Current through Register Vol. 50, No. 9, September 20, 2024
A. Each Community Choices Waiver
applicant/participant shall be assessed using the uniform international
resident assessment instrument (interRAI). This assessment provides researched
and validated measures of an individual's functional status. The assessment is
used to verify if an individual meets nursing facility level of care and
generates a resource utilization group (RUG) score. This score is used to
establish an individual's services and supports budget.
B. The RUG score assigns an individual to one
of 23 distinct groups in seven major groupings. Individuals are assigned to a
group based on a hierarchy and are assigned to the highest group for which they
qualify. The following seven major groupings will be utilized to determine the
waiver assistance needed to complete various activities of daily living (ADLs)
and instrumental activities of daily living (IADLs).
1. Special Rehabilitation. Individuals in
this group had at least 120 minutes of rehabilitation therapy (physical,
occupational and/or speech) within the seven days prior to the interRAI
assessment.
2. Extensive Services.
Individuals in this group received one or more of the following services and
have an ADL index of 7 or more:
a.
tracheostomy;
b. ventilator or
respirator;
c.
suctioning;
d. parenteral/IV
feeding only;
e. combined oral and
parenteral/tube feeding; or
f. IV
medications.
3. Special
Care. Individuals in this group must meet one of the following criteria:
a. have one of the following conditions or
treatments and have an ADL index of 7 or greater:
i. stage 3 or 4 pressure ulcers and
turning/positioning program;
ii.
combined oral and parenteral/tube feeding or nasogastric feeding only and
aphasia;
iii. fever with either
vomiting, weight loss, dehydration, nasogastric tube or parenteral feeding, or
pneumonia; or
iv. radiation
therapy; or
b. have one
of the following conditions and have an ADL index of 10 or greater:
i. cerebral palsy;
ii. multiple sclerosis;
iii. quadriplegia; or
c. are receiving one of the extensive care
services (as listed in B.2 above)and have an ADL index of 6 or less.
d. - h.iv. Repealed.
4. Clinically Complex. Individuals in this
group have one of the following conditions or treatments:
a. septicemia;
b. dehydration;
c. hemiplegia and an ADL index of 10 or
greater;
d. pneumonia;
e. end-stage disease;
f. comatose (confirmed by totally dependent
in the four ADLs used in the ADL index);
g. foot problems that limit/prevent
walking;
h. gastrointestinal (GI)
or genitourinary (GU) bleeding;
i.
diabetes;
j. combined oral and
parenteral/tube feeding or nasogastric tube feeding only;
k. chemotherapy;
l. dialysis;
m. transfusions;
n. oxygen therapy; or
o. one of the special care conditions or
treatments listed in 3.a above and an ADL index of 6 or less.
5. Impaired Cognition. Individuals
in this group have a cognitive performance scale of 3 or more and an ADL index
of 10 or less.
6. Behavior
Problems. Individuals in this group have one or more of the following behavior
problems and an ADL index of 10 or less:
a.
wandering;
b. verbally
abusive;
c. physically
abusive;
d. socially
inappropriate/disruptive;
e.
resists care;
f. sexually
inappropriate;
g. hallucinations;
or
h. delusions.
7. Physical Function. Individuals
who did not meet the criteria for any of the previous categories.
C. Based on the RUG score, the
applicant/participant is assigned to one of the distinct groups and is eligible
for a set annual services budget associated with that group.
1. If the applicant/participant disagrees
with their annual services budget, they or their responsible representative may
request a fair hearing to appeal the decision.
2. The applicant/participant may qualify for
an increase in the annual services budget amount upon showing that:
a. one or more responses on the assessment
are recorded incorrectly (except for the responses in the identification
information, personal intake and initial history, assessment date and reason,
and/or signature sections); or
b.
they need an increase in the annual services budget to avoid entering into a
nursing facility.
D. Each Community Choices Waiver participant
shall be re-assessed at least annually.
AUTHORITY
NOTE: Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.
