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Ohio Administrative Code (Last Updated: January 12, 2021) |
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5160 Medicaid |
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Chapter5160-3. Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities |
5160-3-15.1. Preadmission screening requirements for individuals seeking admission to nursing facilities
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(A) The purpose of this rule is to set forth the level I and level II preadmission screening requirements pursuant to section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019, to ensure that individuals seeking admission, as defined in rule 5160-3-15 of the Administrative Code, to a medicaid-certified nursing facility (NF) who have serious mental illness (SMI) and/or a developmental disability (DD) as defined in rules 5122-21-03 and 5123-14-01 of the Administrative Code are identified and not admitted to a NF unless a thorough evaluation indicates that such placement is appropriate and adequate services will be provided regardless of payor source.
(B) A level I screening as defined in rule 5160-3-15 of the Administrative Code is required:
(1) Prior to any new admission, as defined in rule 5160-3-15 of the Administrative Code, to a NF.
(2) Prior to a categorical determination, as defined in rule 5160-3-15 of the Administrative Code.
(3) When an individual is directly admitted to a NF from any of the following:
(a) A hospital that is maintained, operated, managed or governed by the Ohio department of mental health and addiction services (OhioMHAS) under section 5119.14 of the Revised Code for the care and treatment of mentally ill persons; or
(b) A free standing hospital, or unit of a hospital licensed by OhioMHAS under section 5119.33 of the Revised Code; or
(c) An out-of state psychiatric hospital or unit of such hospital.
(4) When a non Ohio resident is seeking admission to an Ohio NF from an out-of-state NF.
(a) If the non Ohio resident has been determined or suspected to have a SMI and/or DD by the other state, the other state's level II evaluation(s) of the individual and any additional supporting documentation should be submitted with the preadmission request.
(b) Submission of the required forms and documentation does not constitute completion of the level I process.
(c) The NF can not admit an individual until the PASRR screening process as defined in rule 5160-3-15 of the Administrative Code is complete and a determination for the individual is received by the NF pursuant to section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019.
(C) Level I screening requirements.
(1) Level I will be administered by the Ohio department of medicaid (ODM) or its designee, OhioMHAS or its designee, the Ohio department of developmental disability (DODD) or its designee, social worker, professional counselor, hospital discharge planners or one of the professionals listed in paragraph (H) (6) of this rule.
(2) The level I has to be submitted via the electronic system designated by ODM.
(3) The submitter of the level I is responsible for gathering information from the individual, family, legal guardian and available medical records to ensure an accurate level I and, when applicable, level II determination outcomes.
(4) The submitter is expected to include any necessary supporting documentation within the electronic system designated by ODM for validation.
(5) The submitter of the level I has to certify that the level I information that is submitted is true, accurate and complete to the best of their knowledge. The absence of such certification by the submitter will result in an incomplete level I submission.
(6) For an individual seeking medicaid payment, the ODM approved level of care (LOC) assessment will be completed in accordance with rule 5160-3-14 of the Administrative Code, unless the individual is enrolled in a medicaid managed care plan as defined in rule 5160-26-01 of the Administrative Code.
(7) The NF is responsible for ensuring every individual residing in the NF has completed the PASRR screening process as defined in rule 5160-3-15 of the Administrative Code prior to NF admission.
(D) Level I screening outcomes.
(1) An individual will be considered to have indications of DD when the individual meets the criteria specified in rule 5123-14-01 of the Administrative Code or the individual receives services from a county board of DD.
(a) Individuals with indications of DD will be subject to further review by DODD in accordance with rule 5123-14-01 of the Administrative Code.
(b) Such individuals will not be considered to have completed the PASRR screening requirements as defined in rule 5160-3-15 until DODD has issued the level II determination pursuant to section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019 and in accordance with rule 5123-14-01 of the Administrative Code.
(2) An individual will be considered to have indications of a SMI when the individual meets the criteria specified in rule 5122-21-03 of the Administrative Code.
