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 5160-3-15 - Preadmission screening and resident review (PASRR) definitions
Universal Citation: OH Admin Code 5160-3-15
Current through all regulations passed and filed through September 16, 2024
(A) The purpose of this rule is to set forth the definitions for terms contained in rules 5160-3-15.1, 5160-3- 15.2, 5122-21-03 and 5123-14-01 of the Administrative Code.
(B) Definitions:
(1)
"Adverse
determination" means a determination made in accordance with rules 5160-3-15.1,
5160-3- 15.2,
5122-21-03 and
5123-14-01 of the Administrative
Code, that an individual does not require the level of services provided by a
nursing facility or that the individual does or does not require specialized
services.
(2)
"Attending Physician" means the physician to whom a
person, or the family of a person, has assigned primary responsibility for the
treatment or care of the person or, if the person or the person's family has
not assigned that responsibility, the physician who has accepted that
responsibility.
(3)
"Categorical determination" means a preadmission level
II determination which may be made for an individual without a face to face
assessment for an individual diagnosed with a serious mental illness (SMI)
and/or developmental disability (DD) as defined in paragraphs (B)(6) and
(B)(28) of this rule when the individual's circumstances fall within one of the
following two categories:
(a)
The individual requires an 'emergency nursing facility
stay', as defined in paragraph (B)(7) of this rule;
(b)
The individual is
seeking admission to a nursing facility for a 'respite nursing facility stay'
as defined in paragraph (B)(26) of this rule.
(4)
"Community" for
PASRR purposes means a new admission from a setting other than a nursing
facility, Ohio hospital or a unit of a hospital that is not operated by or
licensed by the Ohio department of mental health and addiction services
(OhioMHAS).
(5)
"Current diagnoses'"means a written medical
determination by the individual's attending physician, whose scope of practice
includes diagnosis, listing those diagnosed conditions which currently impact
the individual's health and functional abilities. To be considered current, the
written documentation of the diagnoses must reflect the diagnoses assigned by
the individual's attending physician within one hundred eighty calendar days of
submission for the preadmission screening review certifying that the listed
diagnoses are an accurate reflection of the individual's current
condition.
(6)
"Developmental disability (DD)". An individual is
considered to have a DD when he or she meets the conditions described in rule
5123-14-01 of the Administrative
Code.
(7)
"Emergency nursing facility stay" refers to the
temporary admission of an individual to a nursing facility pending further
assessment in emergency situations requiring protective services as defined in
rule 5101:2-20-01 of the
Administrative Code, with placement in a nursing facility not to exceed seven
days.
(8)
"Guardian" has the same meaning as in section
2111.01 of the Revised
Code.
(9)
"Hospital discharge exemption", also known as hospital
exemption means an exemption from the preadmission screening as defined in
paragraph (B)(21) of this rule, when an individual meets the hospital discharge
exemption criteria in rule
5160-3-15.1 of the
Administrative Code.
(10)
"Indications of developmental disabilities (DD)". An
individual shall be considered to have indications of developmental
disabilities 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.
(11)
"Indications of serious mental illness (SMI)." An
individual shall be considered to have indications of an SMI when the
individual meets the criteria specified in rule
5122-21-03 of the Administrative
Code.
(12)
"Individual", for the purposes of this rule, means a
person, regardless of payment source, who is seeking admission, readmission or
transfer to a medicaid certified nursing facility, or who resides in a medicaid
certified nursing facility or facility in the process of becoming medicaid
certified as a nursing facility.
(13)
"Level I" or
"level I screening" refers to the initial screening that must be given to all
individuals seeking new admission as defined in paragraph (B)(17) of this rule
to a medicaid-certified nursing facility, regardless of payor source, for the
purpose of identifying individuals who may have or are suspected to have
indications of a DD as defined in paragraph (B)(10) of this rule and/or a SMI
as defined in paragraph (B)(11) of this rule.
(14)
"Level II
entities" refers to the state level II authorities which is the OhioMHAS and
the Ohio department of developmental disabilities (DODD).
(15)
"Level II" or
"level II evaluation" refers to the in-depth evaluation of an individual that
has been identified as having indications or suspected of having indications of
a DD and/or a SMI as defined in paragraphs (B)(10) and (B)(11) of this rule by
the level I screening outcome. The level II entity must confirm or disconfirm
the existence of a DD and/or a SMI and make a written determination of the
following:
(a)
The individual's need or continued need for nursing facility
services as defined in paragraph (B)(19) of this rule; and
(b)
If the nursing
facility is or continues to be the most appropriate setting to meet the
individual's long-term care needs; and
(c)
Identification
and recommendation for specialized services as defined in paragraphs (B)(30)
and/or (B)(31) of this rule, if any, that would be needed for the individual
during the individual's nursing facility stay.
(16)
"Long-term
resident" means an individual who has continuously resided in a nursing
facility or a consecutive series of nursing facilities and/or medicare skilled
nursing facilities for at least thirty months prior to the first resident
review determination in which the individual was found not to require the level
of services provided by a nursing facility, but to require specialized services
as defined in paragraphs (B)(30) and (B)(31) of this rule. The thirty months
may include temporary absences for hospitalization, therapeutic leave, or
visits with family or friends as defined in rule
5160-3-16.4 of the
Administrative Code.
