Missouri Code of State Regulations
Title 19 - DEPARTMENT OF HEALTH AND SENIOR SERVICES
Division 30 - Division of Regulation and Licensure
Chapter 81 - Certification
Section 19 CSR 30-81.030 - Evaluation and Assessment Measures for Title XIX Recipients and Applicants
Universal Citation: 19 MO Code of State Regs 30-81.030
Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This amendment adds the level-of-care evaluation and assessment requirements back that were effective prior to October 31, 2021, in order for those individuals who would have qualified for Title XIX-funded services prior to October 31, 2021, to be eligible to receive services funded through the American Rescue Plan Act. The amendment also removes the words "an Intellectual Disability/" on the DHSS-DRL-110 (10-20) form included herein in sections (2) and (3).
PURPOSE: This rule sets the requirements for the periodic evaluation and assessments of residents in long-term care facilities in relationship to evaluation and assessment processes, level of care needed by individuals, and appropriate placement of individuals in order to receive this care. The rule also includes the algorithm utilized for the department's Home and Community Based Services program for its level-of-care determination. The rule includes a second level-of-care determination to be utilized from October 31, 2021, until the funding from the American Rescue Plan Act (temporary enhanced federal medical assistance percentage) has been expended.
(1) For purposes of this rule only, the following definitions shall apply:
(A) Applicant-any resident or prospective
resident of a certified long-term care facility who is seeking to receive
inpatient Title XIX assistance;
(B)
Certified long-term care facility-any long-term care facility which has been
approved to participate in the inpatient program and receives Title XIX funding
for eligible recipients;
(C) Initial
assessment forms-the forms utilized to collect information necessary for a
level-of-care determination pursuant to 19 CSR 30-81.030 and designated Forms
DHSS-DRL-109 (10-20), Nursing Facility Level of Care Assessment and
DHSS-DRL-110 (10-20), Level One Nursing Facility Pre-Admission Screening for
Mental Illness/Intellectual Disability or Related Condition, included
herein.
(D) Inpatient Title XIX
assistance-Title XIX payments for intermediate or skilled nursing care in a
certified long-term care facility;
(E) Level-of-care assessment-the
determination of level-of-care need based on an assessed point count value for
each category cited in subsection (4)(B) of this rule;
(F) Level-of-care determination-the decision
whether an individual qualifies for long-term care facility care;
(G) Long-term care facility-a skilled nursing
facility (SNF), an intermediate care facility (ICF), or a hospital which
provides skilled nursing care or intermediate nursing care in a distinct part
or swing bed under Chapter 197, RSMo;
(H) Pro re nata (PRN)-medication or treatment
ordered by a physician to be administered as needed, but not regularly
scheduled;
(I) Recipient-any
resident in a certified long-term care facility who is receiving inpatient
Title XIX assistance;
(J)
Redetermination of level-of-care-the periodic assessment of the recipients'
continued eligibility and need for continuation at the previously assigned
level of care. Periodic assessment includes, but is not limited to, the
following:
1. Assessment of new admissions to
a long-term care facility;
2.
Assessment of a change in mental and/or physical status for a resident who is
being readmitted to a long-term care facility after transfer to an acute care
facility, and the previous DA-124 A/B or C forms do not reflect the resident's
current care needs; and
3.
Assessment of DA-124 forms as requested by the Department of Social Services,
Family Support Division;
(K) Reevaluation of level-of-care-the
periodic assessment of the recipients' continued eligibility and need for
continuation at the previously assigned level of care. Periodic assessment
includes, but is not limited to, the following:
1. Assessment of new admissions to a
long-term care facility;
2.
Assessment of a change in mental and/or physical status for a resident who is
being readmitted to a long-term care facility after transfer to an acute care
facility, and the previous DHSS-DRL-109 (10-20), Nursing Facility Level of Care
Assessment or DHSS-DRL-110 (10-20), Level One Nursing Facility Pre-Admission
Screening for Mental Illness/Intellectual Disability or Related Condition forms
do not reflect the resident's current care needs; and
3. Assessment of DHSS-DRL-109 (10-20),
Nursing Facility Level of Care Assessment or DHSS-DRL-110 (10-20), Level One
Nursing Facility Pre-Admission Screening for Mental Illness/Intellectual
Disability or Related Condition forms as requested by Department of Social
Services, Family Support Division;
(L) Resident-a person seventeen (17) years or older
who by reason of aging, illness, disease, or physical or mental infirmity
receives or requires care and services furnished by a long-term care facility
and who resides in, is cared for, treated, or accommodated in such long-term
care facility for a period exceeding twenty-four (24) consecutive hours;
and
(M) The department-Department
of Health and Senior Services.
(2) Initial Level-of-Care Determination Requirements.
(A) In accordance with
42 CFR sections
456.370 and
483.104,
the department or its designated agents, or both, will conduct a review and
assessment of the evaluations made by the attending physician for an applicant
in or seeking admission to a long-term care facility. The review and assessment
shall be conducted using the criteria in section (5) of this rule.
(B) The initial level-of-care determination
shall be completed for the following:
1. All
applicants prior to or on admission to a long-term care facility.
2. When an applicant or recipient has been
discharged from a long-term care facility for more than sixty (60)
days.
(C) A referring
individual shall fill out and submit electronically using the department's
online database system available at:
https://health.mo.gov/seniors/nursinghomes/pasrr.php.
the required documentation contained in forms DHSS-DRL-109 (1020), Nursing
Facility Level of Care Assessment and DHSS-DRL-110 (10-20), Level One Nursing
Facility Pre-Admission Screening for Mental Illness/Intellectual Disability or
Related Condition.
