This rule sets forth a process for a state-contracted vendor and the Ohio department of mental health and addiction services to respectively evaluate and determine whether an individual with indications of serious mental illness (SMI) requires those services provided in a medicaid-certified nursing facility (NF), and if so whether that individual needs specialized services for mental illness that exceed NF services.
This rule applies to individuals who have indications of SMI and are seeking admission into a NF, and for NF residents with indications of SMI who are seeking to continue residing in a NF. It also applies to individuals seeking readmission to a NF after having transferred from a NF to a hospital or unit that is licensed or certified by the department, and to individuals with indications of SMI who are transferring from one NF to another NF, with or without an intervening hospital stay.
(1) An administrative letter is a communication device in which the state declines to reconsider a previously issued PASRR determination to the individual or guardian. An administrative letter is not a new PASRR determination, thus it does not carry appeal rights.
(2) Adverse determination means a determination made in accordance with rules 5160-3-15, 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 NF. This includes any PASRR determination issued by the department that allows a time-limited approval, such as a categorical, time specified, or an extension.
(3) Assessor means a professional possessing a clinical licensure approved by the departments medical director to complete the level II PASRR evaluation.
(4) Attending Physician means the physician whom an individual, or the family of an individual, has assigned primary responsibility for the treatment of care of the individual, or if the individual or the individuals family has not assigned responsibility, the physician who has accepted responsibility.
(5) Business day means a day of the week, excluding Saturday, Sunday, or a legal holiday as defined in section 1.14 of the Revised Code.
(6) "Board of alcohol, drug addiction, and mental health services" or "board" means the body constituted according to section 340.02 of the Revised Code, or a community mental health board or an alcohol and drug addiction services board as described in section 340.021 of the Revised Code; which have the same duties as described in section 340.03 of the Revised Code,
(7) Categorical determination means a presumptive pre-admission screen (PAS) approval issued without the completion of a face to face assessment for an individual diagnosed with developmental disabilities (DD) or SMI.
(8) Department means the Ohio department of mental health and addiction services.
(9) Developmental disability (DD) has the same meaning defined in rule 5123-14-01 of the Administrative Code.
(10) DODD means the Ohio department of developmental disabilities.
(11) Evaluation also known as an assessment or a level II evaluation as defined in rule 5160-3-15 of the Administrative Code, includes a face to face interview between an assessor and the individual, their guardian, or authorized representative, if applicable. The purpose of an evaluation is to assess the individuals need for the level of services provided in a NF, and to assess whether the individual would need specialized services for mental illness if approved for NF services.
(12) Extension is a time-limited approval for up to ninety days of additional stay in a NF, following a previously issued specified-period or extension approval, granted in accordance with rule 5160-3-15.2 of the Administrative Code. An extension is given solely to allow for effective discharge planning.
(13) Guardian has the same meaning as in section 2111.01 of Revised Code.
(14) Hospital exemption (exempted hospital discharge) means the same as defined in rule 5160-3-15 of the Administrative Code.
(15) 'Indefinite approval is an approval that permits a NF to admit an individual diagnosed with SMI. Individuals admitted to a NF under an indefinite approval will be required to adhere to all PASRR requirements related to NF residents.
(16) Individual in this rule means a person regardless of payment source, who is seeking admission, readmission, or transfer to a medicaid-certified NF or a facility in the process of becoming medicaid-certified NF.
(17) Level I means the same as defined in rule 5160-3-15 of the Administrative Code.
(18) "Level II means the combination of the disability-specific PASRR evaluation and the determination issued by DODD and/or the department.
(19) Level II determination or "determination" in this rule means the departments finding of whether an individual diagnosed with SMI requires the level of services provided in a NF, and whether the individual requires specialized services for mental illness if found to require NF services.
(20) Long-term resident means the same as defined in rule 5160-3-15 of the Administrative Code.
(21) Nursing facility (NF) has the same meaning as in section 5111.20 of Revised Code. A long-term care facility that has submitted an application packet for medicaid certification to the Ohio department of medicaid (ODM) is considered to be in the process of obtaining its initial medicaid certification by the Ohio department of health (ODH) and shall be treated as NF for purposes of this rule.
(22) Pre-admission screening refers to the level I screening as defined in paragraph (B)(15) of rule 5160-3-15 of the Administrative Code.
(23) Psychiatric unit or hospital refers to those facilities that are licensed or operated by the department.
