(as that term is employed in title XIX)

is designed to provide;

(ii) Does not provide the degree of care required to be provided by a skilled nursing home furnishing services under a State plan approved under title XIX; (iii) Meets such standards of safety and sanitation as are applicable to nursing homes under State law; and

(iv) Regularly provides a level of care and service beyond board and room. The term "intermediate care facility" also includes a Christian Science sanatorium operated, or listed and certified, by the First Church of Christ, Scientist, Boston, Mass.

(4) Range or level of care and services. The range or level of care and services suitable to the needs of individuals described in subparagraph (3) (i) of this paragraph is to be defined by the State agency. The following items are recommended as a minimum.

(i) Admission, transfer, and discharge of residents. The admission, transfer, and discharge of residents of the facility are conducted in accordance with written policies of the institution that include at least the following provisions.

(a) Only those persons are accepted into the facility whose needs can be met within the accommodations and services the facility provides;

(b) As changes occur in their physical or mental condition, necessitating service or care not regularly provided by the facility, residents are transferred promptly to hospitals, skilled nursing homes, or other appropriate facilities;

(c) The resident, his next of kin, and the responsible agency if any, are consulted in advance of the discharge of any resident, and casework services or other means are utilized to assure that adequate arrangements exist for meeting his needs through other resources.

(ii) Personal care and protective services. The types and amounts of protection and personal service needed by each resident of the facility are a matter of record and are known to all staff members having personal contact with the resident. At least the following services are provided.

(a) There is, at all times, a responsible staff member actively on duty in the facility, and immediately accessible to all residents, to whom residents can report injuries, symptoms of illness, or emergencies, and who is immediately responsible for assuring that appropriate action is taken promptly.

(b) Assistance is provided, as needed by individual residents, with routine activities of daily living including such services as help in bathing, dressing, grooming, and management of personal affairs such as shopping.

(c) Continuous supervision is provided for residents whose mental condition is such that their personal safety requires such supervision.

(iii) Social services. Services to assist residents in dealing with social and related problems are available to all residents through one or more caseworkers on the staff of the facility; and/or, in the case of recipients of assistance, through caseworkers on the staff of the assistance agency; or through other arrangements. (iv) Activities. Activities are regularly available for all residents, including social and recreational activities involving active participation by the residents, entertainment of appropriate frequency and character, and opportunities for participation in community activities as possible and appropriate.

(v) Food service. At least three meals a day, constituting a nutritionally adequate diet, are served in one or more dining areas separate from sleeping quarters, and tray service is provided for residents temporarily unable to leave their rooms.

(vi) Special diets. If the facility accepts or retains individuals in need of medically prescribed special diets, the meanus for such diets are planned by a professionally qualified dietitian, or are reviewed and approved by the attending physician, and the facility provides supervision of the preparation and serving of the meals and their acceptance by the resident.

(vii) Health services. Whether provided by the facility or from other sources, at least the following services are available to all residents:

(a) Immediate supervision of the facility's health services by a registered professional nurse or a licensed practical nurse employed full-time in the facility and on duty during the day shift except that, where the State recognizes and describes two or more distinct levels of institutions as intermediate care facilities such personnel are not required in any level that serves only individuals who have been determined by their physicians not to be in need of such supervision and whose need for such supervision is reviewed as indicated, and at least quarterly;

(b) Continuing supervision by a physician who sees the resident as needed and, in no case, less often than quarterly;

(c) Under direction by the resident's physician and (where applicable in accordance with (a) of this subdivision), general supervision by the nurse in charge of the facility's health services, guidance, and assistance for each resident in carrying out his personal health program to assure that preventive measures, treatments, and medications prescribed by the physician are properly carried out and recorded;

(d) Arrangements for services of a physician in the event of an emergency when the resident's own physician cannot be reached;

(e) In the presence of minor illness and for temporary periods, bedside care under direction of the resident's physician including nursing service provided by, or supervised by, a registered professional nurse or a licensed practical

nurse;

(f) An individual health record for each resident including;

(1) The name, address, and telephone number of his physician;

(2) A record of the physician's findings and recommendations in the preadmission evaluation of the individual's condition and in subsequent reevaluations and all orders and recommendations of the physician for care of the resident;

(3) All symptoms and other indications of illness or injury brought to the attention of the staff by the resident, or from other sources, including the date, time, and action taken regarding each.

(viii) Living accommodations. Space and furnishings provide each resident clean, comfortable, and reasonably private living accommodations with no more than four residents occupying a room, with individual storage facilities for clothing and personal articles, and with lounge, recreation and dining areas provided apart from sleeping quarters.

(ix) Administration and management. The direction and management of the facility are such as to assure that the services required by the residents are so organized and administered that they are, in fact, available to the residents on a regular basis and that this is accomplished efficiently and with consideration for the objective of providing necessary care within a homelike atmosphere. Staff are employed by the facility sufficient in number and competence, as

State plan requirements: A State plan under title IV-A of the Social Security Act must provide that:

(a) The appropriate law enforcement officials will be notified in writing promptly as soon as AFDC has been furnished in respect to a child who is believed to have been deserted or abandoned by a parent. This requirement has no effect upon the determination of eligibility. It is a requirement upon the agency, and is fulfilled by providing the following information after a family has been found eligible and been granted assistance: A statement that AFDC has been furnished (date) to relative (name and address) in behalf of children (name and ages) in his home, who appear to have been deserted or abandoned by their parent(s) (name and address, if known). Under this requirement, the appropriate law enforcement officials are those responsible for initiating actions in cases of desertion or abandonment, as those terms are defined under State law.

