Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities
Section 5160-3-05 - Level of care definitions
Universal Citation: OH Admin Code 5160-3-05
Current through all regulations passed and filed through September 16, 2024
(A) This rule contains the definitions used in the process of making a determination of an individual's level of care. The definitions in this rule apply unless a term is otherwise defined in a specific rule.
(B) Definitions.
(1)
"Active Treatment" means a continuous treatment
program including aggressive, consistent implementation of a program of
specialized and generic training, treatment, health services and related
services for individuals with mental retardation and/or other developmental
disabilities that are directed toward the following:
(a)
The acquisition
of the behaviors necessary for the individual to function with as much self
determination and independence as possible; and
(b)
The prevention
or deceleration of regression or loss of current optimal functional
status.
(2)
"Activity of daily living (ADL)" means a personal or
self-care task that enables an individual to meet basic life needs. For
purposes of this rule, the term "ADL" includes the following defined
activities:
(a)
"Bathing" means the ability of an individual to cleanse
one's body by showering, tub, or sponge bath, or any other generally accepted
method.
(b)
"Dressing" means the ability of an individual to
complete the activities necessary to dress oneself and includes the following
two components:
(i)
Putting on and taking off an item of clothing or
prosthesis; and
(ii)
Fastening and unfastening an item of clothing or
prosthesis.
(c)
"Eating" means the ability of an individual to feed
oneself. Eating includes the processes of getting food into one's mouth,
chewing, and swallowing, and/or the ability to use and self-manage a feeding
tube.
(d)
"Grooming" means the ability of an individual to care
for one's appearance and includes the following three components:
(i)
Oral
hygiene;
(ii)
Hair care; and
(iii)
Nail
care.
(e)
"Mobility" means the ability of an individual to use
fine and gross motor skills to reposition or move oneself from place to place
and includes the following three components:
(i)
"Bed mobility"
means the ability of an individual to move to or from a lying position, turn
from side to side, or otherwise position the body while in bed or alternative
sleep furniture;
(ii)
"Locomotion" means the ability of an individual to
move between locations by ambulation or by other means; and
(iii)
"Transfer"
means the ability of an individual to move between surfaces, including but not
limited to, to and from a bed, chair, wheelchair, or standing position.
(f)
"Toileting" means the ability of an individual to
complete the activities necessary to eliminate and dispose of bodily waste and
includes the following four components:
(i)
Using a commode,
bedpan, or urinal;
(ii)
Changing incontinence supplies or feminine hygiene
products;
(iii)
Cleansing self; and
(iv)
Managing an
ostomy or catheter.
(3)
"Adverse level
of care determination" means a determination that an individual does not meet
the criteria for a specific level of care.
(4)
"Alternative
form" means a form that is used in place of and contains all of the data
elements of, the JFS 03697, "Level of Care Assessment" (rev. 4/2003) to request
a level of care determination from the Ohio department of job and family
services (ODJFS) or its designee.
(5)
"Assistance"
means the hands-on provision of help in the initiation and/or completion of a
task.
(6)
"Authorized representative" has the same meaning as in
rule 5101:1-37-01 of the Administrative Code.
(7)
"CBDD" means a
county board of developmental disabilities as established under Chapter 5126.
of the Revised Code.
(8)
"Current diagnoses" means a written medical
determination by the individual's attending physician, whose scope of practice
includes diagnosis, listing those diagnosed conditions that currently impact
the individual's health and functional abilities.
(9)
"Delayed
face-to-face visit" means an in-person visit that occurs within a specified
period of time after a desk review has been conducted that includes the
elements of a long-term care consultation, in accordance with Chapter 173-43 of
the Administrative Code, for the purposes of exploring home and community-based
services (HCBS) options and making referrals to the individual as
appropriate.
(10)
"Desk review" means a level of care determination
process that is not conducted in person.
(11)
"Developmental
delay" means that an individual age birth through five has not achieved
developmental milestones as expected for the individual's chronological age as
measured, documented, and determined by qualified professionals using generally
accepted diagnostic instruments or procedures.
