PAS Draft Rules - Long Term Care Ohio

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Preadmission screening (PAS) requirements
seeking admission to nursing facilities (NFs).
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for individuals
(A) The purpose of this rule is to set forth the preadmision screening (PAS) requirements
in order to comply with section 1919(e)(7) of the Social Security Act, as amended,
which prohibits nursing facilities from admitting or enrolling individuals with
serious mental illness (SMI) (as defmed in paragraph (B)(J2}Qll of rule
5101:3-3-14 of the Administrative Code) or mental retardation and/or other
developmental disabilities (MRDD) (as defined in paragraph (B)[email protected]
of rule
5101:3-3-14 of the Administrative Code) unless a thorough evaluation indicates
that such placement is appropriate and adequate services will be provided. A
preadmission screening identification (PA SlID) is required:
(1) Prior to any new admission to a nursing facility (NF) and prior to any
categorical determination as defined in rule 5101:3-3-14 of the
Administrative Code unless the admission meets the criteria for a hospital
exemption as set forth in para!!.raph (G) of this rule.
(2) When an individual is transferred or directlv admitted to a nursing facility from
a hospital that is either of the following:
(a) A hospital that the Ohio department of mental health and addiction
services (ODMHAS) maintains. operates. manages, and Q:ovemsunder
section 5119.14 of the Revised Code for the care and tTeatment of
mentallv i1l1)erSOns;or
(b) A free-standing hospitaL or unit of a hospital, licensed bv ODMHAS
under section 5119.33 of the Revised Code.
(B) Preadmission screening identification (PAS/ID) requirements:
(1) PASIID must be completed and submitted to the PASSPORT administrative
agency (PAA). the Ohio depmiment of medicaid (ODM) designee, via a JFS
03622 "Preadmission Screening/Resident Review (PAS/RR) Identification
Screen (rev. lli201O) or equivalent approved by ODM) with SU1)porting
documentation to validate answers on the JFS 03622.
(a) For individuals seeking medicaid payment. the JFS 03697 "Level of Care
Assessment" (rev. 4/03) shall also be submitted in accordance with rule
5101:3-3-15 of the Administrative Code to ODM or its designee, unless
the individual is enrolled in <l medicaid managed care plan (MCP) as
defined in rule 5101 :3-3-14 of the Administrative Code.
(b) For those individuals who will be relocating from outside of Ohio. who
are not Ohio residents, and are known to have serious mental illness
(SM1) and/or MRDD or whose JFS 03622 contains indications of
MRDD and/or SMI, the submitter shall obtain and submit with the JFS
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5101 :3-3-15.1
03622, the JFS 03697. the other state's level two evaluation(s) of the
individual and any additional documentation necessary to address the
required
evaluation
elements
specified
in 1111es 5122-21-03
and
5123:2-14-01 of the Administrative Code. Submission of the required
forms and information does not constitute completion of the P ASJ1D
process.
(c) For those individuals identified as new admissions in accordance with
paragraph (B)06) of rule 5101:3-3-14 of the Administrative Code who
already reside in the facility at the time the PASIID is initiated. the
submitter must notify ODM or its designee of the medicaid status of the
facility at the time of the PASfID submission.
Cd) PAS/ID may be initiated bv the individual seeking the new admission, or
by another entity on behalf of the individuaL or by any state agency or
their designee responsible for PAS. The NF is ultimately responsible
for ensuring that the PASIID is completed and the detennination is on
file.
a .,.. to an ) ne\ .• aamission to
(1) Pi\:S/ID must b e e0111191e1,
oatcg
.' Ie acterminatio prior
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dilmffistraliare
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meets the enrn" •
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Cod ,"illth
iii pamgr"l'fl fB)'9)
eel' a hospital
set 1:3
forth
in
eal'R!!l'Ml"1m of tn'
0 pItie'
Hien §!9
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. IS rule. • ",,6 the require... en t,!p
s er 'exem
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(2) PAS/ID
must be completed
and submitted to the PASSPORT administl'ntive
of job tlfid family' services (ODJFS)
designee, via a JFS 03622 'P/'.••
SRR (S}'HlMRDD) Identification Screen' (rcv.