(a) Individuals with indications of a SMI shall be subject to further review by OhioMHAS, in accordance with rule 5122-21-03 of the Administrative Code.
(b) Such individuals will not be considered to have completed the PASRR screening process as defined in rule 5160-3-15 until OhioMHAS has issued the level II determination pursuant to section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019 and in accordance with rule 5122-21-03 of the Administrative Code.
(3) Individuals determined to have no indications of a SMI and/or DD are not subject to a level II evaluation.
(a) Such individuals are considered to have met PASRR screening requirements effective on the date an accurate and complete level I screening was submitted.
(b) The printed result letter generated via the electronic system designated by ODM is evidence of PASRR compliance.
(4) Individuals with indications of both SMI and DD will be subject to further review by both OhioMHAS and DODD in accordance with rules 5122-21-03 and 5123-14-01 of the Administrative Code. Such individuals will not be considered to have met PASRR screening requirements as defined in rule 5160-3-15 of the Administrative Code until both OhioMHAS and DODD have issued the level II determination.
(5) Any individual who has been determined by DODD or OhioMHAS to be ruled out, in accordance with rules 5122-21-03 and 5123-14-01 of the Administrative Code as defined in rule 5160-3-15 of the Administrative Code, is not subject to further PASRR review.
(E) ODM or its designee, OhioMHAS and/or DODD, are the only entities that have the authority to render level I screening result outcomes. The individual must not be admitted into the NF until prescreening requirements as defined in rule 5160-3-15 of the Administrative Code have been met pursuant to section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019.
(F) Categorical determination requirements.
(1) Consists of a level I with sufficient documentation that the individual meets one of the categories following:
(a) Emergency NF stay when the individual is temporarily admitted to a NF pending further assessment in emergency situations requiring protective services, not to exceed seven days; or
(b) Respite NF stay when the individual is being admitted to a NF for a maximum of fourteen days in order to provide respite to in-home caregivers to whom the individual is expected to return following the respite stay.
(2) A face to face assessment is not required for a categorical determination provided there is enough data to determine that the individual meets the categorical requirements. In all other cases, an individualized evaluation will be completed.
(3) The NF has to submit the request for a categorical determination via the electronic system designated by ODM.
(4) The NF has to initiate a resident review as defined in rule 5160-3-15 of the Administrative Code for residents admitted under a categorical determination that require a stay longer than the specified time limit for the category.
(5) The NF can not admit an individual requesting a categorical determination until the NF receives a determination for the individual from the appropriate level II entity.
(G) Hospital discharge exemption requirements.
(1) An individual does not qualify for admission using the hospital discharge exemption unless:
(a) The individual is being admitted to a NF directly from an Ohio hospital or a unit of a hospital that is not operated by or licensed by OhioMHAS under section 5119.14 or section 5119.33 of the Revised Code, after receiving acute inpatient care at that hospital; or
(b) The individual is an Ohio resident seeking admission to a NF directly from an out-of-state hospital that is not an out-of-state psychiatric hospital or psychiatric unit within an out-of-state hospital, after receiving acute inpatient care at that hospital; and
(c) The individual requires the level of services provided by a NF for the condition for which he or she was treated in the hospital; and
(d) The individual's attending physician provides written certification that is signed and dated no later than the date of discharge from the hospital that the individual is likely to require the level of services provided by a NF for less than thirty days.
(2) The discharging hospital has to request a hospital discharge exemption via the electronic system designated by ODM.
(3) When the NF accepts the placement of the individual, the NF acknowledges that the individual meets the criteria described in paragraph (G) of this rule.
(4) The admitting NF is expected to maintain the hospital discharge exemption documentation in the resident's record at the NF.
(5) The NF has to initiate a resident review, as defined in rule 5160-3-15.2 of the Administrative Code, prior to the individual's thirtieth day in the NF when an individual requires a continued stay beyond thirty days.