(24) Reviewer refers to a licensed mental health clinician who reviews the PASRR screen, supporting documents, the level II assessment, and the summary report to issue the states determination of whether the individual requires NF services. If the determination is yes, then the reviewer indicates whether the individual needs specialized services for mental illness. If it is determined that the individual is not in need of NF services, then the reviewer may recommend community service that may address the individuals needs.
(25) Rule-out means a determination made by the department 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 SMI, even though the individual was diagnosed with mental illness.
(b) Has a primary diagnosis of dementia (including Alzheimers disease or a related disorder);
(c) Has a non-primary diagnosis of dementia without a primary diagnosis that is a SMI; or,
(d) The individual has physician-ordered end-of-life services.
(26) Serious mental illness (SMI) includes the following criteria regarding diagnosis, level of impairment and recent treatment:
(a) Diagnosis - The individual does not have dementia for which the treatment is considered primary, but has a major mental disorder diagnosable under the most recent edition of the "Diagnostic and Statistical Manual of Mental Disorders" (DSM); and this mental disorder includes, but is not limited to, one of the following: schizophrenia, mood, delusional (paranoid), panic or other severe anxiety disorder, somatic symptom disorder, personality disorder, other psychotic disorder, or a mental disorder other than developmental disability that may lead to a chronic disability diagnosable under the DSM.
(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.
(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; or
(iii) Is admitted to a psychiatric unit at the time of seeking NF services.
(27) Significant change in condition means the same as is defined in rule 5160-03-15 of the Administrative Code.
(28) Specialized services for mental illness mean those services specified by the PASRR determination for an individual diagnosed with SMI, which are arranged by the department 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 combined with services by the nursing facility, results in the continuous and aggressive implementation of an individualized plan of care in accordance with 42 C.F.R. 483.120, as in effect January 1, 2019.
(29) Specified determinations is a time-limited approval that may be issued to a NF resident for a stay of up to one hundred eighty days, for the completion of prescribed therapies for which a NF is certified to provide, or to allow for effective discharge planning.
(D) The process by which the department receives referrals for determinations is:
(1) All individuals who are seeking admission into a NF, or who are seeking to continue residing in a NF after a RR triggering event, are required by federal and state regulations to undergo a level one PASRR screen to identify whether the individual possesses indications of SMI or DD
(2) All individuals identified in paragraph (D)(1) of this rule who are identified with indications or suspicion of SMI or DD during a level one PASRR screen are referred to the department or DODD, as appropriate, for a level II determination as set forth by this rule.
(E) Evaluation process:
The level II evaluation includes a face to face interview between the assessor and the individual with indication of SMI who is seeking admission into or to continue residing in a NF; and a review of the individuals medical or NF records to determine the individuals functional level. It may also include the assessor interviewing other professionals and any court-appointed guardian who might have in-depth knowledge of the individual.
(1) The required components of a level II evaluation are:
(a) The assessor will determine the need for and arrange for translation service to ensure the individuals or guardians full participation throughout the evaluation.
(b) The assessor will inquire of the the individual or guardian whether there are family members or significant others who should be asked to participate in the evaluation. If yes, then the assessor will arrange to interview these individuals, if available.
(c) A comprehensive history and physical examination. The following areas must be included (if not previously addressed):
(i) Complete medical history;
(ii) Review of all body systems;
(iii) Specific evaluation of the person's neurological system in the areas of motor functioning, sensory functioning, gait, deep tendon reflexes, cranial nerves, and abnormal reflexes;
(iv) In the case of abnormal findings which are the basis for a NF placement, additional evaluations conducted by appropriate specialists;
(v) A comprehensive drug history including current or immediate past use of medications that could mask or mimic symptoms of mental illness; and,
(vi) A psychosocial evaluation of the person, including current living arrangements and medical and support systems;
(d) A comprehensive psychiatric evaluation including a complete psychiatric history, evaluation of general intellectual functioning, memory functioning, orientation, description of current attitudes and overt behaviors, affect, suicidal or homicidal ideation, paranoia degree of reality testing (presence and content of delusions), and hallucinations;
(e) A functional assessment of the individual's ability to engage in activities of daily living and the level of support that would be needed to assist the individual to perform these activities while living in the community. The assessment determines whether this level of services can be provided to the individual in an alternative community setting or whether the level of services needed is such that NF placement is required. The focus must be placed on whether the individual can perform the activities of daily living if given the opportunity. A refusal to perform the activity does not constitute an inability. The functional assessment must address at least the following:
(i) Self-monitoring of health status;
(ii) Self-administering and scheduling of medical treatment, including medication compliance;
(iii) Self-monitoring of nutritional status;
(iv) Handling money;
(v) Dressing appropriately; and,
(vi) Bathing and, grooming.
