Lawriter - OAC - 5160-3-15.1 Preadmission screening requirements for individuals seeking admission to nursing facilities.

5160-3-15.1 Preadmission screening requirements for individuals seeking admission to nursing facilities.

(A) The purpose of this rule is to set forth the preadmission screening (PAS) requirements in order to comply with section 1919(e)(7) of the Social Security Act, as in effect on January 1, 2014, which prohibits nursing facilities from admitting or enrolling individuals with serious mental illness (SMI), as defined in rule 5160-3-15 of the Administrative Code, or mental retardation and/or other developmental disabilities (MRDD), hereafter referred to as developmental disabilities (DD), as defined in rule 5160-3-15 of the Administrative Code, unless a thorough evaluation indicates that such placement is appropriate and adequate services will be provided. A preadmission screening identification (PAS/ID), as defined in rule 5160-3-15 of the Administrative Code is required:

(1) Prior to any new admission, as defined in rule 5160-3-15 of the Administrative Code, to a nursing facility and prior to any categorical determination, as defined in rule 5160-3-15 of the Administrative Code, unless the nursing facility admission meets the criteria for a hospital exemption as described in paragraph (G) of this rule.

(2) When an individual is directly admitted to a nursing facility from a hospital that is any of the following:

(a) A hospital that the Ohio department of mental health and addiction services (OhioMHAS) maintains, operates, manages, and governs under section 5119.14 of the Revised Code for the care and treatment of mentally ill persons;

(b) A free-standing hospital, or unit of a hospital, licensed by OhioMHAS under section 5119.33 of the Revised Code; or

(c) An out-of-state psychiatric hospital or psychiatric unit within an out-of-state hospital.

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

(1) The PAS/ID submitter shall complete and submit to the Ohio department of medicaid (ODM) designee, the PASSPORT administrative agency, the ODM 03622 "Preadmission Screening/Resident Review (PAS/RR) Identification Screen" (rev. 7/2014) or submit the PAS/ID via the electronic system approved by ODM. The submitter shall include any necessary supporting documentation with the ODM 03622 or within the electronic system in order to validate the answers on the ODM 03622.

(a) For an individual seeking medicaid payment, the ODM approved level of care assessment shall also be completed and submitted to ODM or its designee in accordance with rule 5160-3-14 of the Administrative Code, unless the individual is enrolled in a medicaid managed care plan (MCP) as defined in rule 5160-26-01 of the Administrative Code.

(b) For a non-Ohio resident who will be relocating to Ohio who has SMI and/or DD or whose ODM 03622 indicates SMI and/or DD, the submitter shall submit the ODM approved level of care assessment with the ODM 03622, along with the other state's level two evaluation(s) of the individual and any additional documentation 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 a new admission as defined in rule 5160-3-15 of the Administrative Code, when the individual already resides in the facility at the time the PAS/ID is initiated, the submitter must notify ODM or its designee of the medicaid status of the facility at the time of the PAS/ID submission.

(d) A 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 its designee responsible for preadmission screening. The nursing facility is ultimately responsible for ensuring that the PAS/ID is completed and the determination is on file.

(2) ODM or its designee shall review the ODM 03622 or the electronic system to determine whether the individual has a developmental disability and/or indications of SMI.

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

(i) Meets at least two of the three criteria specified in rule 5160-3-15 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 DD when the individual's condition meets the defining criteria set forth in rule 5160-3-15 of the Administrative Code.

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

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

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

(c) Individuals determined to have indications of DD 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 preadmission screening process until DODD has issued the PAS/DD determination.

(d) Individuals determined to have indications of both SMI and DD shall be subject to further review by both OhioMHAS 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 preadmission screening process until OhioMHAS has issued the PAS/SMI determination and DODD has issued the PAS/DD determination.

(e) Any individual twenty-two years of age or older, who has previously been determined by DODD to be ruled out, as defined in rule 5160-3-15 of the Administrative Code, from preadmission screening is not subject to further review.

(4) When an individual has been determined to have indications of SMI and/or DD, ODM or its designee shall forward the ODM 03622 and all supporting documentation to:

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

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

(5) ODM or its designee, OhioMHAS and/or DODD are the only entities that have the authority to render preadmission screening determinations. The individual must not move into an Ohio nursing facility until the preadmission screening determination has been made.

(6) The receiving nursing facilities are responsible for ensuring that all individuals subject to PAS/ID receive a review and determination by ODM or its designee and, if applicable, a PAS/SMI review and determination by OhioMHAS and/or a PAS/DD review and determination by DODD prior to entering the nursing facility.

(7) Nursing facilities which, whether intentionally or otherwise, accept any new admission, readmission, or nursing facility 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 nursing facility stay.

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

(1) There shall be no new admission of any individual with SMI or DD, 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 nursing facility, or has qualified for admission under the hospital exemption provision set forth in paragraph (G) of this rule.

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

(a) For an individual identified as a new admission, as defined in rule 5160-3-15 of the Administrative Code, and regardless of payment source, the PAS/SMI and/or the PAS/DD determination requirements must be met before the individual is admitted to any nursing facility or facility in the process of obtaining its initial medicaid certification and nursing facility provider agreement. Individuals determined not to need nursing facility services shall not be admitted or enrolled and medicaid payment will not be available for nursing facility services.

(b) For an individual identified as a new admission, as defined in rule 5160-3-15 of the Administrative Code who are current residents of the facility, the PAS/SMI and/or the PAS/DD requirements must be met prior to the effective date of the nursing facility provider agreement between ODM and the newly certified nursing facility and/or prior to the availability of medicaid payment for the medicaid eligible individual.

