La. Admin. Code tit. 50 § II-10156

Current through Register Vol. 50, No. 11, November 20, 2024

Section II-10156 - Level of Care Pathways

A. Several potential avenues of functional and medical eligibility shall be investigated by OAAS. These avenues are called pathways. The pathways are utilized to ensure consistency, uniformity, and reliability in making nursing facility level of care determinations. In order to meet the nursing facility level of care, an individual must meet eligibility requirements in only one pathway.

B. When specific eligibility criteria are met within a pathway, that pathway is said to have triggered. The Medicaid program defines nursing facility level of care for Medicaid eligible individuals as the care required by individuals who meet or trigger any one of the established level of care pathways described in this Subchapter. The pathways of eligibility focus on information used to determine if an individual has met or triggered a level of care pathway. When a pathway is triggered, that individual may be approved for a limited stay/length of service as deemed appropriate by OAAS.

C. The level of care pathways elicit specific information, within a specified time period, regarding the individual's:

1. functional capabilities;

2. receipt of assistance with activities of daily living (ADL);

3. current medical treatments and conditions; and

4. other aspects of an individual's life.

D. Activities of Daily Living Pathway

1. The intent of this pathway is to determine the individual's self-care performance in activities of daily living during a specified look-back period (e.g., the last seven days, last three days, etc. from the date the LOC assessment was completed), as specified in prescribed screening and assessment tools.

2. The ADL Pathway i dentifies those individuals with a significant loss of independent function measured by the amount of assistance received from another person in the period just prior to the day the LOC assessment was completed.

3. The ADLs for which the LOC assessment elicits information include but are not limited to:

a. locomotion-how the individual moved around in his or her home;

b. dressing-how the individual dressed/undressed;

c. eating-how the individual ate or consumed food (this does not include meal preparation);

d. bed mobility-how the individual moved around while in bed;

e. transferring-how the individual moved from one surface to another (this excludes getting on and off of the toilet and getting in and out of the tub/shower);

f. toileting-how the individual got on and off the toilet (toilet transfer), wiped, arranged clothes, etc.;

g. personal hygiene-how the individual managed personal hygiene (this excludes baths/showers); and

h. bathing-how the individual took a full-body bath or shower (this excludes washing of hair and back).

4. Since an individual can vary in ADL performance from day to day, OAAS trained assessors shall capture the total picture of ADL performance over the specified time period.

5. In order for an individual to be approved under the ADL Pathway, the individual must score at the:

a. limited assistance level or greater on toileting, transferring, or bed mobility; or

b. extensive assistance level or greater on eating.

E. Cognitive Performance Pathway.

1. This pathway identifies individuals with the following cognitive difficulties:

a. short-term memory which determines the individual's functional capacity to remember recent events;

b. cognitive skills for daily decision making which determines the individual's actual performance in making everyday decisions about tasks or activities of daily living such as:

i. planning how to spend their day;

ii. choosing what to wear;

iii. knowing when to eat;

iv. knowing and using space in home appropriately;

v. using awareness of one's own strengths and limitations to ask for help when needed;

vi. using environmental cues to organize and plan the day;

vii. making prudent decisions regarding how and when to go places; and

viii. using canes/walkers or other assistive devices/equipment reliably.

c. making self understood which determines the individual's ability to express or communicate requests, needs, opinions, urgent problems, and social conversation, whether in speech, writing, sign language, or a combination of these (includes use of word board or keyboard).

2. In order for an individual to be approved under the cognitive performance pathway, the individual must have any one of the conditions noted below:

a. severely impaired or greater impairment in daily decision making (e.g., never or rarely makes decisions);

b. have a short-term memory problem and moderately impaired in daily decision making (e.g., the individual's decisions are consistently poor or unsafe, and cues or supervision are required at all times);

c. have a short-term memory problem and the individual is sometimes understood (e.g., the individual's ability is limited to making concrete requests) or is rarely or never understood;

d. moderately impaired in daily decision making and the individual is often understood (e.g., the individual has difficulty finding words or finishing thoughts, and prompting is usually required);

e. moderately impaired in daily decision making and the individual is sometimes understood (e.g., the individual's ability is limited to making concrete requests) or is rarely or never understood; or

f. minimally impaired in daily decision making (e.g., his/her decisions are poor or unsafe in specific situations, and cues or supervision are needed) and the individual is sometimes understood, (e.g., the individual's ability is limited to making concrete requests) or is rarely or never understood;

g. - i. Repealed.

F. Physician Involvement Pathway

1. The intent of this pathway is to identify individuals with unstable medical conditions that may be affecting his/her ability to care for himself/herself.

