5101:3-3-14 Preadmission screening (PAS) and resident review (RR) definitions.

(A) The purpose of this rule is to set forth the definitions for terms contained in rules 5101:3-3-15.1 , 5101:3-3-15.2, 5122-21-03 and 5123:2-14-01 of the Administrative Code.

(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 client to function with as much self-determination and independence as possible; and

(b) The prevention, deceleration, regression or loss of current optimal functional status.

(2) 'Adverse determination' means a determination made in accordance with rules 5101:3-3-15.1 , 5101:3-3-15.2, 5122-21-03 and 5123:2-14-01 of the Administrative Code, that an individual does not require the level of services provided by a nursing facility(NF). A determination that an individual does not require NF services shall meet both of the following conditions:

(a) A face-to-face assessment of the individual, and a review of the medical records accurately reflecting the individual's current condition, is 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;

(x) Psychologist;

(b) Authorized personnel from the Ohio department of mental health (ODMH) and/or Ohio department of developmental disabilities (DODD), other than the personnel identified in paragraph (B)(2)(a) of this rule who have conducted the face-to-face assessment, have reviewed the assessment and made the final determination regarding the need for NF services and specialized services.

(3) 'Categorical determination' means a preadmission screening mental retardation developmental disabilities (PAS-MRDD) or preadmission screening serious mental illness (PAS-SMI) determination which may be made for an individual with MRDD and/or serious mental illness (SMI) without first completing a full PAS-MRDD and/or PAS-SMI evaluation when the individual's circumstances fall within one of the following two categories:

(a) The individual requires an 'emergency NF stay', as defined in paragraph (B)(7) of this rule;

(b) The individual is seeking admission to a NF for a 'respite NF stay' as defined in paragraph (B)(27) of this rule.

(4) 'Convalescent' exemption has the same meaning as hospital exemption defined in paragraph (B)(10) of this rule.

(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 was assigned by the individuals attending physician within one hundred eighty calendar days of submission for the PAS review certifying that the listed diagnoses are an accurate reflection of the individual's current condition;

(a) 'Primary diagnosis' means the diagnosis identified as the primary diagnosis by the physician, whose scope of practice includes diagnosis. If two or more diagnoses have such indications, none of them can be considered to be the primary diagnosis for the purposes of this rule.

(b) 'Secondary diagnosis' means any diagnoses other than a primary diagnosis as defined in paragraph (B)(5)(a) of this rule.

(6) 'Dementia.' An individual is considered to have dementia if he or she meets either of the following criteria:

(a) The individual has a primary diagnosis of a dementia, including alzheimer's disease or a related disorder, as described in the 'diagnostic and statistical manual of mental disorders,' fourth edition, text revision (DSM-IV-TR); or

(b) The individual has a secondary diagnosis of a dementia, including alzheimer's disease or a related disorder, (as described in the DSM-IV-TR), and a primary diagnosis which is not a major mental disorder specified in paragraph (B)(32)(a) of this rule.

(7) 'Emergency NF stay' means the individual is being admitted to a nursing facility pending further assessment for a period not to exceed seven days when the placement in the NF is necessary to avoid serious risk to the individual of immediate harm or death.

(8) 'Guardian' has the same meaning as in section 2111.01 of the Revised Code.

(9) Hospital (convalescent) exemption means an exemption from preadmission screening (PAS) for a new admission, as defined in paragraphs (B)(17)(a) to (B)(17)(d) of this rule, to a NF that meets the following criteria:

(a) The individual is to be admitted or enrolled directly from an Ohio hospital after receiving acute inpatient care at that hospital or is an Ohio resident being admitted or enrolled directly from an out-of-state hospital after receiving acute inpatient care at the hospital; and

(b) The individual requires the level of services provided by a NF for the condition which was treated in the hospital; and

(c) The individual's attending physician has provided written certification, signed and dated no later than the date of discharge from the hospital, stating that the individual is likely to require the level of services provided by a NF for less than thirty days.

(10) 'ICF/MR' means intermediate care facility for the mentally retarded. An ICF/MR is a long-term care facility certified to provide ICF/MR services, as defined in 42 C.F.R. 440.150 , dated October 1, 2008 to individuals with mental retardation or related conditions requiring active treatment.

(11) 'Indications of mental retardation and/or other developmental disabilities (MRDD)'. An individual shall be considered to have indications of mental retardation and/or other developmental disabilities if the individual meets the criteria specified in paragraph (B)(16) of this rule or the individual receives services from a county board of developmental disabilities (CBDD).

(12) 'Indications of serious mental illness (SMI).' An individual shall be considered to have indications of serious mental illness if the individual meets at least two of the three criteria specified in paragraph (B)(32) of this rule or, due to a mental impairment, receives supplemental security income authorized under Title XVI of the Social Security Act, as amended, or social security disability insurance authorized under Title II of the Social Security Act.

(13) 'Individual' for the purposes of this rule, means a person regardless of payment source, who is seeking admission, readmission or transfer to a NF, or who resides in a NF or facility in the process of becoming certified as a NF.