(12)
"Face-to-face"
means an in-person level of care assessment and determination process with the
individual for the purposes of exploring nursing facility services or HCBS
options and making referrals to the individual as appropriate, that is not
conducted by a desk review only.
(13)
"Habilitation"
in accordance with
42 U.S.C.
1396 n(c)(5) as in effect December 27, 2005,
means services designed to assist individuals in acquiring, retaining, and
improving the self-help, socialization, and adaptive skills necessary to reside
successfully in home and community-based settings.
(14)
"ICF-MR" means
an intermediate care facility for persons with mental retardation.
(15)
"ICF-MR-based level of care" means the levels of care as described in rules
5101:3-3-07, 5101:3-3-15.3, and 5101:3-3- 15.5 of the Administrative
Code.
(16)
"Individual" means a medicaid recipient or person with
pending medicaid eligibility.
(17)
"Instrumental
activity of daily living (IADL)" means the ability of an individual to complete
community living skills. For the purposes of this rule, the term "IADL"
includes the following defined activities:
(a)
"Community
access " means the ability of an individual to use available community services
and supports to meet one's needs and includes the following three
components:
(i)
"Accessing transportation" means the ability to get and use
transportation.
(ii)
"Handling finances" means the ability of an individual
to manage one's money and does not include transportation. Handling finances
includes all of the following:
(a) Knowing where money is;
(b) Knowing how to get money;
(c) Paying bills; and
(d) Knowing how to get and use benefits and services, including but not limited to:
(i) Health benefits and insurance;
(ii) Social benefits; and
(iii) Home utilities.
(iii)
"Telephoning"
means the ability to make and answer telephone calls or use technology to
connect to community services and supports.
(b)
"Environmental
management" means the ability of an individual to maintain the living
arrangement in a manner that ensures the health and safety of the individual
and includes the following three components:
(i)
"Heavy chores"
means the ability to move heavy furniture and appliances for cleaning, turn
mattresses, and wash windows and walls; and
(ii)
"House
cleaning" means the ability to make beds, clean the bathroom, sweep and mop
floors, dust, clean and store dishes, pick up clutter, and take out
trash;
(iii)
"Yard work and/or maintenance" means the ability to
care for the lawn, rake leaves, shovel snow, complete minor home repairs, and
paint.
(c)
"Meal preparation" means the ability of an individual
to prepare or cook food for oneself.
(d)
"Personal
laundry" means the ability of an individual to wash and dry one's clothing and
household items by machine or by hand.
(e)
"Shopping" means
the ability to obtain or purchase one's necessary items.Necessary items
include, but are not limited to, groceries, clothing, and household items.
Shopping does not include handling finances or accessing transportation.
(18)
"Less than twenty-four hour support" means that an
individual requires the presence of another person, or the presence of a remote
monitoring device that does not require the individual to initiate a response,
during a portion of a twenty-four hour period of time.
(19)
"Level of care
determination" means an assessment and evaluation by ODJFS or its designee of
an individual's physical, mental, social, and emotional status, using the
processes described in rules 5101:3-3-15, 5101:3-3-15.3, and 5101:3-3- 15.5 of
the Administrative Code, to compare the criteria for all of the possible levels
of care as described in rules 5101:3-3-06 to 5101:3-3-08 of the Administrative
Code, and make a decision about whether an individual meets the criteria for a
level of care.
(20)
"Level of care validation" means the verification
process for ODJFS or its designee to review and enter an individual's current
level of care in the electronic records of the individual that are maintained
by ODJFS.
(21)
"Long-term services and supports" means institutional
or community-based medical, health, psycho-social, habilitative,
rehabilitative, or personal care services that may be provided to
medicaid-eligible individuals.
(22)
"Major life
area" has the same meaning as in rule 5101:3-3-07 of the Administrative
Code.
(23)
"Manifested" means a condition is diagnosed and
interferes with the individual's ability to develop or maintain functioning in
at least one major life area.
(24)
"Medication
administration" means the ability of an individual to prepare and
self-administer all forms of over-the-counter and prescription
medication.
(25)
"Need" means the inability of an individual to
complete a necessary and applicable task independently, safely, and
consistently. An individual does not have a need when:
(a)
The individual
is not willing to complete a task or does not have the choice to complete a
task.