(D) The
department shall complete the assessment within ten (10) working days of
receipt of all documentation required by section (5) of this rule unless
further evaluation by the State Mental Health Authority is required by
42 CFR
483.100 to
483.138.
(E) The department shall provide written
notice to the individual or referring entity if Level II screening is referred
to the Department of Mental Health. The referring entity shall notify the
applicant or recipient of the results of the screening.
(3) Level-of-Care Reevaluation Requirements.
(A) The level-of-care reevaluation is
applicable for recipients who are eligible for placement in a long-term care
facility. The level-of-care reevaluation shall be completed for the following:
1. When a significant change has occurred in
the resident's physical, mental, or psychosocial status for a resident
diagnosed with mental illness and/or intellectual disability or related
condition; or
2. As requested by
Department of Social Services, Family Support Division or the Department of
Mental Health.
(B) A
referring individual shall fill out and submit electronically using the
department's online database system available at:
https://health.mo.gov/seniors/nurs-inghomes/pasrr.php .
the required documentation contained in forms DHSS-DRL-109 (10-20), Nursing
Facility Level of Care Assessment and DHSS-DRL-110 (10-20), Level One Nursing
Facility Pre-Admission Screening for Mental Illness/Intellectual Disability or
Related Condition.
(C) The
department shall provide written notice to the individual or referring entity
if Level II screening is referred to the Department of Mental Health. The
referring entity shall notify the applicant or recipient of the results of the
screening.
(4) Level-of-Care Criteria for Long-Term Care Facility Care- Qualified Title XIX Recipients and Applicants.
(A) Individuals
will be assessed with the ultimate goal to achieve placement for these
individuals in the least restrictive environment possible, yet enable them to
receive all services required by their physical/mental condition.
(B) The specific areas which will be
considered when determining an individual's ability or inability to function in
the least restrictive environment are-behavioral, cognition, mobility, eating,
toileting, bathing, dressing and grooming, rehabilitative services, treatments,
meal preparation, medication management, and safety.
(C) To qualify for intermediate or skilled
nursing care, an applicant or recipient shall exhibit physical impairment,
which may be complicated by mental impairment or mental impairment which may be
complicated by physical impairment, severe enough to require intermediate or
skilled nursing care.
(5) Assessed Needs Point Designations Requirements.
(A) Applicants or recipients will be assessed
for level-of-care by the assignment of a point count value for each category
cited in subsection (4)(B) of this rule.
(B) Points will be assessed for the amount of
assistance required, the complexity of the care and the professional level of
assistance necessary, based on the level-of-care criteria.
(C) For individuals seeking admission to a
long-term care facility on or after July 15, 2021, the applicant or recipient
will be determined as eligible for Title XIX-funded long-term care services if
he or she is determined to need care with an assessed point level of eighteen
(18) points or above, using the assessment procedure as required in this
rule.
(D) For individuals seeking
admission to a long-term care facility on or after July 15, 2021, an applicant
with less than eighteen (18) points will be determined as ineligible for Title
XIX-funded long-term care services, unless the applicant qualifies as otherwise
provided in subsection (5)(E) of the rule.
(E) An applicant or recipient will be considered
eligible for inpatient Title XIX assistance regardless of the total point count
if the applicant or recipient is unable to meet physical/mental requirements
for residential care facility (RCF) and assisted living facility (ALF)
residency as specified by section
198.073,
RSMo. In order to determine if an applicant or recipient is unable to meet RCF
and ALF residency, the following criteria shall be applied:
1. For RCF residency an applicant or
recipient shall be physically and mentally capable of negotiating a normal path
to safety. In order to meet this requirement, an applicant or recipient,
without staff assistance, must be able to reach and go through a required exit
door to the outside building by-
A.
Responding to verbal direction or the sound of an alarm;
B. Being prepared to leave the facility within five
(5) minutes of being alerted of the need to evacuate;
C. If using a wheelchair, the resident shall be able
to transfer into the wheelchair and propel it or reach the assistive device,
and open all doors without staff assistance; and
D. If using another assistive device, such as
a walker or cane, they shall be able to reach and utilize the assistive device
without staff assistance.
2. For ALF residency, the applicant or
recipient cannot be admitted or retained if they meet the following criteria:
A. Exhibit behaviors that present a
reasonable likelihood of serious harm to himself or herself or
others;
B. Require physical
restraints;
C. Require chemical
restraints;
D. Require skilled
nursing services as defined in subsection 198.073.4, RSMo for which the
facility is not licensed or able to provide;
E. Require more than one (1) person to
simultaneously physically assist the resident with any activity of daily
living, with the exception of bathing and transferring; or
F. Is bedbound or similarly immobilized due
to a debilitating or chronic condition.
(F) Points will be assigned to each category, as
required by subsection (4)(B) of this rule, in multiples of three (3) according
to the following requirements:
1. Behavioral
is defined as the applicant or recipient's repeated behavioral challenges that
affect their ability to function in the community. The applicants or recipients
who exhibit uncontrolled behavior that is dangerous to themselves or others
must be transferred immediately to an appropriate facility. Determine if the
applicant or recipient: receives monitoring for a mental condition, exhibits
one (1) of the following mood or behavior symptoms: wandering, physical abuse,
socially inappropriate or disruptive behavior, inappropriate public sexual
behavior or public disrobing, resists care or exhibits one (1) of the following
psychiatric conditions: abnormal thoughts, delusions, hallucinations. The
applicant or recipient can receive up to nine (9) points in this category. The
applicant or recipient will receive-
A. Zero
(0) points if assessed with a stable mental condition and no mood or behavior
symptoms observed and no reported psychiatric conditions;
B. Three (3) points if assessed with a stable
mental condition monitored by a physician or licensed mental health
professional at least monthly or behavior symptoms exhibited in the past, but
not currently present or psychiatric conditions exhibited in the past, but not
recently present;
C. Six (6) points
if assessed with an unstable mental condition monitored by a physician or
licensed mental health professional at least monthly, or behavior symptoms are
currently exhibited, or psychiatric conditions are recently exhibited;
or
D. Nine (9) points if assessed
with an unstable mental condition monitored by a physician or licensed mental
health professional at least monthly and behavior symptoms are currently
exhibited or psychiatric conditions are currently exhibited.
