5101:3-3-15.1 Preadmission screening (PAS) requirements for individuals seeking admission to nursing facilities (NFs).

(A) The purpose of this rule is to set forth the PAS requirements in order to comply with section 1919(e)(7) of the Social Security Act, as amended, which prohibits nursing facilities from admitting or enrolling individuals with serious mental illness (SMI) (as defined in paragraph (B)(32) of rule 5101:3-3-14 of the Administrative Code) or mental retardation and/or other developmental disabilities (MRDD) (as defined in paragraph (B)(16) of rule 5101:3-3-14 of the Administrative Code) unless a thorough evaluation indicates that such placement is appropriate and adequate services will be provided.

(B) Preadmission screening identification (PAS/ID) requirements:

(1) PAS/ID must be completed prior to any new admission to a NF and prior to any categorical determination as these are defined in rule 5101:3-3-14 of the Administrative Code unless the admission meets the criteria for a hospital(convalescent) exemption as set forth in paragraph (B)(9) of rule 5101:3-3-14 of the Administrative Code and the requirements for exemption set forth in paragraph (G) of this rule.

(2) PAS/ID must be completed and submitted to the PASSPORT administrative agency (PAA), the Ohio department of job and family services (ODJFS) designee, via a JFS 03622 'PASRR (SMI/MRDD) Identification Screen' (rev. 11/09) with supporting documentation sufficient to validate the answers on the JFS 03622.

(a) For individuals seeking medicaid payment, the JFS 03697 'level of care assessment' (rev. 4/03) shall also be submitted in accordance with rule 5101:3-3-15 of the Administrative Code to ODJFS or its designee, unless the individual is enrolled in a medicaid managed care plan(MCP) as defined in rule 5101:3-3-14 of the Administrative Code.

(b) For those individuals who will be relocating from outside of Ohio, who are not Ohio residents, and are known to have serious mental illness (SMI) and/or MRDD or whose JFS 03622 form contains indications of MRDD and/or SMI, the submitter shall obtain and submit with the JFS 03622, the JFS 03697 form, the other state's level two evaluation(s) of the individual and any additional documentation necessary to address the required evaluation elements specified in rules 5122-21-03 and 5123:2-14-01 of the Administrative Code. Submission of the required forms and information does not constitute completion of the PAS/ID process.

(c) For those individuals identified as new admissions in accordance with paragraph (B)(17) of rule 5101:3-3-14 of the Administrative Code who already reside in the facility at the time the PAS/ID is initiated, the submitter must notify ODJFS or its designee of the medicaid status of the facility at the time of the PAS/ID submission.

(d) PAS/ID may be initiated by the individual seeking the new admission, or by another entity on behalf of the individual, or by any state agency or their designee responsible for PAS. The NF is ultimately responsible for ensuring that the PAS/ID is completed and the determination is on file.

(3) ODJFS, or its designee, shall review the JFS 03622 form to determine whether the individual has MRDD and/or indications of SMI.

(a) An individual shall be determined to have indications of SMI if the individual:

(i) Meets at least two of the three criteria specified in paragraph (B)(32) of rule 5101:3-3-14 of the Administrative Code; or

(ii) Due to a mental impairment, receives supplemental security income (SSI) authorized under Title XVI of the Social Security Act, as amended; or

(iii) Due to a mental impairment, receives social security disability insurance (SSDI) authorized under Title II of the Social Security Act, as amended.

(b) An individual shall be determined to have indications of MRDD if the individual's condition meets the defining criteria set forth in paragraph (B)(16) of rule 5101:3-3-14 of the Administrative Code.

(4) PAS/ID results shall determine whether an individual is subject to further review.

(a) Individuals determined to have no indications of SMI and/or MRDD are not subject to further PAS review. Such individuals are considered to have met the PAS requirements effective on the date an accurate and complete record was submitted to ODJFS or its designee, even if the records were received at a later date.

(b) Individuals determined to have indications of SMI shall be subject to further review by the Ohio department of mental health (ODMH), in accordance with rule 5122-21-03 of the Administrative Code. Such individuals shall not be considered to have completed the PAS process until ODMH has issued the PAS/SMI determination.

(c) Individuals determined to have indications of MRDD shall be subject to further review by the Ohio department of developmental disabilities (DODD) in accordance with rule 5123:2-14-01 of the Administrative Code. Such individuals shall not be considered to have completed the PAS process until DODD has issued the PAS/MRDD determination.

