Lawriter - OAC - 5160-3-15 Preadmission screening and resident review (PASRR) definitions.

5160-3-15 Preadmission screening and resident review (PASRR) definitions.

(A) The purpose of this rule is to set forth the definitions for terms contained in rules 5160-3-15.1, 5160-3- 15.2, 5122-21-03 and 5123-14-01 of the Administrative Code.

(B) Definitions:

(1) "Adverse determination" means a determination made in accordance with rules 5160-3-15.1, 5160-3- 15.2, 5122-21-03 and 5123-14-01 of the Administrative Code, that an individual does not require the level of services provided by a nursing facility or that the individual does or does not require specialized services.

(2) "Attending Physician" means the physician to whom a person, or the family of a person, has assigned primary responsibility for the treatment or care of the person or, if the person or the person's family has not assigned that responsibility, the physician who has accepted that responsibility.

(3) "Categorical determination" means a preadmission level II determination which may be made for an individual without a face to face assessment for an individual diagnosed with a serious mental illness (SMI) and/or developmental disability (DD) as defined in paragraphs (B)(6) and (B)(28) of this rule when the individual's circumstances fall within one of the following two categories:

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

(b) The individual is seeking admission to a nursing facility for a 'respite nursing facility stay' as defined in paragraph (B)(26) of this rule.

(4) "Community" for PASRR purposes means a new admission from a setting other than a nursing facility, Ohio hospital or a unit of a hospital that is not operated by or licensed by the Ohio department of mental health and addiction services (OhioMHAS).

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

(6) "Developmental disability (DD)". An individual is considered to have a DD when he or she meets the conditions described in rule 5123-14-01 of the Administrative Code.

(7) "Emergency nursing facility stay" refers to the temporary admission of an individual to a nursing facility pending further assessment in emergency situations requiring protective services as defined in rule 5101:2-20-01 of the Administrative Code, with placement in a nursing facility not to exceed seven days.

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

(9) "Hospital discharge exemption", also known as hospital exemption means an exemption from the preadmission screening as defined in paragraph (B)(21) of this rule, when an individual meets the hospital discharge exemption criteria in rule 5160-3-15.1 of the Administrative Code.

(10) "Indications of developmental disabilities (DD)". An individual shall be considered to have indications of developmental disabilities when the individual meets the criteria specified in rule 5123-14-01 of the Administrative Code or the individual receives services from a county board of DD.

(11) "Indications of serious mental illness (SMI)." An individual shall be considered to have indications of an SMI when the individual meets the criteria specified in rule 5122-21-03 of the Administrative Code.

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

(13) "Level I" or "level I screening" refers to the initial screening that must be given to all individuals seeking new admission as defined in paragraph (B)(17) of this rule to a medicaid-certified nursing facility, regardless of payor source, for the purpose of identifying individuals who may have or are suspected to have indications of a DD as defined in paragraph (B)(10) of this rule and/or a SMI as defined in paragraph (B)(11) of this rule.

(14) "Level II entities" refers to the state level II authorities which is the OhioMHAS and the Ohio department of developmental disabilities (DODD).

(15) "Level II" or "level II evaluation" refers to the in-depth evaluation of an individual that has been identified as having indications or suspected of having indications of a DD and/or a SMI as defined in paragraphs (B)(10) and (B)(11) of this rule by the level I screening outcome. The level II entity must confirm or disconfirm the existence of a DD and/or a SMI and make a written determination of the following:

(a) The individual's need or continued need for nursing facility services as defined in paragraph (B)(19) of this rule; and

(b) If the nursing facility is or continues to be the most appropriate setting to meet the individual's long-term care needs; and

(c) Identification and recommendation for specialized services as defined in paragraphs (B)(30) and/or (B)(31) of this rule, if any, that would be needed for the individual during the individual's nursing facility stay.

(16) "Long-term resident" means an individual who has continuously resided in a nursing facility or a consecutive series of nursing facilities and/or medicare skilled nursing facilities for at least thirty months prior to the first resident review determination in which the individual was found not to require the level of services provided by a nursing facility, but to require specialized services as defined in paragraphs (B)(30) and (B)(31) of this rule. The thirty months may include temporary absences for hospitalization, therapeutic leave, or visits with family or friends as defined in rule 5160-3-16.4 of the Administrative Code.

