Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 44 - NURSING FACILITY LEVEL OF CARE DETERMINATION FOR ADULTS › Section 471-44-003 - LEVEL OF CARE

Current through June 17, 2024
003.01
NURSING FACILITY LEVEL OF CARE (NF LOC) CRITERIA.
The
  person or his or her legal representative must provide information needed to
  determine nursing facility level of care (NF LOC). In order to make a
  determination, the person or representative must be addressed on the basis of
  activities of daily living (ADL), risk factors, medical conditions and
  interventions, and cognitive function, to be determined via discussion and
  observation of the person; reports from caregivers, family, and providers; and
  current medical records.
003.01(A)
LEVEL OF CARE DETERMINATION FOR ADULTS AGE 18 OR
  OLDER.
A person must satisfy one of the four following categories
  to meet nursing facility level of care (NF LOC) eligibility:
(1) A limitation in at least three activities
  of daily living (ADL) and one or more risk factors;
(2) A limitation in at least three activities
  of daily living (ADL) and one or more medical conditions and
  treatments;
(3) A limitation in at
  least three activities of daily living (ADL) and one or more areas of cognitive
  limitation; or
(4) A limitation in
  at least one activity of daily living (ADL) and at least one risk factor and at
  least one area of cognitive limitation.
003.01(A)(i)
ACTIVITIES OF DAILY
  LIVING (ADL).
Information about limitations in activities of daily
  living (ADL) is obtained from observation of the person in the home setting,
  reports from guardians or caregivers, current medical records, school records,
  and standardized assessments. Activities in daily living (ADL) are considered a
  limitation when the person, due to their physical disabilities, requires
  physical assistance from another person on a daily basis, or supervision,
  monitoring, or direction to complete the tasks associated with each activity of
  daily living (ADL) defined in this section. For the purposes of this section,
  the term "ability" must be interpreted to include the physical ability,
  cognitive ability, and endurance necessary to complete identified activities.
  The following activities of daily living (ADL) are considered for nursing
  facility level of care (NF LOC) eligibility:
(1) Bathing;
(2) Continence;
(3) Dressing or grooming;
(4) Eating;
(5) Mobility;
(6) Toileting; and
(7) Transferring.
003.01(A)(ii)
RISK
  FACTORS.
Risk factors must cause significant impact to the
  person's life and functional abilities and require significant intervention in
  a timely manner. Risk factors to be considered are:
(1)
Behavior:
The
  inability to act on one's own behalf, including but not limited to lack of
  interest or motivation to eat, not taking medications, not caring for one's
  self, not maintaining personal safety, wandering, avoiding social activities,
  and relating to others in a socially-inappropriate manner;
(2)
Frailty:
The
  inability to function independently without the presence of a support person,
  including but not limited to mismanaging finances or using poor judgment in
  understanding abilities and health factors to safeguard wellbeing and avoid
  inappropriate safety risk such as risk of falling; and
(3)
Safety:
The lack
  of adequate housing, including the absence of home modification or adaptive
  equipment to assure safety and accessibility, the lack of a formal or informal
  support system, or presence of abuse, neglect, or exploitation in the
  home.
003.01(A)(iii)
MEDICAL CONDITIONS AND TREATMENTS.
Medical conditions
  and treatments to be considered are:
(1) A
  medical condition is present which requires observation and assessment to
  evaluate the person's need for treatment modification or additional medical
  procedures to prevent destabilization when a person has demonstrated an
  inability to self-observe or evaluate the need to contact skilled medical
  professionals;
(2) Due to the
  complexity created by multiple, interrelated medical conditions, there exists
  potential for the person's medical condition to be unstable; and
(3) The person requires at least one ongoing
  medical or nursing service.
003.01(A)(iv)
COGNITIVE
  FUNCTION.
Limitations in cognitive function to be considered are:
(1)
Memory:
Lack of
  short-term recall, unable to perform all or almost all steps in a multitask
  sequence without cues, inability to recognize frequently encountered
  caregivers' names or faces or know location of regularly visited places in
  residential setting;
(2)
Orientation:
Easily distracted, episodes of
  disorganized speech, or variation in mental function over the course of a day;
  behavior must be inconsistent with usual functioning;
(3)
Communication:
Inability to make oneself understood, including inability to express
  information content, both verbal and nonverbal, or the inability to understand
  information conveyed;
(4)
Judgment:
Inability to independently make decisions
  regarding tasks of daily life, except in new situations with only some
  difficulty; and
(5)
Dementia:
Dementia diagnosis, including Alzheimer's
  disease.