Current through all regulations passed and filed through March 18, 2024
(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 of the Administrative Code 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
5160-3-15until
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 following categories:
(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.
(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,
telephonic, or video conference 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;
(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, telephonic, or video conference 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 sixy
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.