(17) "New admission" means the admission to an Ohio medicaid certified nursing facility of an individual:

(a) Who was not a resident of any nursing facility immediately preceding:

(i) The current nursing facility admission; or

(ii) A hospital stay for which the individual is to be admitted directly to a nursing facility;

(b) Seeking admission or admitted to a nursing facility from another state, regardless of prior residence; or

(c) Is transferred or readmitted from a nursing facility following an:

(i) Adverse level II or a resident review determination; or

(ii) Overruled appeal of an adverse level II determination.

(d) For PASRR purposes only and effective on the date the facility submits its application packet for medicaid certification to the Ohio department of medicaid, individuals seeking admission to, or who are currently residing in, a facility that is in the process of obtaining its initial medicaid certification by Ohio department of health, and

(e) With the exception of those circumstances specified in paragraphs (B)(17) (a) to (B)(17)(c) of this rule, nursing facility transfers and readmissions as defined in paragraphs (B)(20) and (B)(24) 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 the Ohio department of medicaid is considered to be in the process of obtaining its initial medicaid certification by the Ohio department of health and shall be treated as a nursing facility for the purposes of this rule.

(19) "Nursing facility level of service" for the purposes of PASRR means a determination made by the DODD and/or OhioMHAS in accordance with rules 5123-14-01 and 5122-21-03 of the Administrative Code as required by section 1919(e)(7) of the Social Security Act, as in effect July 1, 2019 that the individual's need for treatment does not exceed the level of services which can be delivered by the nursing facility to which the individual is seeking admission or is currently admitted to either through nursing facility services alone or, where necessary, through nursing facility services supplemented by specialized services provided by or arranged for by the state.

(20) "Nursing facility transfer." A nursing facility transfer occurs when an individual is transferred from any Ohio medicaid certified nursing facility to another Ohio medicaid certified nursing facility, with or without an intervening hospital stay.

(21) "Preadmission screening" refers to the level I screening as defined in paragraph (B)(13) of this rule and when applicable the completion of the level II evaluation as defined in paragraph (B)(15) of this rule that results in a PASRR determination from the DODD and/or OhioMHAS administered prior to the individuals admission to the nursing facility.

(22) "PASRR" means the preadmission screening and resident review of individuals for the purposes of identifying individuals with serious mental illness as defined in rule 5122-21-03 of the Administrative Code and/or a developmental disability as defined in rule 5123-14-01 of the Administrative Code and required by the "Social Security Act," 42 U.S.C 1396r(e)(7).

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

(24) "Readmission" means the individual is readmitted to the same nursing facility from a hospital to which he or she was sent for the purpose of receiving care.

(25) "Resident review"' is a post admission level II evaluation as defined in paragraph (B)(15) of this rule that results in a determination for nursing facility residents which must be implemented upon a significant change in condition as defined in paragraph (B)(29) of this rule and in accordance with section 1919(e)(7) of the Social Security Act, as in effect on July 1, 2019, which must be implemented in accordance with rules 5160-3-15.2, 5122-21-03 and 5123-14-01 of the Administrative Code.

(26) 'Respite nursing facility stay' means the admission of an individual to a nursing facility 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 respite stay.

(27) "Ruled out" means a determination made by the DODD and/or the OhioMHAS that the individual is not subject to further review. An individual may be ruled out at any time during the PASRR assessment when it is determined that the individual:

(a) Does not have a DD and/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 a SMI, and does not have a diagnosis of a DD or a related condition.

(28) "Serious mental illness" means an individual meets the conditions described in rule 5122-21-03 of the Administrative Code.

(29) "Significant change of condition" means any major decline or improvement in the individual's physical or mental condition, as described in 42 C.F.R. 483.20, as in effect on July 1, 2019 and when 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 a SMI, or who did not previously have indications of a DD, now has such indications; 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 a DD.

(30) "Specialized services for serious mental illness" means those services specified by the level II or the resident review determination for an individual with a SMI which are arranged by OhioMHAS in accordance with rule 5122-21-03 of the Administrative Code and may be provided under the behavioral health services as described in rules 5160-8-05 and 5160-27-02 of the Administrative Code, which when combined with services by the nursing facility, results in the continuous and aggressive implementation of an individualized plan of care in accordance with 42 CFR 483.120, as in effect July 1, 2019.

(31) "Specialized services for developmental disabilities" means the services or supports specified by the level II or the resident review determination for an individual with a DD which is provided or arranged for by the county board of DD in accordance with rule 5123-14-01 of the Administrative Code.

Replaces: 5160-3-15


Effective: 12/30/2019
Five Year Review (FYR) Dates: 12/30/2024
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02 , 5119.40
Prior Effective Dates: 12/01/2009, 11/16/2014