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 5160-3-15 - Preadmission screening and resident review (PASRR) definitions

Current through all regulations passed and filed through July 1, 2024
(A)
								The purpose of this rule is to set forth the
			 definitions for terms contained in rules 5160-3-15.1, 5160-3- 15.2, 5122-21-03
			 and 5123-14-01 of the Administrative Code.
(B)
								Definitions:
(1)
									"Adverse determination" means a determination made in
			 accordance with rules 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 nursing facility or that the individual does or does not
			 require specialized services.
(2)
									"Attending
			 Physician" means the physician to whom a person, or the family of a person, has
			 assigned primary responsibility for the treatment or care of the person or, if
			 the person or the person's family has not assigned that responsibility, the
			 physician who has accepted that responsibility.
(3)
									"Categorical
			 determination" means a preadmission level II determination which may be made
			 for an individual without a face to face assessment for an individual diagnosed
			 with a serious mental illness (SMI) and/or developmental disability (DD) as
			 defined in paragraphs (B)(6) and (B)(28) of this rule when the individual's
			 circumstances fall within one of the following two categories:
(a)
										The individual
			 requires an 'emergency nursing facility stay', as defined in paragraph (B)(7)
			 of this rule;
(b)
										The individual is seeking admission to a nursing
			 facility for a 'respite nursing facility stay' as defined in paragraph (B)(26)
			 of this rule.
(4)
									"Community" for PASRR purposes means a new admission
			 from a setting other than a nursing facility, Ohio hospital or a unit of a
			 hospital that is not operated by or licensed by the Ohio department of mental
			 health and addiction services (OhioMHAS).
(5)
									"Current
			 diagnoses'"means a written medical determination by the individual's attending
			 physician, whose scope of practice includes diagnosis, listing those diagnosed
			 conditions which currently impact the individual's health and functional
			 abilities. To be considered current, the written documentation of the diagnoses
			 must reflect the diagnoses assigned by the individual's attending physician
			 within one hundred eighty calendar days of submission for the preadmission
			 screening review certifying that the listed diagnoses are an accurate
			 reflection of the individual's current condition.
(6)
									"Developmental
			 disability (DD)". An individual is considered to have a DD when he or she meets
			 the conditions described in rule
			 5123-14-01
			 of the Administrative Code.
(7)
									"Emergency
			 nursing facility stay" refers to the temporary admission of an individual to a
			 nursing facility pending further assessment in emergency situations requiring
			 protective services as defined in rule
			 5101:2-20-01
			 of the Administrative Code, with placement in a nursing facility not to exceed
			 seven days.
(8)
									"Guardian" has the same meaning as in section
			 2111.01 of the Revised
			 Code.
(9)
									"Hospital discharge exemption", also known as hospital
			 exemption means an exemption from the preadmission screening as defined in
			 paragraph (B)(21) of this rule, when an individual meets the hospital discharge
			 exemption criteria in rule 5160-3-15.1 of the Administrative
			 Code.
(10)
									"Indications of developmental disabilities (DD)". An
			 individual shall be considered to have indications of developmental
			 disabilities when the individual meets the criteria specified in rule
			 5123-14-01
			 of the Administrative Code or the individual receives services from a county
			 board of DD.
(11)
									"Indications of serious mental illness (SMI)." An
			 individual shall be considered to have indications of an SMI when the
			 individual meets the criteria specified in rule
			 5122-21-03
			 of the Administrative Code.
(12)
									"Individual",
			 for the purposes of this rule, means a person, regardless of payment source,
			 who is seeking admission, readmission or transfer to a medicaid certified
			 nursing facility, or who resides in a medicaid certified nursing facility or
			 facility in the process of becoming medicaid certified as a nursing
			 facility.
