36C24520R0022-0001006.pdf

Attachment 14: Resource Utilization Groups (RUGs) III Description

Community Nursing Home SOP Page 1 of 1 Original Date: o5/02/2016

(VA) Community Nursing Home Program Level of Care – Descriptions – RUG III

Level of Care determinations are based on the VA Resource Utilization Groups (RUGS-III) case-mix, the industry standard. A case-mix system categorizes patients into groups according to their level of care needs. RUGS-III, like other case-mix systems, defines patients for clinical and reimbursement purposes.

Additional information on RUGS III use for VA purposes can be acquired from the Contracting Officer in concert with the appropriate

VA community health official.

Reduced Physical Functioning / Behavioral Group / Impaired Cognition Group: RUG Scores: BB2, BB1, BA2, PE2, PE1, PD2, PD1, PC2, PC1, PB2, PB1, PA2, PA1, IA2, IB2, IB1, IA1. This is the standard skilled care group. This is a catch-all patient grouping. It includes all patients who are not specifically identified in the hierarchy below, except those with minimal care needs who are listed above. The grouping includes most patients who receive a clinically complex treatment but have light to moderate ADL deficiencies and basic to moderate behavior management. It also includes most of the patients who are without special characteristics or needs but need care because of reduced physical functioning.

Clinically Complex Group: RUG Scores: CC2, CC1, CB2, CB1, CA2, CA1. These residents receive complex clinical care or have conditions requiring skilled nursing management and interventions for conditions and treatments such as dialysis, radiation therapy, chemotherapy, burns, coma, septicemia, pneumonia, foot infections or wounds, internal bleeding, dehydration, tube feeding, oxygen, transfusions, IV antibiotic therapy, hemiplegia. Patients may also be receiving care for some moderate to severe behavioral management due to medical, neurological, or psychiatric conditions and patients may be highly disabled in ADLs.

Special Care Group: RUG Scores: SSC, SSB, SSA. These residents receive complex clinical care or have serious medical conditions such as multiple sclerosis, quadriplegia, respiratory therapy, ulcers, stage III or IV pressure ulcers, radiation, surgical wounds or open lesions, tube feeding, parental feeding, fever with dehydration, pneumonia, comatose, or Suctioning. Patients may also be receiving care for some moderate to severe behavioral management due to medical, neurological, or psychiatric conditions. These patients may be moderately or highly disabled in ADLs.

Extensive Services Group: RUG Scores: SE3, SE2, SE1. These residents receive complex clinical care or have complex clinical needs such as IV feeding or medications, suctioning, tracheostomy care, ventilator/respirator and co-morbidities that make the resident eligible for other RUG categories.

Rehabilitation Group: RUG Scores: RVC, RVB, RVA, RHC, RHB, RHA, RMC, RMB, RMA, RLB, RLA. These residents receive physical therapy (PT), occupational therapy (OT), or speech therapy (ST). Therapy must be performed by a licensed PT, licensed OT, licensed speech therapist, or PT/OT assistants who have completed an approved program and work under the supervision of a licensed therapist. Therapy must be approved by a VA provider for a specific period of time, not to exceed one month. Therapy approvals may be recertified by a VA provider. A copy of the therapy notes will be sent to the VA facility each month, or at the discretion of the

VA facility, the therapy notes can be reviewed on-site.

Rehabilitation Plus Extensive Services Group: RUG Scores: RUX, RUL, RVX, RVL, RMX, RHX, RML, RHL, RLX. These residents receive physical therapy (PT), occupational therapy (OT), or speech therapy (ST) AND receive IV feeding or medications, suctioning, tracheostomy care or ventilator/respirator. Therapy must be performed by a licensed PT, licensed OT, licensed speech therapist, or PT/OT assistants who have completed an approved program and work under the supervision of a licensed therapist.

Therapy must be approved by a VA provider for a specific period of time, not to exceed one month. Therapy approvals may be recertified by a VA provider. A copy of the therapy notes will be sent to the VA facility each month, or at the discretion of the VA facility, the therapy notes can be reviewed on-site.

HIV+/AIDS Care: Specialized services for HIV+ and/or AIDS patients. May be specialized program care of an individual patient.

Ventilator Dependent Care: Level of care is self explanatory. This level of care is used in cases which cannot be covered by the ventilator care rates outlined above. Placements are made on an individual, case-by-case basis, and must be made via contract modification. Rates shall be determined based on care needs and shall be negotiated prior to placement with rates incorporated into the contract modification document; however, rates are restricted to VA allowable and maximum rates, and rates are subject to reasonableness determinations.