(A) General The Ohio office of medical assistance form 04080, "Medicaid Resource Assessment Notice" (revised October 2005), shall conform to all conditions set forth in rule 5101:1-39-35 of the Administrative Code.
(1) All intermediate care facilities shall furnish written notice at the time of admission to all individuals with a spouse living in the community of the individual's right to have a resource assessment performed by the county department of job and family services. This includes individuals who, at the time of admission, are eligible for the medicare program, or who are covered by a private third party payer.
(2) The intermediate care facility shall do all of the following:
(a) Give a copy of the resource assessment notice to the resident's family member, legal guardian, or authorized agent; and
(b) Send a copy of the signed resource assessment notice to the county department of job and family services within five working days; and
(c) Post an unsigned copy of the resource assessment notice in a prominent, publicly accessible place within the facility.
(C) Record retention
An intermediate care facility shall keep a signed copy of the resource assessment notice in a resident's record as long as he or she is a resident of the facility. This copy shall be made available upon request to the department, the Ohio office of medical assistance, the county department of job and family services, and the Ohio department of health.