(17)
"New admission" means the admission to an Ohio medicaid
certified nursing facility of an individual:
(a)
Who was not a
resident of any nursing facility immediately preceding:
(i)
The current
nursing facility admission; or
(ii)
A hospital stay
for which the individual is to be admitted directly to a nursing
facility;
(b)
Seeking admission or admitted to a nursing facility
from another state, regardless of prior residence; or
(c)
Is transferred or
readmitted from a nursing facility following an:
(i)
Adverse level II
or a resident review determination; or
(ii)
Overruled appeal of an adverse level
II determination.
(d)
For PASRR
purposes only and effective on the date the facility submits its application
packet for medicaid certification to the Ohio department of medicaid,
individuals seeking admission to, or who are currently residing in, a facility
that is in the process of obtaining its initial medicaid certification by Ohio
department of health, and
(e)
With the exception of those circumstances specified in
paragraphs (B)(17) (a) to (B)(17)(c) of this rule, nursing facility transfers
and readmissions as defined in paragraphs (B)(20) and (B)(24) of this rule are
not considered to be new admissions for the purposes of this
rule.
(18)
"Nursing facility" has the same meaning as in section
5111.20 of the Revised Code. A
long term care facility that has submitted an application packet for medicaid
certification to the Ohio department of medicaid 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 nursing facility for the purposes of this
rule.
(19)
"Nursing facility level of service" for the purposes of
PASRR means a determination made by the DODD and/or OhioMHAS in accordance with
rules 5123-14-01 and
5122-21-03 of the Administrative
Code as required by section 1919(e)(7) of the Social Security Act, as in effect
July 1, 2019 that the individual's need for treatment does not exceed the level
of services which can be delivered by the nursing facility to which the
individual is seeking admission or is currently admitted to either through
nursing facility services alone or, where necessary, through nursing facility
services supplemented by specialized services provided by or arranged for by
the state.
(20)
"Nursing facility transfer." A nursing facility
transfer occurs when an individual is transferred from any Ohio medicaid
certified nursing facility to another Ohio medicaid certified nursing facility,
with or without an intervening hospital stay.
(21)
"Preadmission
screening" refers to the level I screening as defined in paragraph (B)(13) of
this rule and when applicable the completion of the level II evaluation as
defined in paragraph (B)(15) of this rule that results in a PASRR determination
from the DODD and/or OhioMHAS administered prior to the individuals admission
to the nursing facility.
(22)
"PASRR" means the preadmission screening and resident
review of individuals for the purposes of identifying individuals with serious
mental illness as defined in rule
5122-21-03 of the Administrative
Code and/or a developmental disability as defined in rule
5123-14-01 of the Administrative
Code and required by the "Social Security Act,"42
U.S.C
1396r(e)(7).
(23)
"Physician"
means a doctor of medicine or osteopathy who is licensed to practice
medicine.
(24)
"Readmission" means the individual is readmitted to the
same nursing facility from a hospital to which he or she was sent for the
purpose of receiving care.
(25)
"Resident
review"' is a post admission level II evaluation as defined in paragraph
(B)(15) of this rule that results in a determination for nursing facility
residents which must be implemented upon a significant change in condition as
defined in paragraph (B)(29) of this rule and in accordance with section
1919(e)(7) of the Social Security Act, as in effect on July 1, 2019, which must
be implemented in accordance with rules 5160-3-15.2,
5122-21-03 and
5123-14-01 of the Administrative
Code.
(26)
'Respite nursing facility stay' means the admission of
an individual to a nursing facility 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.
(27)
"Ruled out"
means a determination made by the DODD and/or the OhioMHAS that the individual
is not subject to further review. An individual may be ruled out at any time
during the PASRR assessment when it is determined that the individual:
(a)
Does not have a
DD and/or SMI; or
(b)
Has a primary diagnosis of dementia (including
alzheimer's disease or a related disorder); or
(c)
Has a non-primary
diagnosis of dementia without a primary diagnosis that is a SMI, and does not
have a diagnosis of a DD or a related condition.
(28)
"Serious mental
illness" means an individual meets the conditions described in rule
5122-21-03 of the Administrative
Code.
(29)
"Significant change of condition" means any major
decline or improvement in the individual's physical or mental condition, as
described in
42 C.F.R.
483.20, as in effect on July 1, 2019 and when
at least one of the following criteria is met:
(a)
There is a change
in the individual's current diagnosis(es), mental health treatment, functional
capacity, or behavior such that, as a result of the change, the individual who
did not previously have indications of a SMI, or who did not previously have
indications of a DD, now has such indications; or
(b)
The change is
such that it may impact the mental health treatment or placement options of an
individual previously identified as having SMI and/or may result in a change in
the specialized services needs of an individual previously identified as having
a DD.
(30)
"Specialized services for serious mental illness" means
those services specified by the level II or the resident review determination
for an individual with a SMI which are arranged by OhioMHAS in accordance with
rule 5122-21-03 of the Administrative
Code and may be provided under the behavioral health services as described in
rules 5160-8-05 and
5160-27-02 of the Administrative
Code, which when combined with services by the nursing facility, results in the
continuous and aggressive implementation of an individualized plan of care in
accordance with
42 CFR
483.120, as in effect July 1,
2019.
(31)
"Specialized services for developmental disabilities"
means the services or supports specified by the level II or the resident review
determination for an individual with a DD which is provided or arranged for by
the county board of DD in accordance with rule
5123-14-01 of the Administrative
Code.
Replaces: 5160-3-15
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