(f) Assessment for the need of specialized services, as defined in paragraph (C)(28) of this rule.
(2) The evaluation concludes with the submission of a written assessment summary in which the assessor reports their findings to the department, along with supporting documents acquired during the review of the individuals records.
(3) Personnel requirements related to the evaluation process are:
(a) The professionals approved to complete the history and physical examination must be in accordance with those listed in rule 5160-3-15 of the Administrative Codes.
(b) In addition to those licensed clinicians listed in rule 5160-3-15.1 of the Administrative Code, individuals with the following licenses or credentials are eligible to be level II assessors for individuals with indications of SMI:
(i) Licensed independent marriage and family therapist;
(ii) Psychology intern;
(iii) Psychology fellow;
(iv) Psychology assistant;
(vii) Registered nurse;
(viii) Licensed social worker;
(ix) Licensed independent social worker;
(x) Professional counselor; or,
(xi) Professional clinical counselor
(4) Level II evaluations may be moved to desk reviews, instead of a face to face interview between the assessor and the individual with indication of SMI who is seeking admission into or to continue residing in a NF, at the discretion of the department during the COVID-19 state of emergency declared by the governor.
(F) Pre-admission screen (PAS) determination process:
(1) A level II PAS determines whether the individual requires the level of services provided by a NF, based on a comprehensive analysis of all data; the review considers the most inclusive (least restrictive) placement and the need for specialized services for mental illness if NF services are required.
(2) Individualized determinations are performed on all individuals seeking NF services, except those individuals whose admission into a NF are based on categorical determination to require the level of services provided by a NF.
(3) A categorical determination presumes that the individual meets the criteria for NF services, and is defined in paragraph (C)(7) of this rule. A categorical determination does not indicate whether the individual requires specialized services for mental illness, and approves the individual to be admitted into a NF for limited periods as defined in the following categories:
(a) An emergency NF stay is a temporary admission to a NF pending further assessment in emergency situations requiring protective services, with placement in a NF not to exceed seven days, in accordance with rule 5160-3-15 of the Administrative Code. The individual must be admitted to a NF within twenty-four hours of determination or immediately following discharge from a hospital, for a period of no more than seven days; or
(b) A respite admission permits the individual to be admitted into a NF for up to fourteen days, in accordance with rule 5160-3-15 of the Administrative Code. The individual must be admitted to a NF within sixty days of determination for respite of no more than fourteen days and does not need specialized services for mental illness.
(4) Non-residents located within Ohio who are seeking admission to a medicaid-certified NF will be subject to the same standards as Ohio residents who are seeking NF services. If these individuals show indications of SMI upon completing the PASRR screen they will be scheduled for a level II evaluation and will be issued a determination from the department.
The department will not assess non-residents located in Ohio seeking admission into out-of-state NFs.
(G) Resident review (RR) determination process:
(1) A RR determines whether the individual who is already a NF resident requires the level of services provided by a NF, based on a comprehensive analysis of all data; the review considers the most inclusive (least restrictive) placement and the need for specialized services for mental illness if NF services are required.
(2) Individualized determinations are made on all NF residents seeking to continue residing in a NF.
(3) A resident review determination may conclude the following:
(a) The NF resident does require NF services. The determination would also indicate whether the resident requires specialized services for mental illness. If so, the determination would list the services that would meet the residents needs.
(b) The NF resident does not require ongoing NF services but would benefit from a specified period (short-term) stay in the NF to allow for the completion of prescribed therapies. In this case, the determination would also indicate whether the NF resident requires specialized services for mental illness.
(c) The NF resident does not require NF services and is within an approved specified period and found to require an extension of the short-term stay to allow for effective discharge planning directly related to the residents complex needs. In this case, the determination would also indicate whether the NF resident requires specialized services for mental illness.
(d) The NF resident does not require NF services, and is issued a PASRR determination requiring a transition to a more inclusive community option. In this case, the determination would make recommendations for needed supports, including behavioral health services and supports that may address the individuals needs during discharge planning, transition, and to sustain the individual in the community. The NF administration is required to issue a thirty-day notice to discharge the resident, according to rule 3701-61-03 of the Administrative Code.