(13)
									"Level I" or "level I screening" refers to the initial
			 screening that must be given to all individuals seeking new admission as
			 defined in paragraph (B)(17) of this rule to a medicaid-certified nursing
			 facility, regardless of payor source, for the purpose of identifying
			 individuals who may have or are suspected to have indications of a DD as
			 defined in paragraph (B)(10) of this rule and/or a SMI as defined in paragraph
			 (B)(11) of this rule.
(14)
									"Level II entities" refers to the state level II
			 authorities which is the OhioMHAS and the Ohio department of developmental
			 disabilities (DODD).
(15)
									"Level II" or "level II evaluation" refers to the
			 in-depth evaluation of an individual that has been identified as having
			 indications or suspected of having indications of a DD and/or a SMI as defined
			 in paragraphs (B)(10) and (B)(11) of this rule by the level I screening
			 outcome. The level II entity must confirm or disconfirm the existence of a DD
			 and/or a SMI and make a written determination of the following:
(a)
										The individual's
			 need or continued need for nursing facility services as defined in paragraph
			 (B)(19) of this rule; and
(b)
										If the nursing facility is or continues to be the most
			 appropriate setting to meet the individual's long-term care needs;
			 and
(c)
										Identification and recommendation for specialized
			 services as defined in paragraphs (B)(30) and/or (B)(31) of this rule, if any,
			 that would be needed for the individual during the individual's nursing
			 facility stay.
(16)
									"Long-term
			 resident" means an individual who has continuously resided in a nursing
			 facility or a consecutive series of nursing facilities and/or medicare skilled
			 nursing facilities for at least thirty months prior to the first resident
			 review determination in which the individual was found not to require the level
			 of services provided by a nursing facility, but to require specialized services
			 as defined in paragraphs (B)(30) and (B)(31) of this rule. The thirty months
			 may include temporary absences for hospitalization, therapeutic leave, or
			 visits with family or friends as defined in rule 5160-3-16.4 of the
			 Administrative Code.
(17)
									"New admission" means the admission to an Ohio medicaid
			 certified nursing facility of an individual:
(a)
										Who was not a
			 resident of any nursing facility immediately preceding:
(i)
											The current
			 nursing facility admission; or
(ii)
											A hospital stay
			 for which the individual is to be admitted directly to a nursing
			 facility;
(b)
										Seeking admission or admitted to a nursing facility
			 from another state, regardless of prior residence; or
(c)
										Is transferred or
			 readmitted from a nursing facility following an:
(i)
											Adverse level II
			 or a resident review determination; or
(ii)
											Overruled appeal of an adverse level
			 II determination.
(d)
										For PASRR
			 purposes only and effective on the date the facility submits its application
			 packet for medicaid certification to the Ohio department of medicaid,
			 individuals seeking admission to, or who are currently residing in, a facility
			 that is in the process of obtaining its initial medicaid certification by Ohio
			 department of health, and
(e)
										With the exception of those circumstances specified in
			 paragraphs (B)(17) (a) to (B)(17)(c) of this rule, nursing facility transfers
			 and readmissions as defined in paragraphs (B)(20) and (B)(24) of this rule are
			 not considered to be new admissions for the purposes of this
			 rule.
(18)
									"Nursing facility" has the same meaning as in section
			 5111.20 of the Revised Code. A
			 long term care facility that has submitted an application packet for medicaid
			 certification to the Ohio department of medicaid is considered to be in the
			 process of obtaining its initial medicaid certification by the Ohio department
			 of health and shall be treated as a nursing facility for the purposes of this
			 rule.
(19)
									"Nursing facility level of service" for the purposes of
			 PASRR means a determination made by the DODD and/or OhioMHAS in accordance with
			 rules
			 5123-14-01
			 and
			 5122-21-03
			 of the Administrative Code as required by section 1919(e)(7) of the Social
			 Security Act, as in effect July 1, 2019 that the individual's need for
			 treatment does not exceed the level of services which can be delivered by the
			 nursing facility to which the individual is seeking admission or is currently
			 admitted to either through nursing facility services alone or, where necessary,
			 through nursing facility services supplemented by specialized services provided
			 by or arranged for by the state.
