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POLICY 700 – PASRR (PREADMISSION SCREENING/RESIDENT REVIEW

TABLE OF CONTENTS

700.00 Purpose

700.01 Applicability

700.02 Definitions

700.03 Referrals

700.04 Level II Evaluation

700.05 Referral for Categorical Determinations

700.06 Resident Review

700.07 Coordination With the Ohio Department of Mental Health and Addiction Services

700.08 Notification and Determination

700.09 Hospital Discharge Exemption

700.10 Appeals

700.00 Purpose

The purpose of this Policy is to set forth a process for the Ohio Department of Developmental Disabilities (ODDD) and the county board of developmental disabilities to determine whether an individual is eligible for admission to a nursing facility (NF) or eligible to continue to receive services in a NF.

700.01 Applicability

This Policy applies to individuals who are seeking admission to a NF who have indications of developmental disabilities (DD), residents of a NF who have indications of DD, and persons acting on behalf of these applicants or residents. This Policy does not apply to individuals seeking readmission to a NF after having been transferred from a NF to a hospital for care nor to individuals being transferred from one NF to another NF, with or without an intervening hospital stay.

700.02 Definitions

(1) “Adverse determination” means a determination made in accordance with 5123-1401 and rules, 5160-3-15.1, 5160-3-15.2 and 5122-21-03 of the Ohio Administrative Code that an individual does not require the level of services provided by a nursing facility (NF). A determination that an individual does not require NF services shall meet both of the following conditions:

  • An assessment of the individual conducted in person, by video conference, or by telephone and a review of the medical records accurately reflecting the individual’s current condition, is performed by one of the following professionals within the scope of their practice: (i) Physician; (ii) Registered nurse; (iii) Master of science of nursing; (iv) Clinical nurse specialist; (v) Certified nurse practitioner;(vi) Licensed social worker, under supervision of a licensed independent social worker; (vii) Licensed independent social worker; (viii) Professional counselor, under supervision of a professional clinical counselor; (ix) Professional clinical counselor; (x) Psychologist; (xi) Qualified intellectual disability professional; or (xii) Service and Support Administrator.
  • Authorized personnel from the Ohio Department of Developmental Disabilities(ODDD) and/or the Ohio Department of Mental Health and Addiction Services, other than the personnel reflected above who have conducted the assessment, reviewed the assessment and made the final determination regarding the need for NF services and specialized services.

(2) “Categorical determination” means a preadmission screening for developmental disabilities (PAS-DD) orpreadmission screening for serious mental illness (PAS-SMI) determinationwhich may be made for an individual with DD and/or SMI without first completing a full level II evaluation when theindividual’s circumstances fall within one of the following two categories:

  • The individual requires an emergency NF stay, as defined in rule 5160-3-15 of the

Administrative Code; or

  • The individual is seeking admission to a NF for a respite NF stay, as defined in rule 5160-3-15of the Administrative Code.
  • “Hospital dischargeexemption” means an exemption from preadmission screening for a new admission, as defined in rule 5160-3-15of the Administrative Code, to a NF. The discharging hospital shall request a hospital dischargeexemptionvia the electronic system approved by the Ohio Department of Medicaid.  
  • “Preadmission screening” (PAS) means the preadmission portion of the PASRR requirements mandated by section 1919(e)(7) of the Social Security Act, which shall be implemented in accordance with 5123-14-01and rules 5160-3-15.1 and 5122-21-03 of the Administrative Code.
  • Level I screening means the process by which the Ohio Department of Medicaidor its designee screens individuals who are seeking new admissions to identify those who have indications of developmental disabilities or serious mental illness, and who, therefore, shall be further evaluated by ODDD and/or the Ohio Department of Mental Health and Addiction Services.
  • Level II evaluationfor developmental disabilities means the process by which the Department determines:

(a) Whether, due to the individual’s physical and mental condition, an individualwho has

DD requires the level of services provided by a NF or another type of setting; and (b) When the level of services provided by a NF is needed, whether the individual requires specialized services for DD.