(b) Criteria will be established for the selection of cases in which notice is given to law enforcement officials that AFDC has been furnished in respect to a dependent child believed to have been deserted or abandoned by a parent. In fulfilling this requirement, the criteria will include instructions for identification of the classes of persons who, under State law, are defined as parents responsible for support of minor children, and against whom legal action may be taken under such laws for desertion or abandonment.

(c) All applicants affected by the reporting requirement will be informed as early as possible during the application process, and each applicant will be

State plan requirements: A State plan under title I, IV-A, X, XIV, or XVI of the Social Security Act must provide:

(a) That the State agency will establish and maintain:

(1) Methods and criteria for identifying situations in which a question of fraud in the program may exist, and

(2) Procedures developed in cooperation with the State's legal authorities for referring to law enforcement officials situations in which there is valid reason to suspect that fraud has been practiced. The definition of fraud for purposes of this section will be determined in accordance with State law.

(b) For methods of investigation of situations in which there is a question of fraud, that do not infringe on the legal rights of persons involved and are consistent with the principles recognized as affording due process of law.

(c) For the designation of official position(s) responsible for referral of situations involving suspected fraud to the proper authorities.

PART 237-FISCAL ADMINISTRATION OF FINANCIAL ASSISTANCE PROGRAMS

Sec.

237.50 Recipient count, Federal financial participation.

237.60 Maintenance of State effort; Federal financial participation.

AUTHORITY: The provisions of this Part 237 issued under sec. 1102, 49 Stat. 647; 42 U.S.C. 1302.

§ 237.50 Recipient count, Federal financial participation.

Pursuant to the formulas in sections 3, 403, 1003, 1118, 1121, 1403, and 1603 of the Social Security Act, it is necessary to identify expenditures that may be included in claims for Federal financial participation. Except as stated in paragraphs (a), (b), (c), and (d) of this section, the quarterly statement of expenditures and recoveries which is required for OAA, AFDC, AB, APTD, and AABD must include, as a part of the basis for computing the amount of Federal participation in such expenditures, the number of eligible recipients each month.

However, where the State is making claims under section 1118 of the Act or under optional provisions for Federal sharing specified in such paragraphs no recipient count is involved. Vendor payments for medical care may not be considered if the State has a plan approved under title XIX of the Act. The procedures for determining recipient count are set forth in such paragraphs.

(a) Adult assistance categories. For each adult assistance category under title I, X, XIV, or XVI, of the Act, the recipient count for any month may include:

(1) Eligible recipients who receive money payments or in whose behalf protective payments are made for that month, plus

(2) Other eligible recipients in whose behalf vendor payments for medical care are made during that month, plus

(3) Other eligible recipients in whose behalf payments are made for institutional services in intermediate care facilities for that month. However, if the State elects under section 1121 (c) of the Social Security Act to receive matching on the basis of the Federal medical assistance percentage for these payments, then they cannot be included for the purpose of the recipient count.

(b) AFDC category. For the AFDC category under title IV, Part A, of the Act

(1) The recipient count for any month may include:

(i) Eligible recipients in families which receive a money payment (including payments for work performed under the work incentive program for that month), plus

(ii) Other eligible recipients in families in whose behalf vendor payments for medical care are made during that month, plus

(iii) Eligible children in foster care not otherwise counted in whose behalf a foster care payment or vendor payment for medical care is made in such month, plus

(iv) Eligible recipients in families not otherwise counted in whose behalf protective or nonmedical vendor assistance payments are made for such month, not to exceed 10 percent of the total recipients counted under subdivisions (i), (ii), and (iii) of this subparagraph. The 10 percent limitation does not apply with respect to individuals for whom protective or nonmedical vendor payments are made pursuant to section 402(a) (19) (F) of the Act because there has been a re

fusal without good cause to accept employment, work or training.

(2) The recipient count may include all eligible children, plus the eligible relative with whom the children are living (as specified in section 406 (a) (1) of the Act).

(3) (i) When at least one of the children in a family is eligible due to the incapacity of his parent in the home, the recipient count may include all eligible children, the parent, and the parent's spouse with whom the children are living, if the needs of such parent and spouse were included in computing the assistance payment.

(ii) As used in subdivision (i) of this subparagraph, the term "parent" means the natural or adoptive parent, or the stepparent who was ceremonially married to the child's natural or adoptive parent and is legally obligated to support the child under State law of general applicability which requires stepparents to support stepchildren to the same extent that natural or adoptive parents are required to support their children; and the term "spouse" means an individual who is the husband or wife of the child's own parent, as defined above, by reason of a ceremonial or other legal marriage.

