-25-08

 

          He-Hea 2102.09  Staffing Requirements.

 

          (a)  Applicants for a proposed LTACH shall provide a staffing plan that includes licensed professionals who provide services to the LTACH’s patients as:

 

(1)  Employees;

 

(2)  Under contract; or

 

(3)  As members of the LTACH’s organized medical staff.

 

          (b)  The following personnel complement shall be available in the LTACH:

 

(1)  A director of nursing services who shall be a registered nurse currently licensed in the state of New Hampshire;

 

(2)  A medical director who shall be:

 

a.  A medical doctor or doctor of osteopathic medicine currently licensed as a physician in the state of New Hampshire; and

 

b.  Board-certified in a specialty relevant to the services provided by the LTACH;

 

(3)  A pharmacist who shall be currently licensed by the state of New Hampshire;

 

(4)  A dietician who shall be licensed by the state of New Hampshire;

 

(5)  Board-certified, New Hampshire licensed physicians practicing in:

 

a.  Cardiology;

 

b.  Pulmonology;

 

c.  Infectious disease; and

 

d.  Internal medicine;

 

(6)  Additional professionals licensed in the state of New Hampshire, including but not limited to:

 

a.  Registered nurses;

 

b.  Licensed practical nurses;

 

c.  Respiratory care providers;

 

d.  Physical therapists;

 

e.  Occupational therapists;

 

f.  Speech-language assistants; and

 

g.  Speech-language pathologists.

 

(7)  Additional personnel, including but not limited to:

 

a.  Social workers; and

 

b.  Laboratory personnel.

 

Source.  #9110, eff 3-25-08

 

          He-Hea 2102.10  Quality Improvement Program.

 

          (a)  Each facility shall establish and maintain a comprehensive, ongoing, facility wide quality improvement program which involves assessment of all quality improvement activities conducted in the provision of its health care programs and services at all levels which includes no less than:

 

(1)  Establishment of standards and criteria for the assessment of the quality of health care services provided and the appropriateness of the resources utilized;

 

(2)  Assessment of outcomes;

 

(3)  Ongoing review of programs and services by physicians and other health professionals; and

 

(4)  A mechanism to assure the utilization of systematic data collection based on valid samples of the total patient population to measure performance and patient results, and to make recommendations to physicians and departments of needed changes.

 

          (b)  Each facility shall establish and maintain a current and complete clinical record for every patient treated.

 

          (c)  Each applicant currently operating a LTACH and those filing an application for additional services shall provide a copy of its quality improvement program which indicates how the existing and additional services comply with standards required by this section and:

 

(1)  JCAHO, if accredited;

 

(2)  RSA 151;

 

(3)  CMS; or

 

(4)  Other accrediting body that has received deeming authority from CMS.

 

          (d)  An applicant who does not currently provide LTACH services but files an application for a CON shall:

 

(1)  Develop the proposed quality improvement program in accordance with this section;

 

(2)  Include a copy of such plan in its application for a CON; and

 

(3)  Develop each service specified in such plan in accordance with:

 

a.  JCAHO, if accreditation will be sought;

 

b.  RSA 151;

 

c.  CMS; or

 

d.  Other accrediting body that has received deeming authority from CMS.

 

Source.  #9110, eff 3-25-08

 

          He-Hea 2102.11  Impact on Other Providers.

 

          (a)  Applicants proposing to establish, expand or renovate a freestanding LTACH, satellite LTACH or HwH shall demonstrate that the proposed facility shall maintain or improve, for the proposed service area, the:

 

(1)  Quality of care;

 

(2)  Access to and availability of health care services; and

 

(3)  Cost effectiveness of health care services provided.

 

          (b)  Demonstration shall be made by submitting with the application:

 

(1)  A copy of an existing or proposed quality improvement program pursuant to He-Hea 2102.10;

 

(2)  To the extent data is available, a statistical report in the application which shows how the proposed project is projected to affect health care services in the proposed service area in terms of:

 

a.  Utilization;

 

b.  Patient charges;

 

c.  Market share;

 

d.  Physician referral patterns;

 

e.  Personnel resources; and

 

f.  Referral sources.

 

(3)  Any correspondence from other facilities in the service area regarding the impact of the proposed project on their existing health care services including their continued ability to:

 

a.  Maintain quality health care services;

 

b.  Provide essential community services;

 

c.  Provide emergency services; and

 

d.  Provide charity care; and

 

(4)  A report in the application addressing how the establishment, expansion or renovation of a freestanding LTACH, satellite LTACH or HwH will not have a detrimental impact on health services within the proposed service area.