(14) 'Long-term resident' means an individual who has continuously resided in a NF or a consecutive series of NF's and/or medicare skilled nursing facilities for at least thirty months prior to the first resident review (RR) determination in which the individual was found not to require the level of services provided by a NF, but to require specialized services as defined in paragraphs (B)(34) and (B)(35) of this rule. The thirty months may include temporary absences for hospitalization, therapeutic leave, or visits with family or friends as defined in rule 5101:3-3-16.4 of the Administrative Code.

(15) 'Medicaid managed care plan' means a managed care plan (MCP) as defined in rule 5101:3-26-01 of the Administrative Code.

(16) 'Mental retardation and/or other developmental disabilities (MRDD).' An individual is considered to have mental retardation and/or a developmental disability if he or she has:

(a) A level of retardation described in the american association on mental retardation's manual 'mental retardation: definition, classifications and systems of support' (2002); or

(b) A related condition which means a severe, chronic disability meeting all of the following conditions:

(i) It is attributable to:

(a) Cerebral palsy, epilepsy; or

(b) Any other condition other than mental illness, found to be closely related to mental retardation because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with mental retardation, and requires treatment or services;

(ii) It is manifested before the person reaches the age of twenty-two; and

(iii) It is likely to continue indefinitely; and

(iv) It results in substantial functional limitations in three or more of the following areas of major life activity:

(a) Self-care;

(b) Understanding and use of language;

(c) Learning;

(d) Mobility;

(e) Self-direction;

(f) Capacity for independent living; or

(g) Economic self-sufficiency (for persons sixteen years and older);

(v) Individuals who have a developmental disability as defined in section 5123.01 of the Revised Code are considered to have a related condition.

(17) 'New admission' means:

(a) The admission, to an Ohio medicaid certified NF, of an individual who was not a resident of any Ohio medicaid certified NF immediately preceding the current NF admission nor immediately preceding a hospital stay from which the individual is to be admitted directly to a NF (this includes individuals with no previous NF admissions; individuals admitted from other states, regardless of type of prior residence; and individuals with prior Ohio NF admissions who had been discharged from an Ohio NF and did not have either an intervening hospital or other NF stay immediately preceding the current NF admission); and/or

(b) The admission, with or without an intervening hospital stay, to an Ohio medicaid certified NF, of an individual discharged, returning to the same NF or transferred from an Ohio medicaid certified NF subsequent to an adverse PAS or RR determination or following an overruled appeal of an adverse PAS or RR determination immediately preceding the current NF admission; and/or

(c) For PASRR purposes only and effective on the date the facility submits its application packet for medicaid certification to ODJFS, individuals seeking admission to, or are currently residing in, a facility that is in the process of obtaining its initial medicaid certification by Ohio department of health (ODH) and that facility and its residents were not subject to PASRR requirements preceding the submission of this application for medicaid certification. This does not include facilities that have already received medicaid NF certification and are undergoing a change of operator; and/or

(d) With the exception of those circumstances specified in paragraphs (B)(17)(a) to (B)(17)(c) of this rule, NF transfers and readmissions as defined in paragraphs (B)(19) and (B)(25) 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 ODJFS is considered to be in the process of obtaining its initial medicaid certification by the ODH and shall be treated as a NF for the purposes of this rule.

(19) 'NF transfer.' A NF transfer occurs when an individual's place of residence is changed from any Ohio medicaid certified NF to another Ohio medicaid certified NF, with or without an intervening hospital stay.

(20) 'Preadmission screening identification (PAS/ID).' 'PAS/ID', also known as a level one screen, means the process by which ODJFS, or its designee, screens individuals who are seeking new admissions to identify those who have indications of mental retardation and/or other developmental disabilities (MR/DD) or serious mental illness (SMI) as defined in paragraphs (B)(11) and (B)(12) of this rule; and who, therefore, must be further evaluated by ODMH and/or DODD.

(21) 'Physician' means a doctor of medicine or osteopathy who is licensed to practice medicine.

(22) 'Preadmission screening for mental retardation/developmental disabilities (PAS-MRDD), also known as a level two screen, means the process by which DODD determines:

(a) Whether, due to the individual's physical and mental condition, an individual who has MRDD requires the level of services provided by a NF or another type of setting; and

(b) If the level of services provided by a NF is needed, whether the individual requires specialized services for MRDD.

(23) 'Preadmission screening for serious mental illness (PAS/SMI), also known as a level two screen, means the process by which ODMH determines:

(a) Whether, due to the individual's physical and mental condition, an individual who has SMI requires the level of services provided by a NF or another type of setting; and

(b) Whether the individual requires specialized services for serious mental illness.

(24) Preadmission screening (PAS) means the pre-admission portion of the PASRR requirements mandated by section 1919(e)(7) of the Social Security Act, which must be implemented in accordance with rules 5101:3-3-15.1 , 5122-21-03 and 5123:2-14-01 of the Administrative Code.

