Chapter 173-43 Long Term Care Consultation Program

(A) The purpose of Chapter 173-43 of the Administrative Code is to establish the long-term care consultation program pursuant to sections 173.42 and 173.43 of the Revised Code. This program shall provide individuals or their representatives with long-term care consultations that provide information about options available to meet their long-term care needs and factors to consider when making long-term care decisions.

(B) As used in this chapter:

(1) “AAA” means “area agency on aging.”

(2) “Individual” means a person who may qualify to receive a consultation.

(3) “Level of care” (“LOC”) means the review and determination process established by rule 5101:3-3-15 of the Administrative Code.

(4) “Long-term care consultation” (“consultation”) is the face-to-face service defined by division (A)(2) of section 173.42 of the Revised Code.

(5) “Nursing facility” (“NF”) has the same meaning as division (P) of section 5111.20 of the Revised Code.

(6) “ODA” means “the Ohio department of aging.”

(7) “ODA’s designee” means the AAA or another entity under contract with ODA to perform consultations.

(8) “Pre-admission screening and resident review” (“PASRR”) has the same meaning as established by rules 5101:3-3-15.1 and 5101:3-3-15.2 of the Administrative Code.

(9) “Representative” means a person eighteen years of age or older acting on behalf of an individual seeking a consultation, applying for admission to a NF, or residing in a NF. A representative may be a family member, an attorney, a hospital social worker, or any other person chosen by the individual to act on behalf of the individual.

Effective: 06/30/2007

R.C. 119.032 review dates: 06/30/2011

Promulgated Under: 119.03

Statutory Authority: 173.02, 173.42

Rule Amplifies: 173.42

(A) Whenever any individual applies for admission to an NF or indicates an intention to apply for admission to a NF, regardless of the source of payment, and whenever any NF resident applies for medicaid or indicates an intention to apply for medicaid, either the NF or ODA’s designee shall determine whether an individual requires a consultation in accordance with rule 173-43-03 of the Administrative Code.

(B) For an individual who contacts the NF seeking admission or for a current resident of a NF who is seeking medicaid eligibility, the NF may determine that the individual is exempt according to the criteria set forth in paragraph (B) of rule 173-43-03 of the Administrative Code.

(1) If the NF determines that ODA’s designee is not required to provide a consultation to an individual, the NF shall document in the individual’s record the criteria met for the exemption.

(2) If the NF determines that the individual is not exempt from the consultation, the NF shall provide ODA’s designee with the information required in paragraph (E) of this rule.

(C) For a hospitalized individual who has either contacted the NF and was not determined to be exempt or who has not contacted the NF, the hospital shall provide ODA’s designee with the information required in paragraph (E) of this rule.

(D) For an individual who is not covered by paragraph (B) or (C) of this rule, the individual or the representative of the individual shall provide to ODA’s designee the required information in paragraph (E) of this rule to initiate the consultation process.

(E) Whenever a NF, hospital, or individual provides ODA’s designee with information in accordance with paragraphs (B), (C), and (D) of this rule, the NF, hospital, or individual shall provide, at a minimum, all the following information, whether by telephone, in writing, in person or electronically:

(1) The expected length of stay in the NF;

(2) All known information concerning existing formal support systems, existing informal support systems, potential formal support systems, and potential informal support systems that are available to the individual;

(3) Whether the individual has previously been admitted to a NF; and,

(4) For an individual who is not seeking a medicaid payment, a statement demonstrating whether or not the resources of the individual will be depleted within six months of admission, which may make the individual financially eligible for medicaid. The individual or representative of the individual shall base the statement upon knowledge of the current cost for a six-month stay in the NF. If the individual or the representative of the individual does not know the current cost, the NF shall provide that information, upon request, to the individual or the representative of the individual.

(F) If ODA’s designee determines that it is not required to provide a consultation to an individual according to the parameters of paragraphs (B) and (C) of rule 173-43-03 of the Administrative Code, ODA’s designee shall provide documentation to the individual (or to the individual’s representative, if any) and to the NF (if known) that identifies the exemption being met.