 

Source.  #9110, eff 3-25-08

 

PART He-Hea 2103  CRITERIA FOR EVALUATING LONG-TERM ACUTE CARE HOSPITAL SERVICES

 

          He-Hea 2103.01  Criteria.  In addition to the criteria in RSA 151-C:7 and He-Hea 303, applicants shall meet the criteria set forth in this section:

 

          (a)  Proposed LTACH services shall be financially feasible;

 

          (b)  In order to assess the current and long-range financial feasibility of the proposed project, each applicant shall demonstrate that resources:

 

(1)  Are available to fund the proposed capital costs and operating costs; and

 

(2)  Will be available to maintain operations in the event of interruptions to cash flow;

 

          (c)  Demonstration of financial feasibility shall be made by providing with the application:

 

(1)  For those applicants with existing LTACH programs and filing an application for a CON, copies of the facility’s financial statements for:

 

a.  The past 3 fiscal years; or

 

b.  Since the facility has been in existence, if less than 3 years;

 

(2)  For all facilities, documentation in the form of projected financial statements for the next 3 fiscal years; and

 

(3)  A copy of a letter from the applicant’s lender stating the method of financing which includes:

 

a.  Financed amount;

 

b.  Rate of interest; and

 

c.  Term of debt;

 

          (d)  Applicants shall provide a description of the state and patient populations which includes the following:

 

(1)  Demographic characteristics of the state by age and sex compositions;

 

(2)  Income levels of the state population;

 

(3)  Anticipated payer source by population totals and percentages expressed as:

 

a.  Medicare;

 

b.  Medicaid;

 

c.  Private insurance companies;

 

d.  Self-pay; and

 

e.  Health maintenance organizations;

 

(4)  A description of the anticipated patient population that includes, but is not limited to, the DRGs and comorbidities of the patients for whom the applicant anticipates caring;

 

          (e)  Applicants shall document the anticipated impact on patient charges as a result of the proposed project;

 

          (f)  Documentation of the proposed project’s anticipated impact on patient charges shall be made in the form of report included with the application identifying:

 

(1)  For an existing facility, a schedule of patient charges for:

 

a.  The past 3 fiscal years; or

 

b.  Since the facility has been in existence, if less than 3 years;

 

(2)  For all facilities a schedule of patient charges projected for 3 years after project completion; and

 

(3)  The anticipated project-related changes in patient charges;

 

          (g)  LTACH services shall be available and accessible to all persons in the state, including those persons in the state who might not have the means to pay for such services;

 

          (h)  Applicants shall demonstrate the extent to which LTACH services are available and accessible to all persons within its institution by providing a report in the application that:

 

(1)  Delineates the amount that is presently or planned to be budgeted to cover the cost of free care, reduced fee care, and bad debts; and

 

(2)  Separately delineates the amount of free care from bad debts in the projected financial report;

 

          (i)  Personnel resources shall be available to support the proposed LTACH services project;

 

          (j)  Demonstration of sufficient personnel resources for the LTACH services shall be made in the form of a report included in the application which includes:

 

(1)  A table listing the personnel which shall include each position and job title:

 

a.  For an existing facility, for:

 

1.  The past 3 fiscal years; or

 

2.  Since the facility has been in existence, if less than 3 years;

 

b.  For all facilities, projected for 3 years after project completion;

 

(2)  The number of medical staff employed by or with admission privileges to the facility;

 

(3)  An outline of the recruitment policies and procedures;

 

(4)  A schedule of contracted services which shall list the services that are provided, including, but not limited to:

 

a.  Emergency services;

 

b.  Outpatient services;

 

c.  Diagnostic evaluation services;

 

d.  Medical services;

 

e.  Social services; and

 

f.  Surgical services.

 

          (k)  In order to determine the financial feasibility of the project pursuant to RSA 151-C:7, II, applicants shall submit an assessment of costs and methods of construction for the proposed project;

 

          (l)  The assessment shall be made by providing preliminary floor plans showing space allocations expressed on a per square foot basis;

 

          (m)  Applicants shall provide a comparison of the anticipated proposed construction cost per square foot to the January 2007 edition of the Marshall Valuation Service, section 15, for the proposed class and type of construction;

 

          (n)  Applicants shall include a report with the application which provides:

 

(1)  Details of all the project costs and space of the proposed project;

 

(2)  An analysis of the class and quality of construction pursuant to section one of the January 2007 edition of the Marshall Valuation Service;

 

(3)  The allocation of costs within a multiple use building;

 

(4)  The allocations of site costs and land costs where facilities are proposed to have multiple uses;

 

(5)  The methodology used in calculating construction costs for renovations;

 

(6)  The methodology used in calculating construction costs involving leasehold improvements; and

 

(7)  The anticipated useful life of the building;

 

          (o)  The following construction costs shall be compared with the January 2007 edition of the Marshall Valuation Service:

 

(1)  Labor;

 

(2)  Materials;

 

(3)  Fixed equipment;

 

(4)  Building permits;

 

(5)  Architectural and engineering fees;

 

(6)  Site preparation for the building;

 

(7)  Utilities from structure to lot line;

 