(25) 'Readmission' means the individual is readmitted to the same NF, following a stay in the hospital to which he or she was sent for the purpose of receiving care, except as specified in paragraphs (B)(17)(a) to (B)(17)(d) of this rule.

(26) 'Resident review (RR)' means the resident review portion of the PASRR requirements mandated by section 1919(e)(7) of the Social Security Act, which must be implemented in accordance with rules 5101:3-3-15.2 , 5122-21-03 and 5123:2-14-01 of the Administrative Code.

(27) 'Respite NF stay' means the admission of an individual 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 brief respite stay.

(28) 'RR identification (RR/ID)' is the process set forth in rules 5101:3-3-15.2 , 5122-21-03 , and 5123:2-14-01 of the Administrative Code by which individuals who are subject to RR shall be identified.

(29) 'Resident review for mental retardation/developmental disabilities (RR-MRDD)' means the process, set forth in rule 5123:2-14-01 of the Administrative Code, by which the DODD determines whether, due to the individual's physical and mental condition, an individual who is subject to RR, and who has mental retardation/developmental disabilities (MRDD) requires the level of services provided by a NF or another type of setting; and, whether the individual requires specialized services for MRDD.

(30) 'Resident review for serious mental illness (RR-SMI)' means the process, set forth in rule 5122-21-03 of the Administrative Code, by which the ODMH determines whether, due to the individual's physical and mental condition, an individual who is subject to RR, and who has serious mental illness (SMI) requires the level of services provided by a NF or another type of setting; or whether that individual requires specialized services for serious mental illness.

(31) 'Ruled out' means that the individual has been determined not to be subject to further review by DODD or ODMH. An individual may be ruled out for further PASRR review at any point in the PASRR process. If DODD or ODMH finds at any time during the evaluation that the individual being evaluated:

(a) Does not have MRDD 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 serious mental illness, and does not have a diagnosis of MRDD or a related condition.

(32) 'Serious mental illness (SMI)' includes the following criteria regarding diagnosis, level of impairment and recent treatment.

(a) Diagnosis. The individual does not have dementia (as defined in paragraph (B)(6) of this rule), but has a major mental disorder diagnosable under the 'Diagnostic and statistical manual of mental disorders,' fourth edition, text revision (DSM-IV-TR); and this mental disorder is one of the following: a schizophrenic, mood, delusional (paranoid), panic or other severe anxiety disorder, somatoform disorder, personality disorder, other psychotic disorder, or another mental disorder other than mental retardation that may lead to a chronic disability diagnosable under the DSM-IV-TR .

(b) Level of impairment. Within the past six months, due to the mental disorder, the individual has experienced functional limitations on a continuing or intermittent basis in major life activities that would be appropriate for the individual's developmental stage.

(c) Recent treatment. The treatment history indicates that the individual has experienced at least one of the following:

(i) Psychiatric treatment more intensive than counseling and/or psychotherapy performed on an outpatient basis more than once within the past two years; or

(ii) Within the last two years, due to the mental disorder, experienced an episode of significant disruption to the usual living arrangement, for which supportive services were required, or which resulted in intervention by housing or law enforcement officials.

(33) Significant change of condition including any major decline or improvement in condition has the same meaning used in administering the routine resident assessment requirements specified in 42 C.F.R. 483.20 , and that 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 SMI, or who did not previously have indications of MRDD, now has such indications (this includes any individual who may have had indications of one or the other but now has indications of both SMI and MRDD), or who was previously determined by ODMH not to have SMI but who now meets all three of the defining criteria for SMI (set forth in paragraphs (B)(3)(a)(i) to (B)(3)(a)(iii) of rule 5101:3-3-15.1 of the Administrative Code); 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 MRDD.

(34) 'Specialized services for serious mental illness' means those services which are distinct from those available in NFs and results in the continuous and aggressive implementation of an individualized plan of care approved by the medical director of ODMH or designee that:

(a) Is developed and supervised by an interdisciplinary team which includes a physician, trained mental health professionals and, as appropriate, other professionals;

(b) Prescribes specific therapies and treatment activities for an individual experiencing an acute episode of SMI which necessitates supervision by trained mental health personnel in an inpatient setting licensed and/or operated by ODMH; and

(c) Is time limited and directed toward diagnosing and reducing the individual's behavioral symptoms that necessitated intensive and aggressive intervention, improving the individual's level of independent functioning, and achieving a functioning level that permitting reduction in the intensity of mental health services to below the level of specialized services at the earliest possible time.

(35) 'Specialized services for mental retardation and/or other developmental disabilities' means the services specified by the PAS-MRDD or RR-M/DD determination and provided or arranged for by the CBDD resulting in continuous active treatment to address needs in each of the life areas in which functional limitations are identified by the CBDD. Specialized services shall be made available at the intensity and frequency necessary to meet the needs of the individual.

Effective: 12/01/2009
R.C. 119.032 review dates: 12/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.02