2. Cognition is defined as the
applicant or recipient's performance in remembering, making decisions,
organizing daily self-care activities, as well as understanding others and
making self-understood. Determine if the applicant or recipient has an issue in
one (1) or more of the following areas: cognitive skills for daily decision
making, memory or recall ability (short-term, procedural, situational memory),
disorganized thinking/awareness, mental function varies over the course of the
day, or ability to understand others or to be understood. The applicant or
recipient can receive up to eighteen (18) points in this category. The
applicants or recipients with "no discernable consciousness, coma" are presumed
to meet nursing facility level of care. The applicant or recipient will
receive-
A. Zero (0) points if assessed with
no issues with cognition and no issues with memory, mental function, or ability
to be understood or to understand others;
B. Three (3) points if assessed as displaying
difficulty making decisions in new situations or occasionally requires
supervision in decision making and has issues with memory, mental function, or
ability to be understood or to understand others;
C. Six (6) points if assessed as displaying
consistent unsafe or poor decision making requiring reminders, cues, or
supervision at all times to plan, organize, and conduct daily routines, and has
issues with memory, mental function, or ability to be understood or understand
others; or
D. Nine (9) points if
assessed as rarely or never has the capability to make decisions or displaying
consistent unsafe or poor decision making or requires total supervision
requiring reminders, cues, or supervision at all times to plan, organize, and
conduct daily routines, and rarely or never understood by or able to understand
others.
3. Mobility is
defined as the amount of assistance needed by the applicant or recipient to
move from one (1) place or position to another. Determine the applicant or
recipient's primary mode of locomotion and the amount of assistance the
applicant or recipient needs with: locomotion-how one moves walking or
wheeling, if wheeling how much assistance is needed once in the chair, or bed
mobility-transition from lying to sitting, turning, etc. The applicant or
recipient can receive up to eighteen (18) points in this category. The
applicants or recipients who score in the "totally dependent on others to move
or those that are bedbound" are presumed to meet nursing facility level of
care. The applicant or recipient will receive-
A. Zero (0) points if assessed as
independently mobile, in that the applicant or recipient requires no assistance
for transfers or mobility or only has set up or supervision needed;
B. Three (3) points if assessed as requiring
limited or moderate assistance, in that the applicant or recipient performs
more than fifty percent (50%) of tasks independently; or
C. Six (6) points if assessed as requiring
maximum assistance, in that the applicant or recipient needs assistance from
two (2) or more individuals or more than fifty percent (50%) weight-bearing
assistance or totally dependent for bed mobility.
4. Eating is defined as the amount of
assistance needed by applicant or recipient to eat and drink, including special
nutritional requirements or a specialized mode of nutrition. Determine the
amount of assistance the applicant or recipient needs with eating and drinking.
Includes intake of nourishment by other means [e.g. tube feeding or total
parenteral nutrition (TPN)]. Determine if the participant requires a physician
ordered therapeutic diet. The applicant or recipient can receive up to eighteen
(18) points in this category. The applicants or recipients "totally dependent
on others to eat" are presumed to meet nursing facility level of care. The
applicant or recipient will receive-
A. Zero
(0) points if assessed as independent in dietary needs, in that the applicant
or recipient requires no assistance to eat and has no physician ordered
diet;
B. Three (3) points if
assessed as requiring minimum assistance, in that the applicant or recipient
requires physician ordered therapeutic diet, or set up, supervision, or limited
assistance is needed with eating;
C. Six (6) points if assessed as requiring
moderate assistance with eating, in that the applicant or recipient performs
more than fifty percent (50%) of tasks independently; or
D. Nine (9) points if assessed as requiring
maximum assistance with eating, in that the applicant or recipient requires an
individual to perform more than fifty percent (50%) for assistance.
5. Toileting is defined as the
amount of assistance needed by the applicant or recipient to complete all tasks
related to toileting including the actual use of the toilet room (or commode,
bedpan, urinal), transferring on/off the toilet, cleansing self, adjusting
clothes, managing catheters/ostomies, and managing incontinence episodes. The
applicant or recipient can receive up to nine (9) points in this category. The
applicant or recipient will receive-
A. Zero
(0) points if assessed as requiring no assistance, or requires only set up or
supervision needed;
B. Three (3)
points if assessed as requiring limited or moderate assistance, in that
applicant or recipient performs more than fifty percent (50%) of tasks
independently;
C. Six (6) points if
assessed as requiring maximum assistance, in that applicant or recipient needs
two (2) or more individuals, or more than fifty percent (50%) weight-bearing
assistance; or
D. Nine (9) points
if assessed as requiring total dependence on others.