11/09) with supporting aocnmentation
s~lffieient to yulidate the nnuwen; on
the JFS 03622.
agenc), (PA.A). the Ghio department
(a)
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iff 93697
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' of eare
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tire individuai,::;'''6ti",a,
Cod. to o~;::~..eanoe
will; mi.
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' 'viduals who WIn, "'0''11 to Irave
'!IS iff~ieatiflfls ?
(b) For these
residefits, a!!" !lfeJs 03622 lorm een~~ffiit with the JI'S
are fi.'
; 'RDD
or ",ha,e
'Ill """lit lffi""
"alHaiianEsJ al
(8MI) undo'01 ~~JI.U the sllbmltter ~IL _',
level Iwa e, _, to allilre"
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03697 to"", t e ~dee •••n""",,,a. lleee:~"2 n (J3 .Ha
03622, 'fie
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~forms and infoRllution
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docs, not con:jhlute
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completion
of the PAS/ID
, (" fi",I" in l'weordanee "rilli
'R EI ", flew admls,ilO
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',. those individuals iElentl e .a,5 :\~\ of the Administr~lti\:e, ~ode \\r 10
(6) I'e!
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h (8)(17) of rule 5101.3.' .,
h PAS,1D W Ifllhaled, tfie
p~fa-;;:':rfC"iee in the facility fit tfie ~'.:'e .:: of ,He meElieai. ,te'", 61
a Teu ,J ' .. 5, (" "
'v ODlFS or Its ('C.,lg, _' '
~lUhmlttel mu"t nO.tIt. f tl () P /' S/ID SubmiStilon.
the facilitv at the tn11C0 L _y
(d) PASIIl)
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bv ' mu"
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e .,the mdivid
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" another
entit"J on
,) beholf
their
de,i"
of
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•Of _urine
o.ee"onS!
resp
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ua,I or0 by •any
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Of
ft!tt
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tile PAS.'I[), 13
.., completed
:' ,Ie
NF
sate rcspoflsihle
.gency Ol'
andi.t:e\'
11~ntUelY.
etermtnution I'S on
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f;)Q} ODIFSODM,
or its designee, shall review the .JFS 03622 form to determine
whether the individual has MRDD and/or indications of SMI.
(a) An individual
individual:
shall be determined
to have indications
of SMI if the
(i) Meets at least two of the three criteria specified in paragraph (B)(32)
of rule 5101:3-3-14 of the Administrative Code; or
(ii) Due to a mental impairment, receives supplemental security income
(SSI) authorized under Title XVI of the Social Security Act, as
amended; or
(iii) Due to a mental impairment, receives social security disability
insurance (SSDI) authorized under Title II of the Social Security
Act, as amended.
(b) An individual shall be determined to have indications of MRDD if the
individual's condition meets the defining criteria set forth in paragraph
(B)(16) of rule 5101:3-3-14 of the Administrative Code.
f41ill
PAS/ID results shall determine
review.
whether
an individual
is subject to further
(a) Individuals determined to have no indications of SMI and/or MRDD are
not subject to further PAS review. Such individuals are considered to
have met the PAS requirements effective on the date an accurate and
complete record was submitted to ODJFS ODM or its designee, even if
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the records were received at a later date.
(b) Individuals determined to have indications of SMI shall be subject to
further review by the Ohio department
of 111 ental health
(ODMHjODMHAS, in accordance with rule 5122-21-03 of the
Administrative Code. Such individuals shall not be considered to have
completed the PAS process until GUMliODMHAS has issued the
PAS/SMI determination.
(c) Individuals determined to have indications of MRDD shall be subject to
further review by the Ohio department of developmental disabilities
(DODD) in accordance with rule 5123:2-14-01 of the Administrative
Code. Such individuals shall not be considered to have completed the
PAS process until DODD has issued the PASIMRDD determination.
(d) Individuals determined to have indications of both SMI and MRDD shall
be subject to further review by both ODMHODMHAS and DODD in
accordance with rules 5122-21-03 and 5123:2-14-01 of the
Administrative Code. Such individuals shall not be considered to have
completed the PAS process until OD}V'EHODMHl\S has issued the
PAS/SMI determination and DODD has issued the PASIMRDD
determination.