  • “Resident review” (RR) means the resident review portion of the PASRR requirements mandated by section 1919(e)(7) of the Social Security Act, which shall be implemented in accordance with 5123-14-01and rules 5160-3-15.2and 5122-21-03 of the Administrative Code.
  • “Resident review for developmental disabilities” (RR-DD) means the process set forth in 5123-14-01by which the Department determines whether, due to the individual’s physical and mental condition, an individual who is subject to RR, and who has DD, requires the level of services provided by a NF or another type of setting and whether the individual requires specialized services for DD.
  • “Resident review” (RR)means the portion mandated by section 1919 (e)(7) of theSocial Security Act which shall be implemented in accordance with5123-14-01and rules 5160-3-15.2 and 5122-21-03 of the Administrative Code. 
  • “Ruled out” means that an individual has been determined not to be subject to further review byODDD or the Ohio Department of Mental Health and AddictionServices. An individual may be ruled out for further review at any point in the PASRR process if ODDD or the Ohio Department of Mental Health and Addiction Services finds that the individual being evaluated:
  • Does not have DD or SMI; or
  • Has a primary diagnosis of dementia (including Alzheimer’s disease or a related disorder) which is not acute or due to another medical condition or (c) Has a non-primary diagnosis of dementia without a primary diagnosis of

SMI and does not have a diagnosis of DD or a related condition.

(11) “Specialized services for developmental disabilities” (specialized services) means the services or supportsidentified through the level two evaluation forDD or the RR for

DD.  Specialized services shall be provided or arranged for by the county board.  Individuals determined through the processes set forth in 5123-14-01to require specialized services for developmental disabilities shall not be placed on a waiting list for such services. Specialized services for developmental disabilities shall be:

  • Individualized;
  • Based on person-centered assessment, rather that determined categorically based on disability or diagnosis;
  • Made available at the frequency and intensity required to address the individual’s specific needs in each of the areas of major life activity (i.e., self-care, understanding and use of language, learning, mobility, self-direction, capacity for independent living, and economic self-sufficiency) for which functional limitations have been identified; and (d) Unique services that support the individual’s independence or reintegration to the community from an institutional setting (e.g. behavioral support) not otherwise available through the routine, rehabilitative services provided by the nursing facility.

700.03 Referrals

(1) After the level I screening has been completed, the Ohio Department of Medicaidor its designee shall forward a request for a level II evaluationfor individuals who have indications of DD to ODDD. 

  • The Department shall complete the level II evaluation and make a determination regarding:

Requests for individuals relocating from outside of Ohio who are not Ohio residents; or  A request for a categorical determination.

  • All other requests shall be forwarded to the county board of the county in which the request is initiated.  When the county in which the request is initiated is not the county in which the individual resides and/or the county where the nursing facility is located, notification shall also be made to the county board of the county in which the individual resides and the county board of the county where the nursing facility is located.  The county board in which the request is initiated shall be responsible for completing the review and collaborating with the other county boards to agree on a recommendation.

(2) No one who has indications of DD shall move into a NF in Ohio until the level II evaluation of DD determination has been made by ODDD.

700.04 Level II Evaluation

  • Within seven business days of receipt of the referral by the Ohio Department ofMedicaidor its designee of an individual for a level II evaluation for DD, the county board shall gather data, complete an evaluation, and submit its recommendations in the form of a written evaluative report to the Department regarding whether the individual has DD and whether NF services and specialized services are required.
  • The county board shall be responsible for requesting any information necessary to make the level II evaluation for DD and recommendations. The evaluation shall be based on relevant data that are valid, accurate, and reflect the current functional status of the individual being evaluated.
  • Persons completing the level II evaluations for DD shall not have a direct or indirect affiliation with a NF.
  • The level II evaluations for DD shall involve the individual being evaluated, the individual’s guardian, and the individual’s family if available and if the individual or guardian agrees to family participation.
  • The level II evaluations for DD shall be adapted to the cultural background, language, ethnic origin, and means of communication used by the individual being evaluated.
  • The level II evaluation for DD has three components:

(a) DD assessment. The assessment shall be based on the following documentation: (i) Intellectual functioning as measured by a psychologist or other related condition(s) as identified by a physician; and 

(ii) A determination of whether the individual meets DD eligibility criteria pursuant to section 5123.01 of the Revised Code.

(b) NF needs assessment. The assessment shall be based on an evaluation of written documentation which shall include the following information:

  • The history and physical examination performed by a registered nurse, a clinical nurse specialist, a certified nurse practitioner, an individual registered by the state medical board as a physician assistant under Chapter 4730. of the Revised Code, or a physician. If the history and physical examination are performed by someone other than a physician, a physician shall review and concur with the conclusions. If the history and physical examination are performed by a clinical nurse specialist or a certified nurse practitioner who has entered into a standard care arrangement with a collaborative physician in accordance with section 4723.431 of the Revised Code, physician review is only required as indicated in the standard care arrangement.
  • Current nursing care needs.
  • Current medications.
  • Current functional status including any therapy assessments and reports (e.g., physical therapy, speech therapy, occupational therapy, or respiratory therapy). (v) Current social history, including current living arrangement prior to admission and any medical problems, including their impact on the individual’s independent functioning.