6. Bathing is defined as the amount of
assistance needed by the applicant or recipient to complete a full body shower
or bath. Determine the amount of assistance the applicant or recipient needs
with bathing. Bathing includes: taking a full body bath/shower and the
transferring in and out of the bath/shower. The applicant or recipient can
receive up to six (6) points in this category. The applicant or recipient will
receive-
A. Zero (0) points if assessed as no
assistance required, or requiring only set up or supervision needed;
B. Three (3) points if assessed as requiring
limited or moderate assistance, in that applicant or recipient performs more
than fifty percent (50%) of tasks independently; or
C. Six (6) points if assessed as requiring
maximum assistance, in that the applicant or recipient requires two (2) or more
individuals, more than fifty percent (50%) weight-bearing assistance, or total
dependence on others.
7.
Dressing and grooming is defined as the amount of assistance needed by the
applicant or recipient to dress, undress, and complete daily grooming tasks.
Dressing may also include specialized devices such as prosthetics, orthotics,
etc. The applicant or recipient can receive up to six (6) points in this
category. The applicant or recipient will receive-
A. Zero (0) points if assessed as requiring
no assistance, or requiring only set up or supervision needed;
B. Three (3) points if assessed as requiring
limited or moderate assistance, in that applicant or recipient performs more
than fifty percent (50%) of tasks independently; or
C. Six (6) points if assessed as requiring
maximum assistance, in that applicant or recipient requires two (2) or more
individuals, more than fifty percent (50%) of weight-bearing assistance, or
total dependence on others.
8. Rehabilitative services is defined as the
restoration of a former or normal state of health through medically-ordered
therapeutic services either directly provided by or under the supervision of a
licensed qualified professional. Rehabilitative services include physical
therapy, occupational therapy, speech therapy, cardiac rehabilitation, and
audiology. If ordered by the physician, each resident must have an individually
planned and implemented program with written goals and response/progress
documented. Points will be determined by intensity of required services and the
applicant's or recipient's potential for rehabilitation as determined by the
rehabilitation evaluation. The applicant or recipient will receive-
A. Zero (0) points if assessed as requiring
no ordered rehabilitative services;
B. Three (3) points, if assessed as requiring
minimal-ordered rehabilitative services of one (1) time per week;
C. Six (6) points if assessed as requiring
moderate-ordered rehabilitative services of two (2) or three (3) times per
week; or
D. Nine (9) points if
assessed as requiring maximum-ordered rehabilitative services of four (4) times
per week or more.
9.
Treatments are defined as a physician ordered medical care or management that
requires additional hands on assistance. The scoring for treatments will be
zero (0) or six (6). The applicant or recipient with the identified treatments
will receive six (6) points. The applicant or recipient will receive-
A. Zero (0) points if no treatments are
ordered by the physician; or
B. Six
(6) points if assessed as requiring one (1) or more of the physician ordered
treatments requiring daily attention by a licensed professional. These
treatments could include: catheter/ostomy care, alternate modes of nutrition
(tube feeding or TPN), suctioning, ventilator/respirator, and wound care (skin
must be broken).
10. Meal
preparation is defined as the amount of assistance needed to prepare a meal
based on the applicant's or recipient's capacity to complete the task. This
includes planning, assembling ingredients, cooking, and setting out the food
and utensils. The applicant or recipient can receive up to six (6) points in
this category. The applicant or recipient will receive-
A. Zero (0) points if assessed as requiring
no assistance, or requiring only set up or supervision needed;
B. Three (3) points if assessed as requiring
limited or moderate assistance, in that applicant or recipient performs more
than fifty percent (50%) of tasks; or
C. Six (6) points if assessed as requiring
maximum assistance in that the individual performs more than fifty percent
(50%) of tasks for the applicant or recipient, or requires total dependence on
others.
11. Medication
management is defined as the amount of assistance needed by the applicant or
recipient to safely manage their medication regimen. Assistance may be needed
due to a physical or mental disability. Determine the amount of assistance the
applicant or recipient needs to safely manage their medications. The applicant
or recipient can receive up to six (6) points in this category. The applicant
or recipient will receive-
A. Zero (0) points
if assessed as requiring no assistance;
B. Three (3) points if assessed as requiring
setup help needed or supervision needed, or requires limited or moderate
assistance, in that applicant or recipient performs more than fifty percent
(50%) of tasks; or
C. Six (6)
points if assessed as requiring maximum assistance, in that the individual
performs more than fifty percent (50%) of tasks for the applicant or recipient,
or requires total dependence on others.
12. Safety is defined as the identification
of a safety risk associated with vision impairment, falling, problems with
balance, past institutionalization, and age. Determine if the applicant or
recipient exhibits any of the following risk factors: vision impairment,
falling, or problems with balance - balance is moving to standing position,
turning to face the opposite direction, dizziness, or unsteady gait. The
applicant or recipient can receive up to eighteen (18) points in this category.
After determination of a preliminary score, institutionalization and age will
be considered to determine the final score. Three (3) points can be added to
the accumulated score if the applicant or recipient is aged seventy-five (75)
years or older and/or has been institutionalized in the last five (5) years in
a long-term care facility, mental health residence, psychiatric hospital,
inpatient substance abuse, or settings for persons with intellectual
disabilities and only to the specified points category listed. The applicants
or recipients who score eighteen (18) points are presumed to meet nursing
facility level of care. The applicant or recipient will receive-
A. Zero (0) points if assessed with no
difficulty or some difficulty with vision, and no falls in the last ninety (90)
days, and no recent problems with balance;
B. Three (3) points if assessed with severe
difficulty with vision (sees only lights and shapes), or has fallen in the last
ninety (90) days, or has current problems with balance, or has a preliminary
score of zero (0) and is aged seventy-five (75) years or older or has been
institutionalized;
C. Six (6)
points if assessed with no vision or has fallen in the last ninety (90) days
and has current problems with balance, or assessed with a preliminary score of
zero (0) and is aged seventy-five (75) years or older and has been
institutionalized, or assessed with a preliminary score of three (3) points and
is aged seventy-five (75) years or older or has been
institutionalized;
D. Nine (9)
points if assessed with a preliminary score of six (6) points and has been
institutionalized; or
E. Eighteen
(18) points if assessed with a preliminary score of six (6) points and is aged
seventy-five (75) years or older or assessed with a preliminary score of three
(3) points and is aged seventy-five (75) years or older and has been
institutionalized.
