Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 9 - LONG-TERM CARE FACILITIES › Section 317:30-5-123 - Member certification for long-term care

Current through Vol. 41, No. 20, July 1, 2024
(a)
Medical eligibility.
Initial
				  approval of medical eligibility for long-term care is determined by the
				  Oklahoma Department of Human Services (DHS) area nurse, or nurse designee. The
				  certification is obtained by the facility at the time of admission.
(1)
Preadmission screening.
Federal regulations govern the State's responsibility for Preadmission
				  Screening and Resident Review (PASRR) for individuals with mental illness and
				  intellectual disability. PASRR applies to the screening or reviewing of all
				  individuals for mental illness, intellectual disability, or related conditions
				  who apply to or reside in a Title XIX certified nursing facility (NF),
				  regardless of the source of payment for the NF services and/or the individual's
				  or resident's known diagnoses. Individuals referred for admission to a NF must
				  be screened for a major mental disorder, diagnosable under the most current
				  edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The
				  NF must independently evaluate the Level I PASRR screen regardless of who
				  completes the form and determine whether or not to admit an individual to the
				  facility. Nursing facilities which inappropriately admit a person without a
				  PASRR screen are subject to recoupment of funds. PASRR is a requirement for
				  nursing facilities with dually certified (both Medicare and Medicaid) beds.
				  There are no PASRR requirements for Medicare skilled beds that are not dually
				  certified, nor is PASRR required for individuals seeking residency in an
				  intermediate care facility for individuals with intellectual disabilities
				  (ICF/IID).
(2)
PASRR Level I
				  screen.
(A) Form LTC-300R, Nursing
				  Facility Level of Care Assessment, must be completed by an authorized NF
				  official or designee. An authorized NF official or designee must consist of one
				  (1) of the following:
(i) The NF
				  administrator or co-administrator;
(ii) A licensed nurse, social service
				  director, or social worker from the NF; or
(iii) A licensed nurse, social service
				  director, or social worker from the hospital.
(B) Prior to admission, the authorized NF
				  official must evaluate the properly completed Oklahoma Health Care Authority
				  (OHCA) Form LTC-300R and the Minimum Data Set (MDS), if available. Any other
				  readily available medical and social information is also used to determine if
				  there currently exists any indication of mental illness, an intellectual
				  disability, or other related condition, or if such condition existed in the
				  applicant's past history. Form LTC-300R constitutes the Level I PASRR screen
				  and is utilized in determining whether or not a Level II assessment is
				  necessary prior to allowing the member to be admitted. The NF is also
				  responsible for consulting with the Level of Care Evaluation Unit (LOCEU)
				  regarding any information on a mental illness, intellectual disability or
				  related condition that becomes known either from completion of the MDS or
				  throughout the resident's stay.
(C)
				  The NF is responsible for determining from the evaluation whether or not the
				  member can be admitted to the facility. A "yes" response to any question from
				  Form LTC-300R, Section E, will require the facility to contact the LOCEU for a
				  consultation to determine if a Level II assessment is needed. If there is any
				  question as to whether or not there is evidence of mental illness, an
				  intellectual disability, or related condition, LOCEU should be contacted prior
				  to admission. The original Form LTC-300R must be submitted electronically or by
				  mail to the LOCEU within ten (10) days of the resident admission. SoonerCare
				  payment may not be made for a resident whose LTC-300R requirements have not
				  been satisfied in a timely manner.
(D) Upon receipt and review of the Form
				  LTC-300R, the LOCEU may, in coordination with the DHS area nurse, re-evaluate
				  whether a Level II PASRR assessment may be required. If a Level II assessment
				  is not required, the process of determining medical eligibility continues. If a
				  Level II is required, a medical decision is not made until the results of the
				  Level II assessment are known.
(3)
Level II Assessment for
				  PASRR.
(A) Any one of the following
				  three (3) circumstances will allow a member to enter the NF without being
				  subjected to a Level II PASRR assessment.