(b)
The task can be completed with the use of available
assistive devices and accommodations.
(26)
"Nursing
facility (NF)" has the same meaning as in section
5111.20 of the Revised Code. A
facility that has submitted an application packet for medicaid certification to
ODJFS is considered to be in the process of obtaining its initial medicaid
certification by the Ohio department of health and shall be treated as a NF for
the purposes of this rule.
(27)
"NF-based level
of care" means the intermediate and skilled levels of care, as described in
rule 5101:3-3-08 of the Administrative Code.
(28)
"NF-based level
of care program" means a NF, a home and community-based services medicaid
waiver that requires a NF-based level of care, or other medicaid program that
requires a NF-based level of care.
(29)
"PASRR" means
the preadmission screening and resident review requirements mandated by section
1919(e)(7) of the Social Security Act and implemented in accordance with rules
5101:3-3-14, 5101:3-3-15.1, 5101:3-3- 15.2 and
5122-21-03 and
5123:2-14-01 of the
Administrative Code.
(30)
"Physician" means a person licensed under Chapter
4731. of the Revised Code or licensed in another state as defined by applicable
law, to practice medicine and surgery or osteopathic medicine and
surgery.
(31)
"Psychiatrist" means a physician licensed under
Chapter 4731. of the Revised Code or licensed in another state as defined by
applicable law, to practice psychiatry.
(32)
"Psychologist"
means, a person licensed in Ohio as a psychologist or school psychologist, or
licensed in another state as a psychologist as defined by applicable law.
(33)
The
terms "psychologist," "the practice of psychology," "psychological procedures,"
"school psychologist," "practice of school psychology," "licensed
psychologist," "licensed school psychologist," and "certificated school
psychologist" have the same meanings as in section
4732.01 of the Revised
Code.
(34)
"Skilled nursing services" means specific tasks that
must, in accordance with Chapter 4723. of the Revised Code, be provided by a
licensed practical nurse (LPN) at the direction of a registered nurse or by a
registered nurse directly.
(35)
"Skilled
rehabilitation services" means specific tasks that must, in accordance with
Title 47 of the Revised Code, be provided directly by a licensed or other
appropriately certified technical or professional health care personnel.
(36)
"Sponsor" means an adult relative, friend, or guardian of an individual who has
an interest in or responsibility for the individual's welfare.
(37)
"Substantial
functional limitation" means the inability of an individual to independently,
adequately, safely, and consistently perform age-appropriate tasks as
associated with the major life areas and as referenced in paragraph (B)(4) of
this rule, without undue effort and within a reasonable period of time. An
individual who has access to and is able to perform the tasks independently,
adequately, safely, and consistently with the use of adaptive equipment or
assistive devices is not considered to have a substantial functional
limitation.
(38)
"Supervision" means either of the following:
(a)
Reminding an
individual to perform or complete an activity; or
(b)
Observing while
an individual performs an activity to ensure the individual's health and
safety.
(39)
"Twenty-four hour support" means that an individual
requires the continuous presence of another person throughout the course of the
entire day and night during a twenty-four hour period of time.
(40)
"Unstable
medical condition" means clinical signs and symptoms are present in an
individual and a physician has determined that:
(a)
The individual's
signs and symptoms are outside of the normal range for that individual;
(b)
The
individual's signs and symptoms require extensive monitoring and ongoing
evaluation of the individual's status and care and there are supporting
diagnostic or ancillary testing reports that justify the need for frequent
monitoring or adjustment of the treatment regimen;
(c)
Changes in the
individual's medical condition are uncontrollable or unpredictable and may
require immediate interventions; and
(d)
A licensed
health professional must provide ongoing assessments and evaluations of the
individual that will result in adjustments to the treatment regimen as
medically necessary. The adjustments to the treatment regimen must happen at
least monthly, and the designated licensed health professional must document
that the medical interventions are medically necessary.
Replaces: Part of 5101:3-3-05, 5101:3-3-06, 5101:3-3-07,5101:3-3-08, 5101:3-3-15
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