(3) OhioMHAS and DODD are prohibited from utilizing criteria relating to the need for nursing facility care or specialized services that are inconsistent with C.F.R. 483.108 and the ODM approved state plan for medicaid. The approved state plan for medicaid includes level of care criteria, contained in Chapter 5160-3 of the Administrative Code. Therefore, OhioMHAS and DODD must use criteria consistent with Chapter 5160-3 of the Administrative Code in making their determinations regarding whether individuals with SMI and/or DD need the level of services provided by a nursing facility.

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

(1) ODM or its designee, OhioMHAS and/or DODD may request any additional information required in order to make an preadmission screening determination.

(2) When ODM or its designee, OhioMHAS and/or DODD require additional information in order to make the preadmission screening determination they shall provide written notice to the nursing facility, 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, ODM or its designee, OhioMHAS and/or DODD shall provide written notice to the individual, the individual's guardian or authorized representative, if applicable, and the nursing facility that the admission is prohibited due to failure to provide information necessary for the completion of the preadmission screening 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 nursing facility.

(4) When the individual was seeking medicaid coverage of the proposed nursing facility 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) When the individual or other entity submits the requested information within the timeframes specified in the notice, ODM or its designee, or DODD and/or OhioMHAS shall continue with the preadmission screening process.

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

(1) In accordance with all requirements specified in rule 5101:6-2-32 of the Administrative Code, ODM, 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 ODM 03622 and ODM approved level of care assessment (if applicable).

(2) The admitting nursing facility 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 OhioMHAS must provide written notice of the PAS-DD 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. When the individual has applied for medicaid payment of the nursing facility stay, ODM and if applicable, the CDJFS and/or the medicaid managed care plan (MCP), must also be notified. When 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 nursing facility shall retain the written notification of the PAS/SMI and/or PAS/DD determinations received from OhioMHAS 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 when:

(1) The individual received PAS/ID, PAS/SMI and/or PAS/DD that nursing facility services are needed and has not been admitted to a nursing facility within one hundred eighty days for the most recent preadmission screening determination that does not meet the definition of a categorical determination, as defined in rule 5160-3-15 of the Administrative Code;

(2) The individual received PAS/SMI and/or PAS/DD that nursing facility services are needed and has not been admitted to a nursing facility within the time period specified by OhioMHAS or DODD for a preadmission screening that meets the definition of a categorical determination, as defined in rule 5160-3-15 of the Administrative Code.

(G) Criteria for a hospital exemption, as defined in rule 5160-3-15 of the Administrative Code.

(1) The following individuals are eligible for a hospital exemption:

(a) The individual will be admitted to a nursing facility directly from an Ohio hospital or a unit of a hospital that is not operated by or licensed by OhioMHAS under section 5119.14 or section 5119.33 of the Revised Code, after receiving acute inpatient care at that hospital; or

(b) The individual is an Ohio resident who will be admitted to a nursing facility directly from an out-of-state hospital that is not an out-of-state psychiatric hospital or psychiatric unit within an out-of-state hospital, after receiving acute inpatient care at that hospital.

(2) Individuals, as described in paragraph (G)(1) of this rule are eligible for a hospital exemption when:

(a) The individual requires the level of services provided by a nursing facility for the condition for which he or she was treated in the hospital; and

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

(H) Process for a hospital exemption, as defined in rule 5160-3-15 of the Administrative Code.

(1) The discharging hospital shall request a hospital exemption via the ODM 07000 (rev. 7/2014), "Hospital Exemption from Preadmission Screening Notification" or via the electronic system approved by ODM. Effective April 1, 2015, the discharging hospital shall request a hospital exemption via only the electronic system approved by ODM. Exceptions to electronic submission must be approved by ODM or its designee. The ODM 07000 shall be signed and dated by the attending physician no later than the date of discharge from the hospital.

(2) The discharging hospital shall send the completed ODM 07000 to the admitting nursing facility and appropriate PAA.

(3) When the nursing facility accepts the placement of the individual, the nursing facility acknowledges that the individual meets the criteria described in paragraphs (G)(1) and (G)(2) of this rule.

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

(5) The nursing facility shall initiate the resident review process, as specified in rule 5160-3-15.2 of the Administrative Code, prior to the individual's thirtieth day in the nursing facility.

(6) When an individual admitted to a nursing facility under the hospital exemption is admitted to a hospital or transfers to another nursing facility during the first thirty days of the individual's nursing facility stay, the days in the hospital or previous nursing facility count towards the individual's thirty-day hospital exemption time period. A new hospital exemption shall not be granted during the existing exemption time period.

(7) When an individual requires a continued nursing facility stay beyond thirty days, a resident review shall be initiated by the nursing facility in accordance with rule 5160-3-15.2 of the Administrative Code.

(8) When an adverse determination of either a PAS/SMI, PAS/DD, RR/SMI or RR/DD has been issued by OhioMHAS or DODD within the last sixty calendar days prior to the new nursing facility admission, the individual is not eligible for a hospital exemption. A PAS/ID shall be initiated in accordance with paragraph (B)(1) of this rule.

(I) Medicaid payment is not available for nursing facility stays to individuals who are otherwise medicaid-eligible until the date on which the preadmission screening requirements have been met.

(J) Adverse preadmission screening determinations may be appealed in accordance with division 5101:6 of the Administrative Code.

(K) ODM has authority to assure compliance with the provisions of this rule. Nursing facilities, 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 ODM or its designees.

Replaces: 5160-3- 15.1

Effective: 11/16/2014
Five Year Review (FYR) Dates: 11/16/2019
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5119.40, 5162.03, 5164.02 , 5165.03
Prior Effective Dates: 12/30/88 (Emer.), 3/31/89 (Emer.), 6/30/89, 5/1/93, 1/1/98, 12/1/09.