(d) Individuals determined to have indications of both SMI and MRDD shall be subject to further review by both ODMH and DODD in accordance with rules 5122-21-03 and 5123:2-14-01 of the Administrative Code. Such individuals shall not be considered to have completed the PAS process until ODMH has issued the PAS/SMI determination and DODD has issued the PAS/MRDD determination.

(e) Any individual twenty-two years of age or older, who has previously been determined by DODD to be ruled out from PAS as defined in paragraph (B)(31) of rule 5101:3-3-14 of the Administrative Code is not subject to further review.

(5) When an individual has been determined to have indications of SMI and/or MRDD, ODJFS or its designee shall forward the JFS 03622 form and all supporting documentation to:

(a) ODMH and/or DODD for categorical and out of state requests. In addition, for those individuals relocating from outside of Ohio, ODJFS or its designee shall also send the other state's evaluation documentation to ODMH and/or DODD.

(b) The county board of DD (CBDD) and/or the ODMH local evaluator, for all other requests.

(6) ODJFS or its designee, ODMH and/or DODD are the only entities that have the authority to render PAS determinations. The individual must not move into an Ohio NF until the PAS determination has been made.

(7) The receiving NFs are responsible for ensuring that all individuals subject to PAS/ID receive a review and determination by ODJFS or its designee and, if applicable, a PAS/SMI review and determination by ODMH and/or a PAS/MRDD review and determination by DODD prior to entering the NF.

(8) NFs who, whether intentionally or otherwise, accept any new admission, readmission, or NF transfer in violation of this rule are in violation of their medicaid provider agreements. This is true regardless of the payment source for the individual's NF stay.

(C) PAS/SMI and PAS/MRDD determination requirements:

(1) There shall be no new admission of any individual with SMI or MRDD, regardless of payment source, unless the individual has either been determined, in accordance with rules 5122-21-03 and /or 5123:2-14-01 of the Administrative Code, to need the level of services provided by a NF, or has qualified for admission under the hospital exemption provision set forth in paragraph (G) of this rule.

(2) PAS/SMI and/or PAS/MRDD must be completed prior to any new admission of an individual determined by ODMH and/or DODD to have SMI and/or MRDD.

(a) For all such individuals identified as new admissions under the provisions of paragraph (B)(17) of rule 5101:3-3-14 of the Administrative Code, and regardless of payment source, the PAS/SMI and/or the PAS/MRDD determination requirements must be met before the individual is admitted to any NF or facility in the process of obtaining its initial medicaid certification and NF provider agreement. Individuals determined not to need NF services shall not be admitted or enrolled and medicaid payment will not be available for NF services.

(b) For all such individuals identified as new admissions under the provisions of paragraph (B)(17)(c) of rule 5101:3-3-14 of the Administrative Code who are current residents of the facility, the PAS/SMI and/or the PAS/MRDD requirements must be met prior to the effective date of the NF provider agreement between ODJFS and the newly certified NF and/or prior to the availability of medicaid payment for the medicaid eligible individual.

(3) ODMH and DODD are prohibited from utilizing criteria relating to the need for NF care or specialized services that are inconsistent with C.F.R. 483.108 and the ODJFS approved state plan for medicaid. The approved state plan for medicaid includes level of care criteria, contained in Chapter 5101:3-3 of the Administrative Code. Therefore, ODMH and DODD must use criteria consistent with Chapter 5101:3-3 of the Administrative Code in making their determinations regarding whether individuals with SMI and/or MRDD need the level of services provided by a NF.

(D) PAS/ID, PAS/SMI, and PAS/MRDD requests for additional information:

(1) ODJFS or its designee, ODMH and/or DODD may request any additional information required in order to make an PAS determination.

(2) If ODJFS or its designee, ODMH and/or DODD require additional information in order to make the PAS determination they shall provide written notice to the NF, the individual, the hospital, the referring entity, and the individual's representative, if applicable. This notice shall 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, ODJFS or its designee, ODMH and/or DODD shall provide written notice to the individual, the individual's guardian or authorized representative, if applicable, and the NF that the admission is prohibited due to failure to provide information necessary for the completion of the PAS 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, must not be admitted to the NF.

(4) If the individual was seeking medicaid coverage of the proposed NF stay, the county department of job and family services (CDJFS) must also be notified that the individual is not eligible for the admission due to failure to cooperate in the establishment of eligibility.

(5) If the individual or other entity submits the requested information within the timeframes specified in the notice, ODJFS or its designee, or DODD and/or ODMH shall continue with the PAS process.