(4) (i) For periods beginning on or after January 1, 1968, when at least one of the children in a family is eligible due to the unemployment of his father in the home, the recipient count may include all eligible children, the father, and his wife with whom the children are living, if the needs of such father and wife were included in computing the assistance payment.

(ii) As used in subdivision (i) of this subparagraph, the term "father" means the natural or adoptive father, or the stepfather who was ceremonially married to the child's natural or adoptive mother and is legally obligated to support the child under State law of general applicability which requires stepparents to support stepchildren to the same extent that natural or adoptive parents are required to support their children; and the term "wife" means an idividual who is the wife of the child's own father, as defined above, by reason of a ceremonial or other legal marriage.

(5) The recipient count for a month in which only a vendor payment is made for medical services furnished to any eligible child in the family, to any eligible relative with whom the child is living, or to any of the "essential persons," may

include all eligible recipients in the family in the month that the medical service was received.

(6) Where there are two or more dependent children living in a place of residence with two other persons who are not married to each other and each of such other persons is a relative who has responsibility for the care and control of one or more of the dependent children, there may be two separate AFDC families for purposes of aid and recipient count, if neither of such persons is the parent of all the dependent children.

(c) Recipient count involving two categories. Where a vendor payment is made for medical services rendered to an individual in a month in which he was eligible only under one Federally-aided program, the payment may be included as assistance and the recipient may be counted under such program in the month of payment, even though at the time of such vendor payment the individual may be receiving assistance and included in the recipient count under another Federally-aided program.

(d) Essential person: An "essential person" or other ineligible person who is living with the eligible person may not be counted as a recipient.

[34 F.R. 751, Jan. 17, 1969]

§ 237.60 Maintenance of State effort; Federal financial participation.

For the programs administered under titles I, IV-Part A, X, XIV, XVI, and XIX of the Social Security Act:

(a) For fiscal years ending June 30, 1967, and June 30, 1968, a State may, at its option, apply the "maintenance of State effort" provisions under section 1117 of the Social Security Act on a fiscal year basis rather than on a quarterly basis. If a State exercises this option, it must choose, as the base period against which its effort is to be measured, either the fiscal year ending June 30, 1965, or the fiscal year ending June 30, 1964. Subsections (b) and (c) of section 1117 of the Act (relating to the manner of determining expenditures and reductions) would also be applied on a fiscal year basis if the State exercises this option.

(b) A State may, at its option, apply the "maintenance of State effort" provisions under section 1117 of the Act on the basis of several additional alternatives as to the expenditures (total and Federal share) that will be taken into account in determining whether a reduc

tion is necessary under section 1117 of the Act.

(1) The State may take into account, as previously provided, all expenditures under titles I, IV-Part A, X, XIV, XVI, and XIX (including money payments, vendor medical payments, and costs of administration); or

(2) The State may make the determination

(i) On the basis of these expenditures plus the expenditures under section 523 of the Act (or section 422 of the Social Security Act, as amended by section 240 (c) of Public Law 90-248), relating to child welfare services,

(ii) On the basis of money payments alone (under titles I, IV-Part A, X, XIV, and XVI), or

(iii) On the basis of money payments alone plus the expenditures under section 523 or 422 of the Act.

(c) These additional options both as to making the determination on a fiscal year rather than quarterly basis, and as to the expenditures included, may be applied retroactively to July 1, 1966, by any State subject to a reduction under the provisions of section 1117 of the Act as in effect prior to the enactment of section 221 of Public Law 90-248.

(d) The "maintenance of State effort" provisions have been made inapplicable to periods prior to July 1, 1966.

(e) Section 1117 of the Act was repealed, effective July 1, 1968, by section 221(d) of Public Law 90-248.

[34 F.R. 11, Jan. 1, 1969]

PART 246-STATE ORGANIZATIONMEDICAL ASSISTANCE PROGRAMS § 246.10

State medical care advisory committees.

(a) State plan requirements. A State plan for medical assistance under title XIX of the Social Security Act must provide that:

(1) There will be an advisory committee to the State agency director on health and medical care services, appointed by the director of the State agency or a higher State authority. Appointments to the committee will provide for rotation and continuity.

(2) The medical care advisory committee will include:

(i) Board certified physicians and other representatives of the health professions who are familiar with the med

ical needs of low income population groups and with the resources available and required for their care;

(ii) Members of consumers' groups including title XIX recipients, and consumer organizations such as labor unions, cooperatives, consumer-sponsored prepaid group practice plans, and others; and

(iii) The director of the public welfare department or of the public health department, whichever does not head the single State agency for the title XIX plan.

(3) The medical care advisory committee will have adequate opportunity for meaningful participation in policy development and program administration, including the furtherance of recipient participation in the program of the agency.

(4) The medical care advisory committee will be provided such staff assistance from within the agency and such independent technical assistance as are needed to enable it to make effective recommendations, and will be provided with financial arrangements, where necessary, to make possible the participation of recipients in the work of the committee.

(b) Federal financial participation. Federal financial participation of 50 percent is available for the activities of the medical care advisory committee.

(Sec. 1102, 49 Stat. 647; 42 U.S.C. 1302) [36 F.R. 3870, Feb. 27, 1971]