(e) Any individual twenty-two years of age or older, who has previously been
determined by DODD to be ruled out from PAS as defmed in paragraph
(B)(31) of rule 5101:3-3-14 of the Administrative Code is not subject to
further review.
(-§[email protected] When an individual has been determined to have indications of SMI and/or
MRDD, ODJFSODM or its designee shall forward the JFS 03622 form and
all supporting documentation to:
(a) ODMHODMHAS and/or DODD for categorical and out of state requests.
In addition, for those individuals relocating from outside of Ohio,
ODlFS ODM or its designee shall also send the other state's evaluation
documentation to ODMHODMHAS and/or DODD.
(b) The county board of DD (CBDD) and/or the OD?vll-lODM.HAS local
evaluator, for all other requests.
f61ill GDJFS
ODM or its designee, GD.tvIHODMHAS and/or DODD are the only
entities that have the authority to render PAS determinations. The individual
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5101:3-3-15.1
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must not move into an Ohio NF until the PAS determination has been made.
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The receiving NFs are responsible for ensuring that all individuals subject to
PASIID receive a review and determination by ODJFSODM or its designee
and, if applicable,
a PAS/SMI
review and determination
by
ODMHODMHAS and/or a PASIMRDD review and determination by DODD
prior to entering the NF.
f8iQ1 NFs who, whether intentionally or otherwise, accept any new admission,
readmission, or NF transfer in violation of this rule are in violation of their
medicaid provider agreements. This is true regardless of the payment source
for the individual's NF stay.
(C) PAS/SMI and PASIMRDD determination requirements:
(1) There shall be no new admission of any individual with SMI or MRDD,
regardless of payment source, unless the individual has either been
determined, in accordance with rules 5122-21-03 and/or 5123:2-14-01 of the
Administrative Code, to need the level of services provided by a NF, or has
qualified for admission under the hospital exemption provision set forth in
paragraph (G) of this rule.
(2) PAS/SMI and/or PASIMRDD must be completed prior to any new admission of
an individual determined by OD:f>·lJIODMHASand/or DODD to have SMI
and/or MRDD.
(a) For all such individuals identified as new admissions under the provisions
of paragraph (B)~QQl
of rule 5101:3-3-14 of the Administrative
Code, and regardless of payment source, the PAS/SMI and/or the
PASIMRDD determination requirements must be met before the
individual is admitted to any NF or facility in the process of obtaining
its initial medicaid certification and NF provider agreement. Individuals
determined not to need NF services shall not be admitted or enrolled
and medicaid payment will not be available for NF services.
(b) For all such individuals identified as new admissions under the provisions
of paragraph (B)fH7f.l6l(c) of rule 5101:3-3-14 of the Administrative
Code who are current residents of the facility, the PAS/SMI and/or the
PAS/MRDD requirements must be met prior to the effective date of the
NF provider agreement between ODJFS ODM and the newly certified
NF and/or prior to the availability of medicaid payment for the
medicaid eligible individual.
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5101:3-3-15.1
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(3) ODMTIODMHAS and DODD are prohibited from utilizing criteria relating to
the need for NF care or specialized services that are inconsistent with C.F.R.
483.108 and the ODJFSODM approved state plan for medicaid. The
approved state plan for medicaid includes level of care criteria, contained in
Chapter 5101:3-3 of the Administrative Code. Therefore, OD~lHODMHAS
and DODD must use criteria consistent with Chapter 5101:3-3 of the
Administrative Code in making their determinations regarding whether
individuals with SMI and/or MRDD need the level of services provided by a
NF.
(D) PAS/ID, PAS/SMI, and PASIMRDD requests for additional information:
(1) ODJFS ODM or its designee, ODMHODMRA..S and/or DODD may request any
additional information required in order to make an PAS determination.
(2) If ODJFS ODM or its designee, ODMHODMHAS and/or DODD require
additional information in order to make the PAS determination they shall
provide written notice to the NF, the individual, the hospital, the referring
entity, and the individual's representative, if applicable. This notice shall
specify the missing forms, data elements and other documentation needed to
make the required determinations.
