Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-3 - Long-Term Care Facilities; Nursing Facilities; Intermediate Care Facilities for the Individuals with Intellectual Disabilities › Section 5160-3-16.4 - Nursing facilities (NFs): covered days and bed-hold days

Current through all regulations passed and filed through July 1, 2024
(A) Definitions.
(1) "Home and community-based services"
			 (HCBS) means services that enable individuals to live in a community setting
			 rather than in an institutional setting such as a NF, an intermediate care
			 facility for individuals with intellectual
			 disabilities (ICF-IID), or a hospital.
(2) "Hospitalization" means transfer
			  of a NF resident to a medical
			 institution as defined in paragraph (A)(4) of this rule.
			 A NF resident is considered hospitalized if the
			 resident is formally admitted to a medical institution, or is on observation
			 status in a medical institution.
(3) "Institution for mental disease" (IMD)
			 means a hospital, NF, or other institution of more than sixteen beds that is
			 engaged primarily in the diagnosis, treatment, and care of persons with mental
			 diseases, and that provides medical attention, nursing care, and related
			 services. An institution is determined to be an IMD when its overall character
			 is that of a facility established and maintained primarily for the care and
			 treatment of individuals with mental diseases, whether or not it is licensed as
			 such.
(4) "Medical institution"
			 means an institution other than a NF that meets all of the following criteria:
(a) Is organized to provide medical care,
			 including nursing and convalescent care.
(b) Has the necessary professional personnel,
			 equipment, and facilities to manage the medical, nursing, and other health care
			 needs of patients on a continuing basis in accordance with accepted
			 standards.
(c) Is
			 authorized under state law to provide medical care.
(d) Is staffed by professional personnel who
			 are responsible to the institution for professional medical and nursing
			 services. Professional medical and nursing services shall include all of the
			 following:
(i) Adequate and continual medical
			 care and supervision by a physician.
(ii) Registered nurse or licensed practical
			 nurse supervision and services sufficient to meet nursing care needs.
(iii) Nurses' aid services sufficient to meet
			 nursing care needs.
(iv) A
			 physician's guidance on the professional aspects of operating the
			 institution.
(5) "NF admission" means the act that allows
			 an individual who was not considered a resident of any Ohio medicaid certified
			 NF during the time immediately preceding their current NF residence to
			 officially enter a facility to receive NF services. This may include former NF
			 residents who have exhausted their bed-hold days while in the community and/or
			 hospital and returned to the facility. A NF
			 admission may be a new admission or a return admission after an official
			 discharge. A NF admission is distinguished from the readmission of a resident
			 who has not exhaused all bed-hold days.
(6) "NF bed-hold day," also referred to as
			 "NF leave day," means a day for which a bed is reserved for a NF resident while
			 the resident is temporarily absent from the NF for hospitalization, therapeutic
			 leave days, or visitation with friends or relatives. Payment for NF bed-hold
			 days may be made only if the resident has the intent and ability to return to
			 the same NF. A resident on NF bed-hold day status is not considered discharged
			 from the NF.
(7) "NF discharge"
			 means the full release of a NF resident from the facility, allowing the
			 resident who leaves the facility to no longer be counted in the NF's census.
			 Reasons for NF discharge include but are not limited to the resident's transfer
			 to another facility, exhaustion of NF bed-hold days , decision to reside in a
			 community-based setting, or death.
(8) "NF occupied day" means one of the
			 following:
(a) A day of admission
			 or readmission.
(b) A day during which a medicaid eligible
			 resident's stay in a NF is eight hours or more, and for which the facility
			 receives the full per resident per day payment directly from medicaid in
			 accordance with Chapter 
										5165. of the 
										Revised Code.
(9) "NF readmission" means the status of a
			 resident who is readmitted to the same NF following a stay in a hospital to
			 which the resident was sent to receive care, or the status of a resident who
			 returns after a therapeutic program or visit with friends or relatives. A NF
			 resident can only be readmitted to a facility if that individual was not
			 officially discharged from the facility during that NF stay.
(10) "NF therapeutic leave day" means a day
			 that a resident is temporarily absent from a NF with intent and ability to
			 return, and is in a residential setting other than a long-term care facility,
			 hospital, or other entity eligible to receive federal, state, or county funds
			 to maintain a resident, for the purpose of receiving a regimen or program of
			 formal therapeutic services.
(11)
			 "NF transfer" means the events that occur when a person's place of residence
			 changes from one Ohio medicaid certified NF to another, with or without an
			 intervening hospital stay. However, when the person has an intervening IMD
			 admission, or when the person is discharged from a NF during a hospital stay
			 due to exhaustion of available NF bed-hold days and is admitted to a different
			 NF immediately following that hospital stay, the change of residence is not
			 considered a NF transfer.
(12)
			 "Skilled nursing facility" (SNF) means a 
									facility certified to participate in the medicare
			 program.