(E) PAS/ID, PAS/SMI, and PAS/MRDD notification:

(1) In accordance with all requirements specified in rule 5101:6-2-32 of the Administrative Code, ODJFS, or its designee, shall report the outcome of the PAS/ID to the individual, their guardian, or authorized representative (if applicable) and to the entity which initiated the review, and the applicable state department(s) who receive the JFS 03622 and JFS 03697 (if applicable).

(2) The admitting NF shall maintain the results of the PAS/ID in the individual's resident record at the facility.

(3) In accordance with all requirements specified in rule 5101:6-2-32 of the Administrative Code, DODD and/or ODMH must provide written notice of the PAS-MRDD and/or PAS-SMI determination to the individual, their legal guardian of person or authorized representative (if applicable), the individual's physician and the facility. If the individual has applied for medicaid payment of the NF stay, ODJFS and if applicable, the CDJFS and/or the medicaid managed care plan (MCP), must also be notified. If an adverse determination is issued, the facility must then provide the individual, regardless of payment source, with notice of the intent to discharge in accordance with section 3721.16 of the Revised Code.

(4) The admitting NF shall retain the written notification of the PAS/SMI and/or PAS/MRDD determinations received from ODMH and/or DODD in the individual's resident record at the facility.

(F) An individual shall be required to undergo a new PAS/ID in accordance with the provisions of this rule if:

(1) The individual received PAS/ID, PAS/SMI and/or PAS/MRDD that NF services are needed and has not been admitted to a NF within one hundred eighty days for the most recent PAS determination that does not meet the definition in paragraph (B)(3) of rule 5101:3-3-14 of the Administrative Code;

(2) The individual received PAS/SMI and/or PAS/MRDD that NF services are needed and has not been admitted to a NF within the time period specified by ODMH or DODD for a PAS that meets the definition of paragraph (B)(3) of rule 5101:3-3-14 of the Administrative Code.

(G) Hospital (convalescent) exemption from PAS requirements:

(1) The discharging hospital must complete the hospital (convalescent) exemption from preadmission screening notification form (JFS 07000) (11/09). The form must be signed and dated by the attending physician no later than the date of discharge from the hospital certifying that all of the hospital (convalescent) exemption criteria as defined in paragraph (B)(9) of rule 5101:3-3-14 of the Administrative Code have been met.

(2) The discharging hospital must send the completed form to the admitting NF and appropriate PAA.

(3) If the NF accepts the placement of the individual, the NF acknowledges that all three exemption criteria are met as delineated in paragraph (B)(9) of rule 5101:3-3-14 of the Administrative Code.

(4) The admitting NF shall maintain the documentation in the resident's record at the facility.

(5) The NF shall initiate the resident review process, as specified in rule 5101:3-3-15.2 of the Administrative Code, prior to the individual's thirtieth day in the facility.

(6) The PAA shall send a copy of the form to ODMH and/or DODD if the individual has symptoms of SMI and/or a diagnosis of MRDD.

(7) If an individual admitted to a NF under the hospital (convalescent) exemption is admitted to a hospital or transfers to another NF during the first thirty days of their NF stay, the days in the hospital or previous NF will count toward their thirty day hospital (convalescent) exemption time period. A new hospital exemption shall not be granted during the existing exemption time period. A resident review (RR) shall be initiated by the NF in accordance with rule 5101:3-3-15.2 of the Administrative Code if the individual requires a continued NF stay beyond thirty days.

(8) If an adverse determination of either a PAS/SMI, PAS/MRDD, RR/SMI or RR/MRDD determination has been issued by ODMH or DODD within the last sixty calendar days prior to the new admission or enrollment, the individual is not eligible for a hospital exemption and a PAS ID shall be initiated in accordance with paragraph (B)(2) of this rule.

(H) Medicaid payment is not available for NF stays to individuals who are otherwise medicaid-eligible until the date on which the PAS requirements have been met.

(I) Adverse PAS determinations may be appealed in accordance with division 5101:6 of the Administrative Code.

(J) ODJFS has authority to assure compliance with the provisions of this rule. NF's, local administrators, hospitals and all state agencies and their designees shall comply, with accuracy and timeliness, to all requests for records and compliance plans issued by ODJFS or its designees.

Replaces: 5101:3-3- 15.1

Effective: 12/01/2009
R.C. 119.032 review dates: 12/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.202 , 5101.02
Prior Effective Dates: 12/30/88 (Emer.), 3/31/89 (Emer.), 6/30/89, 5/1/93, 1/1/98