(c) Specialized services needs assessment. The county board shall evaluate and recommend whether the individual currently has a need for specialized services for DD.  The county board shall submit via the ODDD web-based assessment center the recommendation, the type of specialized services to be provided, and who will provide the specialized services for DD.  When a determination is made to admit or allow to remain in a NF an individual who requires specialized services for developmental disabilities, the determination shall be supported by assurances that the specialized services for developmental disabilities will be provided while the individual resides in the NF.

  • If the individual does not meet DD eligibility criteria, no further review by the county board is required; the county board shall submit documentation and a recommendation to the Department that the individual be ruled out.
  • The county board shall submit its recommendations in the form of a written evaluative report to the Department regarding whether the individual has

DD and whether NF services and specialized services are required. The report shall: (a) Identify the name and professional title of the persons who performed the evaluations and the dates upon which the evaluations were performed;

(b) Provide a summary of the evaluated individual’s medical and social history; (c) If NF services are recommended, identify the services which are required to meet the evaluated individual’s needs;

  • Identify whether specialized services are needed;
  • Include the basis for the report’s conclusions; and
  • Include copies of the documentation gathered and reviewed in accordance with 700.04 (6)of this Policy.
  • The Department may request additional information when necessary to make a determination.
  • Within two business days of receipt of the county board’s recommendations and documentation, the Department shall determine:
  • Whether the individual has DD.
  • Whether the individual requires the level of services provided by a NF based on a comprehensive analysis of all data and consideration of the most appropriate placement such that the individual’s needs for treatment do not exceed the level of services which can be delivered in the NF.
  • Whether the individual requires specialized services for DD.
  • The Department shall issue a determination in the form of a written report in accordance with 700.08 of this Policy.
  • One of two outcomes of the level II evaluation for DDis possible:
  • The individual requires the level of services provided by a NF and therefore may be admitted to a NF.
  • The individual does not require the level of services provided by a NF and therefore shall not be admitted to a NF. The county board shall assist the individual and/or their guardian with alternative placement options, services, and resources as may be necessary to ensure the health and welfare of the individual.

700.05 Referral for Categorical Determination

  • The Ohio Department of Medicaid or its designee shall refer a request for categorical determination made by or on behalf or an individual with DD to the Department.
  • The Department shall make a categorical determination that an individual requires the level of services provided by a NF when:

(a) The individual is seeking admission to a nursing facility that is not to exceed a seven-day stay pending further assessment in emergency situations requiring protective services and such placement occurs within twenty-four hours from the date of the categorical determination or immediately following discharge from a hospital setting; or (b) Within the next sixty days, the individual is seeking admission to a nursing facility for up to fourteen days of respite for the caregiver and plans to return to the caregiver at the end of the nursing facility stay.

(3) The Department shall issue a determination in the form of a written report in accordance with 700.08 of this policy which:

  • Identifies the name and professional title of the persons making the categorical determination and the date on which the determination was made;
  • Documents the type of categorical determination made and describes the nature of any further screening that is required;
  • Identifies, to the extent possible based on the available data, NF services, including any mental health or specialized psychiatric rehabilitative services, that may be needed; and
  • Includes the basis for the report’s conclusions.

(4) An individual who, on the basis of the categorical determination, requires the services provided by a NF, shall not receive specialized services for DD. (G) Level II evaluationfor developmental disabilities for individuals being directly admitted to a nursing facility from a psychiatric hospital

(1) The Department or its designee shall complete a written evaluative report regarding:

  • Whether the individual has developmental disabilities;
  • Whether the individual requires the level of services provided by a nursing facility based on a comprehensive analysis of all data and consideration of the most appropriate placement such that the individual’s needs for treatment do not exceed the level of services that can be delivered in a nursing facility; and
  • Whether the individual requires specialized services for developmental disabilities. (2) The Department shall issue a determination in the form of a written report in accordance with 700.08 of this Policy.