(6) When an individual is admitted under the hospital discharge exemption and is subsequently admitted to a hospital or transfers to another NF during the first thirty days of the individual's NF stay, the days in the hospital or previous NF count towards the individual's thirty day hospital discharge exemption time period. A new hospital discharge exemption can not be granted during the existing exemption time period.
(7) When an adverse determination has been issued by OhioMHAS or DODD within the last sixty calendar days prior to the new NF admission, the individual is not eligible for a hospital discharge exemption. A level I screening has to be initiated in accordance with paragraph (C) of this rule.
(H) Level II evaluation and determination requirements.
(1) The new admission of an individual with a SMI or DD is not permitted unless the individual has either been determined, in accordance with rules 5122-21-03 and 5123:2-14-01 of the Administrative Code, to need the level of services provided by a NF, or qualifies for admission under the hospital discharge exemption provision set forth in paragraph (G) of this rule, regardless of the individual's payor source.
(2) Individuals determined by OhioMHAS and/or DODD not to meet NF level of service as defined in rules 5160-3-15, 5122-21-03 and 5123-14-01 of the Administrative Code will not be admitted and medicaid payment will not be available for NF services.
(3) The level II evaluation will be complete and determination made prior to any new admission of an individual to a NF in the process of obtaining its initial medicaid certification and NF provider agreement.
(4) For current residents of a facility in the process of obtaining its initial medicaid certification and NF provider agreement, the level II requirements have to be met prior to the effective date of the NF provider agreement between ODM and the newly certified NF or prior to the availability of medicaid payment for the medicaid eligible individual.
(5) The level II determinations are made by OhioMHAS and/or DODD in accordance with section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019.
(6) Before an adverse determination as defined in rule 5160-3-15 of the Administrative Code can be issued, both of the following conditions have to be met:
(a) A face-to-face assessment of the individual and a review of the medical records accurately reflecting the individual's current condition are performed by one of the following professionals within the scope of his/ her practice:
(i) Medical doctor or doctor of osteopathic medicine;
(ii) Registered nurse (RN);
(iii) Master of science of nursing;
(iv) Clinical nurse specialist;
(v) Certified nurse practitioner;
(vi) Licensed social worker, under supervision of a licensed independent social worker (LISW);
(vii) Licensed independent social worker;
(viii) Professional counselor, under supervision of a licensed professional clinical counselor (PCC);
(ix) Professional clinical counselor;
(x) Psychologist;
(xi) Qualified mental health professional as defined in rule 5122-21-03 of the Administrative Code; or
(xii) Qualified intellectual disability professional; or
(xiii) Service and support administrator as defined in section 5126.15 of the Revised Code.
(b) Authorized personnel from OhioMHAS and DODD other than the personnel identified in paragraph (H)(6)(a) of this rule who have conducted the face-to-face assessment, have reviewed the assessment and, made the final determination regarding the need for NF services and specialized services.
(I) NF to NF transfer requirements.
(1) The admitting NF is responsible for ensuring that all individuals have met the PASRR screening requirements as defined in rule 5160-3-15 of the Administrative Code prior to entering the NF.
(2) The admitting NF will initiate a referral for a resident review as defined in rule 5160-3-15 of the Administrative Code for any individual transferred to its facility upon the discovery of a significant change in the individual's condition as defined in rule 5160-3-15 of the Administrative Code.
(3) The admitting NF is responsible for ensuring that copies of the resident's most recent level I screening results letter and, if applicable, level II evaluation and determination accompany the transferring resident.
(4) The admitting NF is expected to retain the written notification of the level II determinations received from the transferring NF in the individual's resident record at the facility.
(J) Level I and level II requests for additional information.
(1) ODM or its designee, OhioMHAS and/or DODD may request any additional information required in order to make a preadmission screening determination.