(i)
				  The member has no current indication of mental illness, intellectual
				  disability, or other related condition and there is no history of such
				  condition in the member's past.
(ii) The member does not have a diagnosis of
				  intellectual disability or related condition.
(iii) An individual may be admitted to a NF
				  if he/she has indications of mental illness, intellectual disability, or other
				  related condition, but is not a danger to self and/or others, and is being
				  released from an acute care hospital as part of a medically prescribed period
				  of recovery (exempted hospital discharge). If an individual is admitted to a NF
				  based on an exempted hospital discharge, it is the responsibility of the NF to
				  ensure that the individual is either discharged by the 30th day or that a Level
				  II has been requested and is in process. An exempted hospital discharge is
				  allowed only if all three (3) of the following conditions are met:
(I) The individual must be admitted to the NF
				  directly from a hospital after receiving acute inpatient care at the hospital
				  (not including psychiatric facilities);
(II) The individual must require NF services
				  for the condition for which he/she received care in the hospital; and
(III) The attending physician must
				  certify in writing before admission to the facility that the individual is
				  likely to require less than thirty (30) days of NF services. The NF will be
				  required to furnish this documentation to OHCA upon request.
(B) If the member has
				  current indications of mental illness, intellectual disability, or other
				  related condition, or if there is a history of such condition in the member's
				  past, the member cannot be admitted to the NF until the LOCEU is contacted for
				  consultation to determine if a Level II PASRR assessment must be performed.
				  Results of any Level II PASRR assessment ordered must indicate that NF care is
				  appropriate prior to allowing the member to be admitted.
(C) The OHCA LOCEU authorizes advance group
				  determinations for the mental illness and intellectual disability authorities
				  in the following categories listed in (i) through (iii) of this subparagraph.
				  Preliminary screening by the LOCEU may indicate eligibility for NF level of
				  care prior to consideration of the provisional admission.
(i)
Provisional admission in cases of
				  delirium.
Any person with mental illness, intellectual disability, or
				  related condition that is not a danger to self and/or others, may be admitted
				  to a Title XIX certified NF if the individual is experiencing a condition that
				  precludes screening, i.e., effects of anesthesia, medication, unfamiliar
				  environment, severity of illness, or electrolyte imbalance.
(I) A Level II evaluation is completed
				  immediately after the delirium clears. The LOCEU must be provided with written
				  documentation by a physician that supports the individual's condition which
				  allows provisional admission as defined in (i) of this subparagraph.
(II) Payment for NF services will not be made
				  after the provisional admission ending date. If an individual is determined to
				  need a longer stay, the individual must receive a Level II evaluation before
				  continuation of the stay may be permitted and payment made for days beyond the
				  ending date.
(ii)
Provisional admission in emergency situations.
Any person with
				  mental illness, intellectual disability, or related condition, who is not a
				  danger to self and/or others, may be admitted to a Title XIX certified NF for a
				  period not to exceed seven (7) days pending further assessment in emergency
				  situations requiring protective services. The request for Level II evaluation
				  must be made immediately upon admission to the NF if a longer stay is
				  anticipated. The LOCEU must be provided with written documentation from DHS
				  Adult Protective Services which supports the individual's emergency admission.
				  Payment for NF services will not be made beyond the emergency admission ending
				  date.
(iii)
Respite care
				  admission.
Any person with mental illness, intellectual disability, or
				  related condition, who is not a danger to self and/or others, may be admitted
				  to a Title XIX certified NF to provide respite to in-home caregivers to whom
				  the individual is expected to return following the brief NF stay. Respite care
				  may be granted up to fifteen (15) consecutive days per stay, not to exceed
				  thirty (30) days per calendar year.
(I) In
				  rare instances, such as illness of the caregiver, an exception may be granted
				  to allow thirty (30) consecutive days of respite care. However, in no instance
				  can respite care exceed thirty (30) days per calendar year.