(G) For an individual for whom ODA’s designee is required to provide a consultation, ODA’s designee shall determine whether to perform a consultation prior to admission to a NF or after admission to a NF. ODA’s designee may determine that a consultation may be conducted after admission to a NF if any of the following applies:

(1) ODA’s designee decides that a limited length of stay in a NF would be beneficial in order for alternative service arrangements to be put into place, or for the individual to rehabilitate so that alternative service arrangements are then able to meet the needs of the individual;

(2) The consultation cannot be completed within the required number of days in accordance with rule 173-43-04 of the Administrative Code and ODA’s designee has not exempted the individual from the requirement to receive a consultation;

(3) ODA or ODA’s designee determines that a individual has an emergency need for admission to a NF based upon credible information from sources that include, but are not limited to, the following:

(a) An adult protective services worker;

(b) A categorical PAS-SMI, as defined in rule 5122-21-03 of the Administrative Code; or,

(c) A categorical PAS-MR/DD determination as defined in rule 5123:2-14-01 of the Administrative Code.

(4) If the need for an emergency admission to a NF arises during the time when ODA’s designee is not open for business and is not able to make the determination that the individual has an emergency need for admission, the NF may admit the individual (although paragraph (L) of this rule still applies). The NF shall provide notification of the admission to ODA’s designee no later than twenty-four hours after the admission.

(H) Only a person who is certified by ODA or ODA’s designee pursuant to rule 173-43-05 of the Administrative Code may perform a consultation.

(I) At a minimum, every consultation shall provide each of the following components:

(1) Any long-term care options available to the individual (public and private) that may meet the needs of the individual;

(2) Information explaining the methods to use to apply for the long-term care options mentioned in accordance with paragraph (I)(1) of this rule;

(3) A personalized list of factors to consider when deliberating over long-term care options mentioned in accordance with paragraph (I)(1) of this rule, including, but not limited to, any known potential risks that may be associated with the options and applicable resources that the individual may use to learn about the quality of services; and,

(4) Information explaining the opportunities and methods for maximizing the independence and self-reliance of the individual, including information about support services provided by the family, friends, and community of the individual that may be able to meet the needs of the individual.

(J) At the conclusion of the consultation, ODA’s designee shall provide the individual or the representative of the individual with a written summary of options and resources available to meet the needs of the individual.

(K) Although the summary mandated by paragraph (J) of this rule may specify that an alternative source of long-term care is appropriate and available, the individual is not required to seek the alternative source. Instead, the individual may be admitted to a NF or continue to reside in a NF, unless the individual does not meet the applicable requirements under rules 5101:3-3-15.1 and 5101:3-3-15.2 of the Administrative Code.

(L) An individual who is subject to a PASRR and/or a LOC review shall comply with the requirements of a PASRR and/or a LOC review. This is the case even if ODA’s designee is not required to provide a consultation to the individual and even if ODA’s designee is not required to provide a consultation until after admission to a NF.

(M) If a consultation includes any portion of a PASRR and/or a LOC review, any determinations made in relation to these reviews shall comply with rules 173-43-05, 5101:3-3-15, 5101:3-3-15.1, and 5101:3-3-15.2 of the Administrative Code.

(N) A NF that has a provider agreement with the department of job and family services may only admit or retain an individual as a resident upon receipt of evidence that the individual is exempt from or has met the requirements of this rule.

Replaces: 5101:3-3-14

Effective: 06/30/2007

R.C. 119.032 review dates: 06/30/2011

Promulgated Under: 119.03

Statutory Authority: 173.02, 173.42

Rule Amplifies: 173.42

Prior Effective Dates: 1/1/95

This rule sets forth the conditions under which determinations are made concerning whether an individual is required to be provided a consultation or may be exempt from that requirement. It also describes the conditions under which a NF or ODA’s designee may exempt an individual from the requirement to be provided a consultation.

(A) ODA’s designee shall provide each individual in the following categories with a consultation:

(1) An individual who applies or indicates an intention to apply for admission to a NF, regardless of the source of payment to be used for the care in the NF, so long as the individual is not exempted by paragraph (B) or (C) of this rule;

(2) A NF resident who applies or indicates an intention to apply for medicaid, so long as the individual is not exempted by paragraph (B) or (C) of this rule;

(3) An individual who is not seeking medicaid payment and is likely to deplete his or her financial resources within six months after admission to a NF to a level at which the individual would become financially eligible for medicaid as described in paragraph (D)(1) of this rule, so long as the individual is not exempted by paragraph (B) or (C) of this rule;

(4) A NF resident who was admitted under a time-limited convalescent exemption or who was admitted under a categorical determination in accordance with rule 5101:3-3-15.1, rule 5122-21-03, or rule 5123:2-14-01 of the Administrative Code, but has since been found to require a stay in a NF that will exceed the time limits specified in those rules, so long as the individual is not exempted by paragraph (B) or (C) of this rule. In this case, the NF shall inform ODA’s designee of such an individual no later than seventy-two hours after the expiration of the time limit. Upon being notified, ODA’s designee shall determine whether or not a consultation is required; or,

(5) Any individual who requests a consultation.