(6) Level of Care Determination for Home and Community Based Services Program. The department uses level of care determination for Home and Community Based Services (HCBS). The department utilizes the InterRAI Home Care Assessment System (HC), © InterRAI. Questions are scored within the InterRAI assessment using an algorithm, included herein. The HCBS assessment process is outlined in 19 CSR 15-7.021, 19 CSR 158.200, and 13 CSR 70-91.010.
(7) Dual level-of-care assessments to be performed to determine level-of-care need from October 31, 2021, until the date that all of the temporary enhanced federal medical assistance percentage funds from the American Rescue Plan Act of 2021 are expended.
(A) The department is eligible
to receive an additional ten percent (10%) enhanced federal medical assistance
percentage for home and community based services provided from April 1, 2021,
through March 31, 2022, through the American Rescue Plan Act of 2021. This
funding will allow the department to determine level-of-care need under the
department's previous scoring system directly prior to the department's
level-of-care transformation which takes effect on October 31, 2021, through
formal rulemaking. Therefore, if an individual does not qualify for level of
care under the current level-of-care assessment as set forth in sections (5)
and (6) of this rule from October 31, 2021, until the date that all of the
temporary enhanced federal medical assistance percentage funds from the
American Rescue Plan Act of 2021 are expended, then individuals shall also be
assessed using a level-of-care assessment as set forth in section (8) of this
rule. An individual may qualify for level-of-care need under either of these
level of care assessments from October 31, 2021, until the date that all of the
temporary enhanced federal medical assistance percentage funds from the
American Rescue Plan Act of 2021 are expended.
(8) Second level-of-care determination to be performed from October 31, 2021, until the date that all of the temporary enhanced federal medical assistance percentage funds from the American Rescue Plan Act of 2021 are expended.
(A) Initial
determination of level-of-care needs requirements.
1. For the purpose of making a determination
of level-of-care need and in accordance with
42 CFR sections
456.370 and
483.104,
the department or its designated agents, or both, will conduct a review and
assessment of the evaluations made by the attending physician for an applicant
in or seeking admission to a long-term care facility. The review and assessment
shall be conducted using the criteria in subsection (8)(D) of this
rule.
2. The department shall
complete the assessment within ten (10) working days of receipt of all
documentation required by subsection (8)(D) in this rule unless further
evaluation by the State Mental Health Authority is required by
42 CFR
483.100 to
483.138.
(B) Redetermination of level-of-care
requirements.
1. Redetermination of
level-of-care of individual recipients who are eligible for placement in
long-term care facilities shall be conducted by the department through a review
and assessment of the DA-124A/B (10-21) Initial Assessment - Social and
Medical, DA-124C (10-21) Level One Nursing Facility Pre-Admission Screening for
Mental Illness/Intellectual Disability or Related Condition, and DA-124C ATT
(10-21) Notice to Applicant included herein and any documentation provided by
the resident's attending physician. A referring individual shall fill out and
submit the forms to the department at COMRU@health.mo.gov.
(C) Level-of-care criteria for long-term care
facility care-qualified Title XIX recipients and applicants.
1. Individuals will be assessed with the
ultimate goal to achieve placement for these individuals in the least
restrictive environment possible, yet enable them to receive all services
required by their physical/mental condition.
2. The specific areas which will be
considered when determining an individual's ability or inability to function in
the least restrictive environment are mobility, dietary, restorative services,
monitoring, medication, behavioral, treatments, personal care, and
rehabilitative services.
3. To
qualify for intermediate or skilled nursing care, an applicant or recipient
shall exhibit physical impairment, which may be complicated by mental
impairment or mental impairment which may be complicated by physical impairment
severe enough to require intermediate or skilled nursing care.
(D) Assessed needs point
designations requirements.
1. Applicants or
recipients will be assessed for level-of-care by the assignment of a point
count value for each category cited in paragraph (8)(C)2. of this
rule.
2. Points will be assessed
for the amount of assistance required, the complexity of the care, and the
professional level of assistance necessary, based on the level-of-care
criteria. If the applicant's or recipient's records show that the applicant's
or recipient's attending physician has ordered certain care, medication or
treatments for an applicant or recipient, the department will assess points for
a PRN order if the applicant or recipient has actually received or required
that care, medication, or treatment within the thirty (30) days prior to review
and evaluation by the department.
3. For individuals seeking admission to a
long-term care facility on or after October, 31, 2021, the applicant or
recipient will be determined to be qualified for long-term care facility care
if he or she is determined to need care with an assessed point level of
twenty-four (24) points or above, using the assessment procedure as required in
paragraph (8)(D)7. of this rule.
4.
For individuals seeking admission to a long-term care facility on or after
October 31, 2021, an applicant with twenty-one (21) points or lower will be
assessed as ineligible for Title XIX-funded long-term care in a long-term care
facility, unless the applicant qualifies as otherwise provided in section (5),
section (6), or paragraphs (8)(D)5. or 6. in this rule.