(3) In the event the individual and/or other entity does not provide the necessary
information within fourteen calendar days, 9DlFS ODM or its designee,
OmvfnODMHAS and/or DODD shall provide written notice to the
individual, the individual's guardian or authorized representative, if
applicable, and the NF that the admission is prohibited due to failure to
provide information necessary for the completion of the PAS process and that
the individual may appeal the determination in accordance with the
provisions of division 5101:6 of the Administrative Code. The individual,
regardless of payment source, must not be admitted to the NF.
(4) If the individual was seeking medicaid coverage of the proposed NF stay, the
county department of job and family services (CDJFS) must also be notified
that the individual is not eligible for the admission due to failure to cooperate
in the establishment of eligibility.
(5) If the individual or other entity submits the requested information within the
timeframes specified in the notice, ODJFS ODM or its designee, or DODD
and/or ODMHODMHAS shall continue with the PAS process.
(E) PAS/ID, PAS/SMI, and PASIMRDD notification:
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(1) In accordance with all requirements specified in rule 5101:6-2-32 of the
Administrative Code, ODJfSODM, or its designee, shall report the outcome
of the PASIID to the individual, their guardian, or authorized representative
(if applicable) and to the entity which initiated the review, and the applicable
state department(s) who receive the JFS 03622 and JFS 03697 (if applicable).
(2) The admitting NF shall maintain the results of the PASIID in the individual's
resident record at the facility.
(3) In accordance with all requirements specified in rule 5101:6-2-32 of the
Administrative Code, DODD and/or ODMHODMHAS must provide written
notice of the PAS-MRDD and/or PAS-SMI determination to the individual,
their legal guardian of person or authorized representative (if applicable), the
individual's physician and the facility. If the individual has applied for
medicaid payment of the NF stay, GDlFS ODM and if applicable, the CDJFS
and/or the medicaid managed care plan (MCP), must also be notified. If an
adverse determination is issued, the facility must then provide the individual,
regardless of payment source, with notice of the intent to discharge in
accordance with section 3721.16 of the Revised Code.
(4) The admitting NF shall retain the written notification of the PAS/SMI and/or
PASIMRDD determinations received from GDMHODMHAS and/or DODD
in the individual's resident record at the facility.
(F) An individual shall be required to undergo a new PAS/ID in accordance with the
provisions of this rule if:
(1) The individual received PAS/ID, PAS/SMI and/or PASIMRDD that NF services
are needed and has not been admitted to a NF within one hundred eighty days
for the most recent PAS determination that does not meet the definition in
paragraph (B)(3) of rule 5101:3-3-14 of the Administrative Code;
(2) The individual received PAS/SMI and/or PASIMRDD that NF services are
needed and has not been admitted to a NF within the time period specified by
GDMHODMHAS or DODD for a PAS that meets the definition of paragraph
(B)(3) of rule 5101:3-3-14 of the Administrative Code.
(G) Criteria for a Hospital (convaleseent)hospital exemption, as defined in rule
5101:3-3-14 of the Administrative Code. from PAS reouiremenh
(1) An individual is to be admitted or enrolled directly from an Ohio hospital or a
till}t of a hospital that is not operated by or I.icensed bv ODMHAS under
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5101:3-3-15.1
section 5119:14 or section 5119.33 of the Revised Code. after receiving acute
inpatient care at that hospital or is an Ohio resident being admitted or enrolled
directly from an out-of-state hospital after receiving acute inpatient care at the
hospital: and
(2) The individual
requires the level of services provided
which was treated in the hospital; and
(3) The individual's
attending
physician
has provided
by a NF for the condition
written certification,
si2:ned
and dated no later tban the date of discharge from the hospita1. stating that the
individual is likely to require the level of services provided by a NF for less
than thirty days.
(l) The difjcilRrging hospital must complete the hospitni (convule:Jcent) exemption
from preadmission screening notification form OF'S 07(00) (11/09). The ferm
must be signed and dated by the attending physician no later than the date of
discharge from the hospitul certifying that all of the hospital (eom'uleseent)
exemption criteria os defined in pnrugraph (B)(9) of rule 5101:3 3 14 ofthe
Administn~tive Code huve been met.