700.06 Resident review 

  • The NF shall submit the resident review requestto the Department in accordance with rule 5160-3-15.2 of the Administrative Code.
  • Upon receipt of the resident review request, the Department shall notify the county board.
  • Within seven business days of notification by the Department, the county board shall gather data, complete an evaluation, and submit its recommendations and documentation to the Department in accordance with the process set forth in 700.04 (2) to (8) of this policy.
  • Within two business days of receipt of the county board’s recommendations and documentation, the Department shall determine whether the individual has

DD, whether the individual requires the level of services provided by a NF, and whether the individual requires specialized services for DD in accordance with the process set forth in 700.04 (9) to (11)of this policy.

  • Possible outcomes of the resident review for DDinclude:
  • A NF resident with DD who is determined to require the level of services provided by a NF may continue to reside in the NF.
  • A NF resident with DD who has resided in a NF for thirty months or longer who is determined not to require the level of services provided by a NF, but does require specialized services for DD, may choose to continue to reside in the NF or receive covered services in an alternative setting. The Department shall inform the resident of the institutional and non-institutional alternatives covered in the state plan for medical assistance. If the resident chooses to leave the NF, the Department shall clarify the effect on eligibility for services under the state plan for medical assistance, including its effect on readmission to the facility. Wherever the resident chooses to reside, the county board shall meet the resident’s specialized services needs as identified in the individual’s service plan.
  • A NF resident with DD who has resided in a NF for less than thirty months who is determined not to require the level of services provided by a NF, but does require specialized services for DD shall be discharged to an appropriate setting where the county board shall meet the resident’s specialized services needs as identified in the individual’s service plan. The county board, in conjunction with the NF, shall arrange for a safe and orderly discharge to an appropriate setting.
  • A NF resident with DD who has resided in a NF for less than thirty months who is determined not to require the level of services provided by a NF shall be discharged. The county board, in conjunction with the NF, shall arrange for a safe and orderly discharge to an appropriate setting.

700.07 Coordination with the Ohio Department of Mental Health and Addiction Services

The Department shall coordinate with the Ohio Department of Mental Health andAddiction Serviceson determinations for individuals who are subject to both level II evaluation for DD or resident review for DD and level II evaluation for serious mental illness or resident review for serious mental illness.

700.08 Notification of Determination 

(1) The Department shall prepare a written report which includes:

  • The determination as to whether the individual has DD;
  • The determination as to whether the individual requires the level of services provided by a NF;
  • The determination as to whether the individual requires specialized services for DD that shall be provided or arranged for by the county board resulting in continuous active treatment to address needs in each of the life areas for which functional limitations are identified by the county board;
  • The placement and/or service options that are available to the individual consistent with these determinations;
  • Discharge arrangements, if applicable; and
  • The right to appeal, as outlined in 700.10of this policy.

(2) The Department shall provide a copy of its written report to:

  • The evaluated individual and when applicable, their guardian;
  • The individual’s attending physician;
  • The admitting or retaining NF for inclusion in the individual’s medical record;
  • The discharging hospital if the individual is seeking NF admission from a hospital; (e) The county board where the individual resides and when applicable, the county board where the NF is located; and

(f) In the case of an adverse resident review determination, the Ohio Department of Medicaid.

(3) The Department shall document all determinations in the individual’s file which shall be maintained at the Department.

700.09 Hospital Discharge Exemption

  • Upon notification from the Ohio Department of Medicaid  or its designee of a NF admission based on a hospital dischargeexemption, the Department shall begin to monitor the admission in accordance with rule 5160-3-15.1of the Administrative Code.
  • The Department shall notify the county board in the individual’s home county and when applicable, the county board where the NF is located.
  • The Department shall contact the NF prior to the thirtieth day of the individual’s stay to assess the need for a resident review.
  • If the NF indicates that the individual may need more than a thirty-day stay, the Department shall request that the NF initiate the resident review process.

700.10 Appeals

  • The individual or the individual’s guardian may appeal adverse determinations made by the Department within ninety calendar days of the date of determination by filing an appeal with the Ohio Department of Medicaid in accordance with division 5101:6 of the Administrative Code.
  • The Department shall conduct an informal reconsideration of the case when notified of appeal or at the request of the individual or guardian.
  • If the individual is subject to both level II evaluation for DD or resident review for DD and level II evaluation for serious mental illness or resident review for serious mental illness, the informal reconsideration and appeal shall be conducted jointly by the

Department and the Ohio Department of Mental Health and Addiction Services.