(8)  Insurance costs during construction; and

 

(9)  Interest costs during construction;

 

          (p)  The applicant shall follow the outline of the calculator method set forth in section 10 of the January 2007 edition of the Marshall Valuation Service to determine construction costs according to the Marshall Valuation Service;

 

          (q)  The costs and factors to take into account pursuant to (o) above shall include:

 

(1)  The base cost found in the general hospital table in section 15, page 24;

 

(2)  An adjustment to heating, ventilating, and air-conditioning costs for:

 

a.  Extreme climate; and

 

b.  A different type of HVAC system from that assumed in the table, if necessary;

 

(3)  All fire protection systems costs;

 

(4)  Elevator costs, if not included in the base cost;

 

(5)  Number of stories multiplier;

 

(6)  Story height multipliers;

 

(7)  Floor area - perimeter multipliers; and

 

(8)  Cost multipliers from section 99 of the January 2007 edition of the Marshall Valuation Service;

 

          (r)   LTACH services shall be provided in a safe and efficient manner;

 

          (s)  In the case of existing facilities, demonstration of safe services shall be made by providing with the application:

 

(1)  Copies of inspection surveys and reports from state, federal, or accrediting agencies;

 

(2)  Copies of corrective action plans if deficiencies have been cited by state, federal or accrediting agencies;

 

(3)  A copy of the facility’s emergency procedure and evacuation plan to be followed in case of fire or other emergencies;

 

(4)  A report detailing how patients will be protected from hazards which might occur during the construction or renovation project; and

 

(5)  A signed statement made by the applicant pursuant to He-Hea 303.05(c) or (d);

 

          (t)  For new facilities, demonstration of safe services shall be made by providing with the application:

 

(1)  A copy of the facility’s emergency procedure and evacuation plan to be followed in case of fire or other emergencies; and

 

(2)  A signed statement made by the applicant pursuant to He-Hea 303.05(c) or (d);

 

          (u)  Applicants shall document the planned use of beds by patients originating from outside the State of New Hampshire and the impact of these services on the accessibility of beds by New Hampshire residents; and

 

          (v)  Demonstration of the use of beds by out-of-state patients shall be in the form of a report including:

 

(1)  The projected utilization by non-New Hampshire residents; and

 

(2)  Referral agreements from physicians and other medical personnel.

 

Source.  #9110, eff 3-25-08

 

PART He-Hea 2104  REQUEST FOR APPLICATIONS

 

          He-Hea 2104.01  Request for Applications (RFA).  In accordance with RSA 151-C:8, I, a request for applications shall be issued if a need for additional long-term acute care beds pursuant to He-Hea 2102.04 has been delineated, subject to a minimum of 10 beds.

 

Source.  #9110, eff 3-25-08

 

          He-Hea 2104.02  Submission of Applications.  Applications in response to an RFA shall be submitted within 90 days of the publication of the RFA.

 

Source.  #9110, eff 3-25-08

 

PART He-Hea 2105  GRANTING CERTIFICATES OF NEED

 

          He-Hea 2105.01  Approval of Applications.

 

          (a)  The board shall issue multiple CONs to satisfy the need for which a request for applications was issued if it determines multiple applicants demonstrate that they equally satisfy and comply with the standards listed in RSA 151-C:9, II.

 

          (b)  The total number of beds approved shall not exceed the unmet need determined pursuant to He-Hea 2102.04.

 

          (c)  Any CON issued under this chapter shall carry a condition that shall:

 

(1)  Limit the applicant to offering or developing long-term acute care beds and services consistent with the board’s approval; and

 

(2)  Prohibit the applicant from offering or developing any new institutional health services, including but not limited to, comprehensive physical rehabilitation services, without first securing an appropriate CON from the board.

 

Source.  #9110, eff 3-25-08

 


APPENDIX

 

RULE

STATUTE

 

 

He-Hea 2101.01

RSA 151-C:2, RSA 151-C:11, I

He-Hea 2102.01 – He-Hea 2102.04

RSA 151-C:5(f)(1), RSA 151-C:11, I

He-Hea 2102.05

RSA 151-C:5(f)(1), RSA 151-C:11, I, RSA 151-C:7, III

He-Hea 2102.06 – He-Hea 2102.08

RSA 151-C:5(f)(1), RSA 151-C:11, I

He-Hea 2102.09

RSA 151-C:5(f)(1), RSA 151-C:11, I, RSA 151-C:7, II

He-Hea 2102.10

RSA 151-C:5(f)(1), RSA 151-C:11, I, RSA 151-C:7, IV

He-Hea 2102.11

RSA 151-C:5(f)(1), RSA 151-C:11, I

He-Hea 2103

RSA 151-C:5(f)(1), RSA 151-C:11, I, RSA 151-C:7, I

He-Hea 2104

RSA 151-C:8, I

He-Hea 2105

RSA 151-C:9, II, II