(2) The dischurging hospital must send the completed
frDol"ooriate Pi\.'\:.
fOFm to tho ndmitting NF and
. dg9)
es of
thatrule
all
acknowle
ofetthe
(B)(
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pla~emen
us
delineated the:NF
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NF shull maintain the documentation
in the resident's
record at
the f/lei I itv.
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(6) The PAA shall send n copy of the form to ODME and/or DODD if the
individual hus svmotoms of 81••.11andlor a dia2:nosis of MRDD.
(7) If
0:11 individual admitted to u NJt4ta.Uer the hOLlpital (convalescent)
exemption is
admitted to n hospital Of tn-;.nsfers to 8:11otherHF during the tlrst thirty days of
their NF Gta)" the days in the hOGpital or previous Pili' \vill count to\-vardtheir
thirty day hospital (eoflvaleclcent) exemption time period. A new hospital
exemption shall not be granted during the existing exemption time period. A
resident revie;.,,- ERR) shall bc initiated by theN¥' in acoordanoe with rule
5101:3 3 15.2 of the i\dministrative Code if the individual requires a
continued NF stav bevolld thirtv davs.
(8) If /ln adverse
detem1ination
of either a PA8/S1vlL PAS,'IvIRDD.
RR/SMT or
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RR/:;\lRDD determination has been issued by ODf'vlH or DODD v;ithin the
lant ~,ixty calendar days prior to the no' •••· admi:;;jion or enrollment the
individual is Hot eligible for u h03pitul cxcmptien and a PAS 10 r;hall be
initintAc1 in nf'f'AnlHl1Cc \,<'ith nflmrrmnh n~)(2) ofthiR rule
(H) Process for a hospital exemption.
(1) The discharging
hospital must complete the
"Hospital Exemption from Preadmission
equivalent approved by ODM. The JFS 07000
the attending physician no later than the date of
JFS 07000 (rev. 1112010),
Screening Notification" or
must be signed and dated bv
discharge from the hospitaL
(2) The discharging hospital must send the completed IFS 07000 to the admitting
NF and appropriate PAA.
(3)
When the NF accepts the placement of the individual, the NF acknowledges that
all three exemption criteria are met as described in paragraph (0) 0[th1S rule.
(4) The admitting NF shall maintain the documentation in the resident's record at
the facility.
(5) The NF shall initiate the resident review process, as specified in rule
5101:3-3-15.2 of the AdministTative Code, prior to the individual's thirtieth
day in the facility.
(6) The PAA shall send a copy of the JFS 07000 to ODMHAS and/or DODD if the
individual has symptoms of SMI and/or a diagnosis ofMRDD.
(7) When an individual admitted to a NF lmder the hospital exemption is admitted
to a hospital or transfers to another NF during the first thirty days of their NF
stay, the days in the hospital or previous NF will count toward their thirtv day
hospital exemption time period. A new hospital exemption shall not be
granted during the existing exemption time period. A resident review (RR)
shall be initiated by the NF in accordance with rule 5101:3-3-15.2 of the
Administrative rode if the individual requires a continued NF stay bevond
thirty davs.
(8)
tH7ill
When an adverse detemlination of either a PAS/SMI, PAS/MRDD, RRISMI or
RR/MRDD determination has been issued by ODMHAS or DODD within the
last sixty calendar days prior to the new admission or enrollment. the
individual is not eligible for a hospital exemption and a PAS 10 shall be
initiated in accordance with paragraph (B)(1) of this rule.
Medicaid payment is not available for NF stays to individuals who are otherwise
medicaid-eligible until the date on which the PAS requirements have been met.
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~ill Adverse PAS determinations may be appealed in accordance with division 5101:6
of the Administrative Code.
f::B(K) ODJFSODM has authority to assure compliance with the provisions of this rule.
NF's, local administrators, hospitals and all state agencies and their designees shall
comply, with accuracy and timeliness, to all requests for records and compliance
plans issued by ODJFSODM or its designees.