(B) Either the NF to which the individual is seeking admission, the NF to which the individual is seeking continued residency, or ODA’s designee shall determine that ODA’s designee is not required to provide each individual in the following categories with a consultation unless the individual or the individual’s representative requests a consultation:

(1) An individual who is to receive care in a NF under a contract for continuing care as defined in section 173.13 of the Revised Code;

(2) An individual who has a contractual right to admission to a NF operated as part of a system of continuing care in conjunction with one or more facilities that provide a less-intensive level of services, including a residential care facility licensed under Chapter 3721. of the Revised Code, an adult care facility licensed under Chapter 3722. of the Revised Code, or an independent living arrangement;

(3) An individual who is to receive continual care in a home for the aged that is exempt from taxation under section 5701.13 of the Revised Code;

(4) An individual who is seeking admission to a facility that is not a NF with a provider agreement under section 5111.22 of the Revised Code;

(5) An individual who is seeking a NF transfer. A NF transfer occurs when an individual’s place of residence is changed from one Ohio medicaid-certified NF to another Ohio medicaid-certified NF, with or without an intervening hospital stay;

(6) An individual who is to be readmitted to the same NF following a period of hospitalization;

(7) An individual who is seeking admission to a NF to receive hospice services;

(8) An individual who is currently enrolled in an HCBS waiver, or was enrolled in a HCBS waiver prior to the NF admission being sought, regardless of the payment source being sought for the NF admission; or,

(9) An individual who is seeking admission to a NF, or who is already a resident of a NF, who is being actively case managed by medicare or another funding source that will case manage the individual while in the NF.

(C) ODA’s designee may determine that it is not required to provide each individual in the following categories with a consultation unless the individual or the individual’s representative requests a consultation:

(1) An individual who is being admitted to a NF directly from a hospital and is expected to have a short length of stay (ninety days or less) . In making this determination, ODA’s designee shall consider factors such as medical condition, probable need for long-term care services, history of hospitalizations, availability of informal supports, and awareness of options available;

(2) An individual who has care needs that clearly exceed the services that are available to the individual in an alternative setting to the NF. To make this determination, ODA’s designee shall consider the availability of existing formal and informal support systems, the availability of potential formal and informal support systems, the functional abilities and limitations of the individual, the individual’s diagnosis, the individual’s prognosis, and the individual’s plan of treatment, placing special emphasis on end-of-life treatment, because such a treatment is most likely an indicator that the individual will not benefit from a consultation;

(3) An individual who has been admitted to a NF under a convalescent exemption from PASRR, or under a time-limited categorical PAS-SMI or PAS-MR/DD determination as defined in rules 5122-21-03 and 5123:2-14-01 of the Administrative Code; and,

(4) An individual for whom ODA’s designee cannot complete a consultation within the required time frame, as described in paragraph (D) of rule 173-43-04 of the Administrative Code.

(D) An individual or the representative of an individual may forego the opportunity to participate in a consultation only if either of the following conditions exist:

(1) The individual has not applied for, or indicated an intent to apply for, medicaid payment for their NF stay and ODA’s designee has determined that the individual is not likely to spend down his or her resources within six months of admission. ODA’s designee shall make this determination based upon a statement demonstrating whether or not the resources of the individual will be depleted within six months of admission, which may make the individual financially eligible for medicaid. The individual or representative of the individual shall base the statement upon knowledge of the current cost for a six-month stay in the NF. If the individual or the representative of the individual does not know the current cost, the NF shall provide that information, upon request, to the individual or the representative of the individual; or,

(2) The individual has already received an in-person LTC consultation from the administrative agency; regardless of the payment source being sought for the NF admission.

(E) At the individual’s request, ODA’s designee may provide written or verbal information regarding long-term care services even if the individual does not require a consultation.