5. Applicants or recipients may occasionally
require care or services, or both, which could qualify as long-term care
facility services. In these instances, a single nursing service requirement may
be used as the qualifying factor, making the individual eligible for long-term
care facility care regardless of the total point count. The determining factor
will be the availability of professional personnel to perform or supervise the
qualifying care services. Qualifying care services may include, but are not
limited to:
A. Administration of levine tube
or gastrostomy tube feedings;
B.
Nasopharyngeal and tracheotomy aspiration;
C. Insertion of medicated or sterile
irrigation and replacement catheters;
D. Administration of parenteral
fluids;
E. Inhalation therapy
treatments;
F. Administration of
injectable medications other than insulin, if required other than on the day
shift; and
G. Requirement of
intensive rehabilitation services by a professional therapist at least five (5)
days per week.
6. An
applicant or recipient will be considered eligible for inpatient Title XIX
assistance regardless of the total point count if the applicant or recipient is
unable to meet physical/mental requirements for residential care facility (RCF)
or assisted living facility (ALF) residency as specified by section
198.073,
RSMo.
7. Points will be assigned to
each category, as required by paragraph (8)(C)2. in this rule, in multiples of
three (3) according to the following requirements:
A. Mobility is defined as the individual's
ability to move from place to place. The applicant or recipient will receive-
(I) Zero (0) points if assessed as
independently mobile, in that the applicant or recipient requires no assistance
for transfers or mobility. The applicant or recipient may use assistive devices
(cane, walker, wheelchair) but is consistently capable of negotiating without
assistance of another individual;
(II) Three (3) points if assessed as
requiring minimum assistance, in that the applicant or recipient is
independently mobile once the applicant or recipient receives assistance with
transfers, braces, or prosthesis application or other assistive devices, or a
combination of these (example, independent use of wheelchair after assistance
with transfer). This category includes individuals who are not consistently
independent and need assistance periodically;
(III) Six (6) points if assessed as requiring
moderate assistance, in that the applicant or recipient is mobile only with
direct staff assistance. The applicant or recipient must be assisted even when
using canes, walker, or other assistive devices; and
(IV) Nine (9) points if assessed as requiring
maximum assistance, in that the applicant or recipient is totally dependent
upon staff for mobility. The applicant or recipient is unable to ambulate or
participate in the ambulation process, requires positioning, supportive device,
application, prevention of contractures or pressure sores, and active or
passive range of motion exercises;
B. Dietary is defined as the applicant's or
recipient's nutritional requirements and need for assistance or supervision
with meals. The applicant or recipient will receive-
(I) Zero (0) points if assessed as
independent in dietary needs, in that the applicant or recipient requires no
assistance to eat. The applicant or recipient has physician's orders for a
regular diet, mechanically altered diet, or requires only minor modifications
(example, limited desserts, no salt or sugar on tray);
(II) Three (3) points if assessed as
requiring minimum assistance, in that the applicant or recipient requires meal
supervision or minimal help, such as cutting food or verbal encouragement.
Calculated diets for stabilized conditions shall be included;
(III) Six (6) points if assessed as requiring
moderate assistance, in that the applicant or recipient requires help,
including constant supervision during meals, or actual feeding. Calculated
diets for unstable conditions are included; and
(IV) Nine (9) points if assessed as requiring
maximum assistance, in that the applicant or recipient requires extensive
assistance for special dietary needs or with eating, which could include
enteral feedings or parenteral fluids;
C. Restorative services are defined as
specialized services provided by trained and supervised individuals to help
applicants or recipients obtain and/or maintain their optimal highest
practicable functioning potential. Each applicant or recipient must have an
individual overall plan of care developed by the provider with written goals
and response/progress documented. Restorative services may include, but are not
limited to, applicant or recipient teaching program (self-transfer,
self-administration of medications, self-care), range of motion, bowel and
bladder program, remotivational therapy, validation therapy, patient/family
program, and individualized activity program. The applicant or recipient will
receive-
(I) Zero (0) points if restorative
services are not required;
(II)
Three (3) points if assessed as requiring minimum services in order to maintain
level of functioning;
(III) Six (6)
points if assessed as requiring moderate services in order to restore the
individual to a higher level of functioning; and
(IV) Nine (9) points if assessed as requiring
maximum services in order to restore to a higher level of functioning. These
are intensive services, usually requiring professional supervision or direct
services;
D. Monitoring
is defined as observation and assessment of the applicant's or recipient's
physical and/or mental condition. This monitoring could include assessment of
routine laboratory work, including, but not limited to, evaluating digoxin and
coumadin levels, measurement and evaluation of blood glucose levels,
measurement and evaluation of intake and output of fluids the individual has
received and/or excreted, weights and other routine monitoring procedures. The
applicant or recipient will receive-
(I) Zero
(0) points if assessed as requiring only routine monitoring, such as monthly
weights, temperatures, blood pressures, and other routine vital signs and
routine supervision;
(II) Three (3)
points if assessed as requiring minimal monitoring, in that the applicant or
recipient requires periodic assessment due to mental impairment, monitoring of
mild confusion, or both, or periodic assessment of routine procedures when the
recipient's condition is stable;
(III) Six (6) points if assessed as requiring
moderate monitoring, in that the applicant or recipient requires recurring
assessment of routine procedures due to the applicant's or recipient's unstable
physical or mental condition; and
(IV) Nine (9) points if assessed as requiring
maximum monitoring, which is intensive monitoring usually by professional
personnel due to applicant's or recipient's unstable physical or mental
condition;
E. Medication
is defined as the drug regimen of all physician-ordered legend medications, and
any physician-ordered nonlegend medication for which the physician has ordered
monitoring due to the complexity of the medication or the condition of the
applicant or recipient. The applicant or recipient will receive-
(I) Zero (0) points if assessed as requiring
no medication, or has not required PRN medication within the thirty (30) days
prior to review and evaluation by the department;
(II) Three (3) points if assessed as
requiring any regularly scheduled medication and the applicant or recipient
exhibits a stable condition;
(III)
Six (6) points if assessed as requiring moderate supervision of regularly
scheduled medications, requiring daily monitoring by licensed personnel;
and
(IV) Nine (9) points if
assessed as requiring maximum supervision of regularly scheduled medications, a
complex medication regimen, unstable physical or mental status or use of
medications requiring professional observation and assessment, or a combination
of these;
F. Behavioral
is defined as an individual's social or mental activities. The applicant or
recipient will receive-
(I) Zero (0) points if
assessed as requiring little or no behavioral assistance. Applicant or
recipient is oriented and memory intact;
(II) Three (3) points if assessed as
requiring minimal behavioral assistance in the form of supervision or guidance
on a periodic basis. Applicant or recipient may display some memory lapses or
occasional forgetfulness due to mental or developmental disabilities, or both.
