5101:3-3-05 Skilled level of care (SLOC).

(A) This rule sets forth the criteria used to determine whether an individual who is seeking medicaid payment for long term care needs services at the skilled care level. The term “skilled care”, as defined and used in this rule, has no relationship to the provision of either skilled nursing services under the rules governing private duty nursing set forth in Chapter 5101:3-8 of the Administrative Code or skilled care as defined under the medicare program provisions of the Social Security Act as amended.

(B) Definitions.

(1) “Individual” has the same meaning as in rule 5101:3-3-15 of the Administrative Code.

(2) “Instability of the individual’s condition” means that an individual’s condition changes frequently and/or rapidly, so that constant monitoring and/or the frequent adjustment of treatment regimens is required. An individual is considered to have an unstable medical condition if one of the following conditions is met:

(a) The physician has ordered that the nurse or therapist monitor and evaluate the individual’s condition on an ongoing basis and make any necessary adjustments to the treatment regimen, and the nursing or therapist’s progress notes indicate that such interventions or adjustments have been both necessary and made; or

(b) The physician’s orders dealing with the individual’s unstable condition reflect that changes and/or adjustments have been made at least monthly.

(3) “Skilled care level” means that an individual receives at least one skilled nursing service at least seven days per week, and/or a skilled rehabilitation service at least five days per week. For the delivery of skilled services to qualify for the skilled care level, the services must be ordered by a physician, and must be delivered by the licensed or certified professional due to either:

(a) The instability of the individual’s condition and the complexity of the prescribed service; or

(b) The instability of the individual’s condition and the presence of special medical complications.

(4) “Skilled nursing services” are those specific tasks which must, in accordance with Chapter 4723. of the Revised Code, be delivered by a licensed practical nurse (LPN) under the supervision of a registered nurse (RN), or by an RN.

(5) “Skilled rehabilitation services” are those specific tasks which must, in accordance with Title 47 of the Revised Code, be delivered directly by licensed or other appropriately certified technical or professional health care personnel.

(C) An individual may be determined to require a skilled level of care (SLOC) only if both of the following conditions are met:

(1) The individual’s physical and mental condition and resulting service needs have been evaluated and compared to all of the possible levels of care (in accordance with rule 5101:3-3-15 of the Administrative Code) and it has been determined that:

(a) The individual requires services beyond the minimum of those of protective care (set forth in rule 5101:3-3-08 of the Administrative Code); and

(b) The individual requires services beyond the minimum of those of intermediate care (set forth in rule 5101:3-3-06 of the Administrative Code); and/or

(c) The individual requires services beyond the minimum of those of an intermediate care facility for the mentally retarded developmentally disabled level of care (ICF-MR/DD LOC) (set forth in rule 5101:3-3-07 of the Administrative Code); and

(2) At least one of the following applies:

(a) The individual’s condition necessitates, and the individual’s physician has ordered, that at least one skilled nursing service (as defined in paragraph (B)(4) of this rule) be provided at the skilled care level (as defined in paragraph (B)(3) of this rule);

(b) The individual’s condition necessitates, and the individual’s physician has ordered, that at least one skilled rehabilitation service (as defined in paragraph (B)(5) of this rule) be provided at the skilled care level (as defined in paragraph (B)(3) of this rule); however

(3) An individual who meets the requirements of paragraphs (C)(1)(c) and (C)(2) of this rule may be determined to require an SLOC unless the individual has applied to a specific intermediate care facility for the mentally retarded (ICF-MR) that is equipped to provide services at the skilled care level (as defined in paragraph (B)(3) of this rule). An individual who has applied to an ICF-MR that is equipped to provide services at the skilled care level may be determined to require an ICF-MR/DD LOC if there is written certification that the facility can meet the individual’s skilled care needs.

Effective: 07/01/2008

R.C. 119.032 review dates: 04/07/2008 and 07/01/2013

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.204

Prior Effective Dates: 7/1/80, 10/1/93 (Emer.), 12/31/93