(2) When ODM or its designee, OhioMHAS and/or DODD need additional information in order to make the preadmission screening determination, they will provide written notice to the NF, the individual, the hospital, the referring entity, and the individual's representative, if applicable. This notice will specify the missing forms, data elements and other documentation needed to make the required determinations.
(3) In the event the individual and/or other entity does not provide the necessary information within fourteen calendar days, ODM or its designee, OhioMHAS and DODD is expected to provide written notice to the individual, the individual's guardian or authorized representative, if applicable, and the NF that the admission is not permitted due to failure to provide information necessary for the completion of the preadmission screening process and that the individual may appeal the determination in accordance with the provisions of division 5101:6 of the Administrative Code. The individual, regardless of payment source, cannot be admitted to the NF.
(4) When the individual or other entity submits the requested information within the timeframes specified in the notice, ODM or its designee, OhioMHAS and/or DODD will proceed with the preadmission screening process.
(K) An individual will undergo a new level I screening in accordance with the provisions of this rule when:
(1) The individual received a completed preadmission screening as defined in rule 5160-3-15 of the Administrative Code indicating that NF services are needed but the individual has not been admitted to a NF within one hundred eighty days of the most recent level II that was not a categorical determination, as defined in rule 5160-3-15 of the Administrative Code; or
(2) The individual received a categorical determination by OhioMHAS and/or DODD that NF services are needed and the individual has not been admitted to a NF immediately following discharge from a hospital setting, or within twenty fours hours from the date of the catergorical emergency determination, or within sixty days from the date of the categorical respite determination.
(L) Level I and level II notification and record retention.
(1) In accordance with all requirements specified in rule 5101:6-2-32 of the Administrative Code, ODM, or its designee, has to report the outcome of the level I to the individual, their guardian, or authorized representative, if applicable, the NF and the appropriate level II entity.
(2) In accordance with all requirements specified in rule 5101:6-2-32 of the Administrative Code, DODD and OhioMHAS will provide a printed copy of the level II determination to the individual, their guardian or authorized representative, if applicable, the individual's physician and the NF. The level II determination will contain notice of the individual's right to appeal an adverse determination made by the level II entities.
(3) When an adverse determination is issued, the facility will provide the individual, their guardian or authorized representative, if applicable, with notice of the intent to discharge in accordance with section 3721.16 of the Revised Code.
(4) The NF is expected to maintain a printed copy of the level I result notice and, if applicable, a printed copy of the level II determination received from OhioMHAS and DODD in the individual's resident record at the facility
(M) Preadmission screening compliance.
(1) NFs which, whether intentionally or otherwise, fail to accept any new admission, readmission, or NF transfers pursuant to this rule are in violation of their medicaid provider agreements. This is true regardless of the payment source for the individual's NF stay.
(2) PASRR level I screening and/or level II determinations will not be backdated.
(3) An adverse determination as the result of a preadmission evaluation performed by OhioMHAS or DODD may be appealed in accordance with division 5101:6 of the Administrative Code.
(4) Level II determinations made by OhioMHAS or DODD in accordance with section 1919(e)(7) of the Social Security Act, as in effect, July 1, 2019 cannot be overturned by ODM and/or Ohio department of health. Only appeal determinations made in accordance with division 5101:6 of the Administrative Code may overturn an adverse PASRR determination.
(5) Medicaid payment is not available for NF stays for individuals who are otherwise medicaid-eligible until the date on which the preadmission screening requirements as defined in rule 5160-3-15 of the Administrative Code have been met.
(6) ODM has authority to ensure compliance with the provisions of this rule, including but not limited to the following:
(a) Official notice to the NF of PASRR noncompliance;
(b) Development of a compliance corrective action plan;
(c) Mandatory PASRR training;
(d) NF site visits;
(e) Recoupment of funds for number of days PASRR requirements were not met for the resident.
(7) NF, local administrators, hospitals and all state agencies and their designees will comply, with accuracy and timeliness, to all requests for records and compliance plans issued by ODM.