Effective: 06/30/2007

R.C. 119.032 review dates: 06/30/2011

Promulgated Under: 119.03

Statutory Authority: 173.02, 173.42

Rule Amplifies: 173.42

(A) If an individual has applied for medicaid coverage, ODA’s designee shall complete the consultation in accordance with the applicable time frame for providing the LOC determination as specified in rule 5101:3-3-15 of the Administrative Code.

(B) Except for a consultation mentioned in paragraph (A) of this rule, ODA’s designee shall complete every consultation no later than five calendar days after ODA’s designee receives a request for the consultation.

(C) An individual or the representative of the individual may request that ODA’s designee provide a consultation on a date that is later than the date required. In such cases, ODA’s designee shall provide the consultation at a time that is mutually agreed-upon between the individual (or the representative of the individual) and ODA’s designee.

(D) If ODA’s designee cannot complete the consultation within the number of days required, or if the individual was admitted to a NF due to an emergency in accordance with paragraph (G)(4) of rule 173-43-02 of the Administrative Code, ODA’s designee may take the following action:

(1) Exempt the individual from the consultation if it is decided that it would not be beneficial to perform the consultation after the NF admission;

(2) Provide the consultation as soon as practicable after the individual has been admitted to a NF in the case of an applicant for admission to a NF; or,

(3) Provide the consultation as soon as practicable in the case of a NF resident for whom ODA’s designee is required to provide a consultation.

Effective: 06/30/2007

R.C. 119.032 review dates: 06/30/2011

Promulgated Under: 119.03

Statutory Authority: 173.02, 173.42

Rule Amplifies: 173.42

(A) Only a person who is certified by ODA may perform a consultation.

(B) ODA shall only certify a person to perform a consultation who is currently an employee of ODA’s designee and who meets at least one of the following criteria:

(1) The person possesses a valid license to practice as a registered nurse in accordance with Chapter 4723. of the Revised Code, a valid license to practice as a licensed social worker in accordance with Chapter 4757. of the Revised Code, a valid license to practice as a licensed professional counselor in accordance with Chapter 4757. of the Revised Code, or a valid license to perform in a related profession upon approval by ODA;

(2) The person possesses a bachelor of arts degree or a bachelor of science degree and also possesses at least one year of experience in the following:

(a) Providing individuals with information about options available to meet long-term care needs or providing individuals with related information such as that which is provided through information and referral, information and assistance; or,

(b) Managed care experience or other such health care experience related to the long-term care needs of the individual.

(3) The person possesses at least three years of experience in the following:

(a) Providing individuals with information about options available to meet long-term care needs or providing individuals with related information such as that which is provided through information and referral, information and assistance; or,

(b) Managed care experience or other such health care experience related to the long-term care needs of the individual.

(C) ODA shall only certify a person who meets the following conditions to perform an in-person consultation that includes an assessment of the individual’s functional capabilities, any portion of a required PASRR determination in accordance with rule 5101:3-3-15.1 or 5101:3-3-15.2 of the Administrative Code, or any portion of a LOC review in accordance with rule 5101:3-3-15 of the Administrative Code:

(1) A person who meets the requirements of paragraph (B) of this rule; and,

(2) A person who possesses at least a valid license to practice as a registered nurse in accordance with Chapter 4723. of the Revised Code, a valid license to practice as a licensed social worker in accordance with Chapter 4757. of the Revised Code, or a valid license to practice as a counselor in accordance with Chapter 4757. of the Revised Code.

(D) ODA shall provide to its designee the date the person is certified. Once certified, a person shall successfully complete fifteen clock hours of professional development every two years beginning with the date of certification. The professional development curriculum shall transmit knowledge relevant to the duties involved in providing a consultation.

(E) If, at any time, the certified person no longer meets the requirements of this rule, the person shall not perform another consultation until compliance with this rule is re-established.

(F) For each certified individual, ODA’s designee shall track and keep records demonstrating that the requirements of this rule are met.

(G) ODA’s designee shall train and orient each certified individual. Training and orientation shall include, but is not limited to, the following:

(1) Local availability of publicly-financed and privately-financed long-term care options, programs, services, and benefits;

(2) Factors to consider when choosing among available options; and,

(3) Opportunities and methods for individuals to maximize independence and self-reliance.

Effective: 06/30/2007

R.C. 119.032 review dates: 06/30/2011

Promulgated Under: 119.03

Statutory Authority: 173.02, 173.43

Rule Amplifies: 173.43