Applicant or recipient generally relates well with others (positive or neutral)
but needs occasional emotional support;
(III) Six (6) points if assessed as requiring
moderate behavioral assistance in the form of supervision due to
disorientation, mental or developmental disabilities, or uncooperative
behavior; and
(IV) Nine (9) points
if assessed as requiring maximum behavioral assistance in the form of extensive
supervision due to psychological, developmental disabilities, or traumatic
brain injuries with resultant confusion, incompetency, hyperactivity,
hostility, severe depression, or other behavioral characteristics. This
category includes residents who frequently exhibit bizarre behavior, are
verbally or physically abusive, or both, or are incapable of self-direction.
Applicants or recipients who exhibit uncontrolled behavior that is dangerous to
themselves or others must be transferred immediately to an appropriate
facility;
G. Treatments
are defined as a systematized course of nursing procedures ordered by the
attending physician. The applicant or recipient will receive-
(I) Zero (0) points if no treatments are
ordered by the physician;
(II)
Three (3) points if assessed as requiring minimal type-ordered treatments,
including nonroutine and preventative treatments, such as whirlpool baths and
other services;
(III) Six (6)
points if assessed as requiring moderate type-ordered treatments requiring
daily attention by licensed personnel. These treatments could include: daily
dressings, PRN oxygen, oral suctioning, catheter maintenance care, treatment of
stasis or pressure sore ulcers, wet/moist packs, maximist, and other such
services; and
(IV) Nine (9) points
if assessed as requiring maximum type-ordered treatments of an extensive nature
requiring provision, direct supervision, or both, by professional personnel.
These treatments could include intratrachial suctioning, insertion or
maintenance of suprapubic catheter, continuous oxygen, new or unregulated
ostomy care, dressings of deep draining lesions more than once daily, care of
extensive skin disorders such as advanced pressure sore or necrotic lesions,
infrared heat, and other services;
H. Personal care is defined as activities of
daily living, including hygiene; personal grooming, such as dressing, bathing,
oral and personal hygiene, hair and nail care, shaving; and bowel and bladder
functions. Points will be determined based on the amount of assistance required
and degree of assistance involved in the activity. The applicant or recipient
will receive-
(I) Zero (0) points if assessed
as requiring no assistance with personal care, in that the applicant or
recipient is an independent, self-care individual. No assistance is required
with personal grooming; the applicant or recipient has complete bowel and
bladder control;
(II) Three (3)
points if assessed as requiring minimal assistance with personal care, in that
the applicant or recipient requires assistance with personal grooming, and/or
exhibits infrequent incontinency (once a week or less);
(III) Six (6) points if assessed as requiring
moderate assistance with personal care, in that the applicant or recipient
requires assistance with personal grooming, requiring close supervision or
exhibits frequent incontinency (incontinent of bladder daily but has some
control or incontinent of bowel two (2) or three (3) times per week), or a
combination of these; and
(IV) Nine
(9) points if assessed as requiring maximum assistance with personal care, in
that the applicant or recipient requires total personal care to be performed by
another individual, and/or exhibits continuous incontinency all or most of the
time; and
I.
Rehabilitation is defined as the restoration of a former or normal state of
health through medically ordered therapeutic services either directly provided
by or under the supervision of a qualified professional. Rehabilitation
services include, but are not limited to, physical therapy, occupational
therapy, speech therapy, and audiology. If ordered by the physician, each
resident must have an individually planned and implemented program with written
goals and response/progress documented. Points will be determined by intensity
of required services and the applicant's or recipient's potential for
rehabilitation as determined by the rehabilitation evaluation. The applicant or
recipient will receive-
(I) Zero (0) points if
assessed as requiring no ordered rehabilitation services;
(II) Three (3) points, if assessed as
requiring minimal-ordered rehabilitation services of one (1) time per
week;
(III) Six (6) points if
assessed as requiring moderate-ordered rehabilitative services of two (2) or
three (3) times per week; or
(IV)
Nine (9) points if assessed as requiring maximum-ordered rehabilitative
services of four (4) times per week or more.
GUIDE #1 - ASSESSED NEEDS:
1. MOBILITY - individual's ability to move
from place to place. Do they require assistive device, physical assist with
transfer, mobile only with physical assist or unable to ambulate and/or totally
dependent?