(H) A determination that an individual needs specialized services for mental illness shall result in the aggressive implementation of an individualized plan of care approved by the medical director of the department or designee that:
(1) Is developed and supervised by an interdisciplinary team which includes a physician, trained mental health professionals and, as appropriate, other professionals;
(2) Prescribes specific therapies and treatment activities for an individual exhibiting symptom of SMI which necessitates supervision by trained mental health personnel;
(3) Is available in the community; and is time limited and directed toward diagnosing and reducing the individual's behavioral symptoms that necessitated intervention, improving the individual's level of independent functioning, and achieving a functioning level that permits an optimal quality of life.
(1) The department notifies the following entities or individuals when it issues a determination of findings in response to an individual who was suspected of possessing SMI and seeking NF services.
(a) The individual seeking NF services or court-appointed guardian.
(b) The NF administration.
(c) The individuals attending physician, if provided.
(d) The discharging hospital, except if the individual utilized the hospital exemption.
(2) The notice of findings includes the following information and is distributed to hospital discharge planners, NF administrations, individuals located in the community, or court-appointed guardians:
(a) A determination as to whether the individual was found to require NF level of services.
(b) A determination as to whether the individual requires specialized services for mental illness, if the individual was found to require NF services, and provides recommendations for community behavioral health services to individuals who were not found to require the level of services provided in a NF.
(c) Identifies the placement option that is the most inclusive in which the individual can access needed supports and services, that is consistent with the determination for the need for the level of NF services.
(d) Discharge arrangements, if applicable; and
(e) Appeal rights as outlined in paragraph (J) of this rule.
(3) The department will notify the community behavioral health boards of all instances when one of its residents applied to be admitted into or to continue residing in a NF. This will occur via the electronic board reporting function that is maintained within the departments PASRR data management system.
(a) The purpose of the board notification is to inform an individuals community of residence that the individual might benefit from access to community behavioral health services.
(b) The notification also presents the board with an opportunity to deter its resident from unnecessary institutionalization, or to facilitate effective discharge planning to allow the NF resident to transition to the community when the NF placement is inappropriate, or the NF resident chooses to reside in the community.
(4) Turnaround times:
(a) The department shall meet the national standard of issuing a determination on the annual average of seven to nine business days (approximately fourteen calendar days) from the point of receiving a referral.
(b) The department shall expedite issuing determinations associated with individuals being discharged from psychiatric units or hospitals that are licensed or operated by the department at the time of application. The department shall issue an expedited determinations within an average of forty-eight hours from the point of receiving a referral from an individual admitted to a psychiatric unit or hospital.
(5) Possible outcomes for a PASRR determination for an individual diagnosed with SMI seeking NF services:
(a) Yes NF/no specialized services
(b) Yes NF/yes specialized services
(c) No NF/no specialized services (may benefit from access to community services)
(J) Appeal rights:
(1) The individual or the court-appointed guardian may appeal an adverse PASRR determination issued by the department within the timeframes set forth in rule 5101:6-6-01 of the Administrative Code.
(2) The department may conduct an informal reconsideration of an adverse determination when notified by the bureau of state hearings (BSH) of a scheduled hearing, or upon a request from the individual and or court-appointed guardian to submit additional information.
(3) The department will work collaboratively with relevant staff at DODD to jointly reconsider an adverse determination issued to an individual diagnosed with SMI and DD.
(1) The department will monitor the utilization of hospital exemptions associated with individuals who possess a diagnosis of mental illness.
(2) The department will monitor the following types of time-specified determinations for individuals diagnosed with SMI:
(a) A categorical emergency NF admission, as defined in paragraph (F)(3)(a) of this rule.
(b) A categorical respite admission, as defined in paragraph (F)(3)(b) of this rule.
(c) A specified determination approval, as defined in paragraph (C)(29) of this rule.
(d) An extension, as defined in paragraph (C)(12) of this rule.
(3) Reporting instances of a failure to comply with PASRR requirements:
(a) All identified instances in which the department concludes that a NF administration failed to comply with PASRR requirements will be referred to ODM.
(b) Residents diagnosed with mental illness admitted to or retained in a NF who receive an adverse PASRR determination will be referred to the appropriate board of alcohol, drug addiction, and mental health services, on a case by case basis, for possible assistance with accessing needed community supports.