(II) Respite care must be approved by LOCEU
				  staff prior to the individual's admission to the NF. The NF provides the LOCEU
				  with written documentation concerning circumstances surrounding the need for
				  respite care, the date the individual wishes to be admitted to the facility,
				  and the date the individual is expected to return to the caregiver. Payment for
				  NF services will not be made after the respite care ending date.
(4)
Resident Review.
(A) The
				  facility's routine resident assessment will identify those individuals
				  previously undiagnosed as intellectually disabled or mentally ill. A new
				  condition of intellectual disability or mental illness must be referred to
				  LOCEU by the NF for determination of the need for the Level II assessment. The
				  facility's failure to refer such individuals for a Level II assessment may
				  result in recoupment of funds.
(B)
				  A Level II resident review may be conducted the following year for each
				  resident of a NF who was found to experience a serious mental illness with no
				  primary diagnosis of dementia on his or her preadmission Level II, to determine
				  whether, because of the resident's physical and mental condition, the resident
				  requires the level of services provided by a NF and whether the resident
				  requires specialized services.
(C)
				  A significant change in a resident's mental condition could trigger a Level II
				  resident review. If such a change should occur in a resident's condition, it is
				  the responsibility of the NF to notify the LOCEU of the need to conduct a
				  resident review.
(5)
Results of Level II Preadmission Assessment and Resident Review.
Through contractual arrangements between the OHCA and the mental illness or
				  intellectual disability authorities, individualized assessments are conducted
				  and findings presented in written evaluations. The evaluations determine if NF
				  services are needed, if specialized services or less than specialized services
				  are needed, and if the individual meets the federal PASRR definition of mental
				  illness, intellectual disability, or related conditions. Evaluations are
				  delivered to the LOCEU to process formal, written notification to member,
				  guardian, NF, and interested parties.
(6)
Readmissions and interfacility
				  transfers.
The preadmission screening process does not apply to
				  readmission of an individual to a NF after transfer for a continuous hospital
				  stay, and then back to the NF. There is no specific time limit on the length of
				  absence from the NF for the hospitalization. Interfacility transfers are also
				  subject to preadmission screening. In the case of transfer of a resident from a
				  NF to a hospital or to another NF, the transferring NF is responsible for
				  ensuring that copies of the resident's most recent LTC-300R and any PASRR
				  evaluations accompany the transferring resident. The receiving NF must submit
				  an updated LTC-300R that reflects the resident's current status to LOCEU within
				  ten (10) days of the transfer. Failure to do so could result in possible
				  recoupment of funds. LOCEU should also be contacted prior to admitting
				  out-of-state NF applicants with mental illness, intellectual disability, or
				  related condition, so that PASRR needs can be ascertained. Any PASRR
				  evaluations previously completed by the referring state should be forwarded to
				  LOCEU as part of this PASRR consultation.
(7)
PASRR appeals process.
(A) Any individual who has been adversely
				  affected by any PASRR determination made by the State in the context of either
				  a preadmission screening or an annual resident review may appeal that
				  determination by requesting a fair hearing. If the individual does not consider
				  the PASRR decision a proper one, the individual or their authorized
				  representative must contact the local county DHS office to discuss a hearing.
				  Forms for requesting a fair hearing (DHS Form 13MP001E, Request for a Fair
				  Hearing), as well as assistance in completing the forms, can be obtained at the
				  local county DHS office. Any request for a hearing must be received by OHCA
				  within thirty (30) days of the date of written notice. Appeals of these
				  decisions are available under Oklahoma Administrative Code (OAC)
				  317:2-1-2. All individuals
				  seeking an appeal have the same rights, regardless of source of payment. Level
				  I determinations are not subject to appeal.
(B) When the individual is found to
				  experience mental illness, intellectual disability, or related condition
				  through the Level II assessment, the PASRR determination made by the mental
				  illness or intellectual disability authorities cannot be countermanded by the
				  OHCA, either in the claims process or through other utilization control/review
				  processes, or by the State Department of Health. Only appeals determinations
				  made through the fair hearing process may overturn a PASRR determination made
				  by the mental illness or intellectual disability authorities.