2. DIETARY - individual's
nutritional requirements and need for assist and/or supervision with meals. Do
they have a special diet, require tray set up, cueing, feeding or on tube
feedings or IV fluids?
3.
RESTORATIVE - specialized services provided to help individual obtain/maintain
optimal function potential. Is individual receiving ROM, B & B program, RO,
frequency, and amount of assistance required?
4. MONITORING - Observation and assessment of
individual's physical and mental condition. This may include routine lab work,
I & O, clinitest, acetest, weights and other routine procedures.
5. MEDICATION - A drug regimen of all
physician ordered legend and non-legend drugs for which a physician has ordered
monitoring due to complexity of drug or condition of individual.
6. BEHAVIORAL - individual's social or mental
activities. Does individual require supervision/guidance or assist due to their
behavior? Are they alert, oriented, disoriented, uncooperative, abusive or
incapable of self-direction?
7.
TREATMENTS - a systematized course of nursing procedures ordered by the
attending physician. What is the treatment and how often is it ordered? Is the
treatment non-routine and preventive, require daily attention by a professional
or require extensive direct supervision?
8. PERSONAL CARE - activities of daily
living, including hygiene, personal grooming (dressing, bathing, oral hygiene,
hair and nail care, shaving), and bowel and bladder function. Does daily care
require supervision, close supervision or total care?
9. REHABILITATION - restoration of former or
normal state of health through medically ordered therapeutic services either
directly provided by or under the supervision of a qualified professional,
which may include PT, OT, ST and audiology. What type of rehab is individual
receiving and how often do they receive it?
NOTE: Refer to 19 CSR 30-81.030 for complete details of point count system.
GUIDE #2 - INSTRUCTIONS (for Pre-Admission Screenings):
A. NURSING FACILITY
ADMISSIONS FROM HOSPITALS-
1. If the person is
hospitalized and will or MAY seek placement in a Medicaid certified bed within
a skilled or intermediate nursing facility upon discharge, the hospital
completes the Level One (I) Screening (DA-124C form) as soon as possible. If a
Level Two (II) Screening is then indicated, the hospital also completes the
DA-124A/B form (all questions must be answered). Email both forms to:
COMRU@health. mo.gov. NOTE: The hospital must take immediate action since the
Level II Screening process takes 7-9 working days to complete. The physician's
signature, discipline, license number and date are ALWAYS required.
2. In Missouri, Federal & State
regulations require that Level II Screenings be completed PRIOR to nursing
facility placement EXCEPT when a person qualifies for a SPECIAL ADMISSION
CATEGORY (follow directions on DA-124C form). NOTE: COMRU nurse may require
copy of History & Physical.
B. NURSING FACILITY ADMISSIONS FROM HOME OR
RCF OR ALF-
1. Skilled/intermediate nursing
facilities receiving persons directly from home should assist families in
completing the Level I Screening (DA-124C) with instructions for them to obtain
the family physician's signature. If a Level II Screening is indicated,
completion of the DA-124A/B follows, as outlined in section A, #1 and
2.
2. EMERGENCY ADMISSIONS FROM HOME
OR RCF OR ALF-If the person is a danger to himself or others, or if protective
oversight is necessary, call the Adult Abuse and Neglect Hotline,
1-800-392-0210. Explain the emergency and ask that a DHSS Worker review the
client for EMERGENCY admission to a skilled/intermediate nursing facility.
Complete the DA-124A/B & C forms and contact COMRU immediately
(573-522-3092). If the emergency occurs at night or on a weekend, do the same
and contact COMRU at open of next business day before emailing the forms. If
the person will require more than 7 days in a nursing facility, notify COMRU
immediately.
3. All Medicaid
certified beds, including swing beds, within skilled/ intermediate nursing
facilities MUST have a completed DA-124C form. If the person is PRIVATE PAY and
their Level I Screening does NOT indicate the need for a Level II Screening,
the DA-124C form is kept in their chart (on file) until they apply for
Medicaid. At that time, a current DA-124A/B form is completed, attached to the
original DA-124C form, and mailed to the same address as in section A,
#1.
C. NURSING FACILITY
TRANSFERS-
1. When persons transfer from one
skilled/intermediate nursing facility to another, the sending facility
furnishes a copy of their DA-124A/B & C forms to the receiving facility.
The receiving facility then notifies their local FSD office of the
transfer.
2. When persons transfer
from one skilled/intermediate nursing facility to another and application for
Medicaid is not indicated, the ORIGINAL DA-124C form must follow to the next
facility.
D. TRANSFERS
FROM A FACILITY TO A HOSPITAL TO ANOTHER FACILITY-
1. When the person transfers from one
skilled/intermediate facility to a hospital, then to another
skilled/intermediate facility, hospitals must consider the following prior to
placement:
a. If the person did not need a
Level II Screening prior to placement at the sending facility, no new forms are
indicated if this hospital stay does not exceed 60 days (unless a current Level
I Screening indicates the need for a Level II Screening).
b. If the person had a Level II Screening
prior to placement at the sending facility, but is being hospitalized for acute
medical treatment, no new forms are necessary if the hospital stay does not
exceed 60 days.
E. PERSON IS DISCHARGED HOME BUT UNABLE TO
STAY-
1. If person is out of facility less
than 60 days, no new forms are required. Notify local FSD office of person's
readmission.
*Original authority: 192.006, RSMo 1993, amended 1995; 198.079, RSMo 1979; and 660.050, RSMo 1984, amended 1988, 1992, 1993, 1994, 1995, 2001.
Disclaimer: These regulations may not be the most recent version. Missouri may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