(20)
									"Nursing
			 facility transfer." A nursing facility transfer occurs when an individual is
			 transferred from any Ohio medicaid certified nursing facility to another Ohio
			 medicaid certified nursing facility, with or without an intervening hospital
			 stay.
(21)
									"Preadmission screening" refers to the level I
			 screening as defined in paragraph (B)(13) of this rule and when applicable the
			 completion of the level II evaluation as defined in paragraph (B)(15) of this
			 rule that results in a PASRR determination from the DODD and/or OhioMHAS
			 administered prior to the individuals admission to the nursing
			 facility.
(22)
									"PASRR" means the preadmission screening and resident
			 review of individuals for the purposes of identifying individuals with serious
			 mental illness as defined in rule
			 5122-21-03
			 of the Administrative Code and/or a developmental disability as defined in rule
			 5123-14-01
			 of the Administrative Code and required by the "Social Security Act,"
			 42 U.S.C
			 1396r(e)(7).
(23)
									"Physician"
			 means a doctor of medicine or osteopathy who is licensed to practice
			 medicine.
(24)
									"Readmission" means the individual is readmitted to the
			 same nursing facility from a hospital to which he or she was sent for the
			 purpose of receiving care.
(25)
									"Resident
			 review"' is a post admission level II evaluation as defined in paragraph
			 (B)(15) of this rule that results in a determination for nursing facility
			 residents which must be implemented upon a significant change in condition as
			 defined in paragraph (B)(29) of this rule and in accordance with section
			 1919(e)(7) of the Social Security Act, as in effect on July 1, 2019, which must
			 be implemented in accordance with rules 5160-3-15.2, 5122-21-03 and 5123-14-01
			 of the Administrative Code.
(26)
									'Respite nursing
			 facility stay' means the admission of an individual to a nursing facility for a
			 maximum of fourteen days in order to provide respite to in-home caregivers to
			 whom the individual is expected to return following the respite
			 stay.
(27)
									"Ruled out" means a determination made by the DODD
			 and/or the OhioMHAS 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 a DD and/or SMI; or
(b)
										Has a primary
			 diagnosis of dementia (including alzheimer's disease or a related disorder);
			 or
(c)
										Has a non-primary diagnosis of dementia without a
			 primary diagnosis that is a SMI, and does not have a diagnosis of a DD or a
			 related condition.
(28)
									"Serious mental
			 illness" means an individual meets the conditions described in rule
			 5122-21-03
			 of the Administrative Code.
(29)
									"Significant
			 change of condition" means any major decline or improvement in the individual's
			 physical or mental condition, as described in
			 42 C.F.R.
			 483.20, as in effect on July 1, 2019 and when
			 at least one of the following criteria is met:
(a)
										There is a change
			 in the individual's current diagnosis(es), mental health treatment, functional
			 capacity, or behavior such that, as a result of the change, the individual who
			 did not previously have indications of a SMI, or who did not previously have
			 indications of a DD, now has such indications; or
(b)
										The change is
			 such that it may impact the mental health treatment or placement options of an
			 individual previously identified as having SMI and/or may result in a change in
			 the specialized services needs of an individual previously identified as having
			 a DD.
(30)
									"Specialized services for serious mental illness" means
			 those services specified by the level II or the resident review determination
			 for an individual with a SMI which are arranged by OhioMHAS in accordance with
			 rule
			 5122-21-03
			 of the Administrative Code 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 when combined with services by the nursing
			 facility, results in the continuous and aggressive implementation of an
			 individualized plan of care in accordance with
			 42 CFR
			 483.120, as in effect July 1,
			 2019.
(31)
									"Specialized services for developmental disabilities"
			 means the services or supports specified by the level II or the resident review
			 determination for an individual with a DD which is provided or arranged for by
			 the county board of DD in accordance with rule
			 5123-14-01
			 of the Administrative Code.
Replaces: 5160-3-15