2. The following are investigated for this pathway:

a. physician visits occurring during the 14-day look-back period (excluding emergency room exams); and

b. physician orders issued during the 14-day look-back period (excluding order renewals without change and hospital inpatient visits).

3. In order for an individual to be approved under the physician involvement pathway, the individual must have:

a. one day of doctor visits and at least 4 new order changes within the 14-day look-back period; or

b. at least 2 days of doctor visits and at least 2 new order changes during the 14-day look-back period.

i. - iii. Repealed.

4. Supporting documentation is required and must include:

a. a copy of the physicians orders; or

b. the home health care plans, or other medical provider documentation documenting the diagnosis, treatments, and conditions within the designated time frames; or

c. the appropriate form designated by OAAS to document the individuals medical status and condition.

G. Treatments and Conditions Pathway

1. The intent of this pathway is to identify individuals with unstable medical conditions that may be affecting a persons ability to care for himself/herself.

a. - h. Repealed.

2. The following are investigated for this pathway:

a. stage 3-4 pressure sores during the 14-day look-back period;

b. intravenous feedings during the 7-day look-back period;

i. - iii. Repealed.

c. intravenous medications during the 14-day look-back period;

d. daily tracheostomy care and ventilator/respiratory suctioning during the 14-day look-back period;

e. pneumonia during the 14-day look-back period and the individual had associated need for assistance with IADLs, ADLs, or restorative nursing care;

f. daily respiratory therapy provided by a qualified professional during the 14-day look-back period;

g. daily insulin injections with two or more order changes during the 14-day look-back period; or

h. peritoneal or hemodialysis during the 14-day look-back period.

3. In order for an individual to be approved under the treatments and conditions pathway, the individual must have:

a. any one of the conditions listed in G.2.a-h above; and

b. supporting documentation for the specific condition(s) identified. Acceptable documentation must include:

i. a copy of the physicians orders; or

ii. the home health care plans, or other medical provider documentation documenting the diagnosis, treatments and conditions within the designated time frames; or

iii. the appropriate form designated by OAAS to document the individuals medical status and condition.

4. Repealed.

H. Skilled Rehabilitation Therapies Pathway

1. The intent of this pathway is to identify individuals who have received, or are scheduled to receive physical therapy, occupational therapy or speech therapy.

2. In order for an individual to be approved under this pathway, the individual must:

a. have received at least 45 minutes of active physical therapy, occupational therapy, and/or speech therapy during the seven-day look-back period; or

b. be scheduled to receive at least 45 minutes of active physical therapy, occupational therapy, and/or speech therapy scheduled during the seven-day look-forward period.

i. - v. Repealed.

3. Supporting documentation of the therapy received/scheduled during the look-back/look-forward period is required and must include:

a. a copy of the physicians orders for the received/scheduled therapy;

b. the home health care plan notes indicating the received/scheduled therapy;

c. progress notes indicating the physical, occupational, and/or speech therapy received;

d. nursing facility or hospital discharge plans indicating the therapy received/scheduled; or

e. the appropriate form designated by OAAS to document the individuals medical status and condition.

4. Repealed.

I. Behavior Pathway

1. Effective upon promulgation of this Rule, the behavior pathway will be eliminated as a pathway for meeting nursing facility level of care.

2. Individuals receiving services who met the nursing facility level of care only by triggering the behavior pathway prior to promulgation of this Rule shall continue to remain eligible for services requiring nursing facility level of care until:

a. the individual is discharged from long term care services; or

b. the individual has been found eligible for services in another program or setting more appropriate to their needs.

J. Service Dependency Pathway

1. The intent of this pathway is to identify individuals who are currently in a nursing facility or receiving services through the Adult Day Health Care Waiver, the Community Choices Waiver, Program of All Inclusive Care for the Elderly (PACE) or receiving long-term personal care services.

2. In order for individuals to be approved under this pathway, the afore-mentioned services must have been approved prior to December 1, 2006 and ongoing services are required in order for the individual to maintain current functional status.

3. There must have been no break in services during this time period.

La. Admin. Code tit. 50, § II-10156

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Aging and Adult Services, LR 37:342 (January 2011), amended LR 39:1471 (June 2013), Amended LR 39:1471 (June 2013), LR 411289 (7/1/2015), Amended by the Department of Health, Bureau of Health Services Financing and the Office of Aging and Adult Services, LR 432187 (11/1/2017), Amended LR 441019 (6/1/2018), Amended by the Department of Health, Bureau of Health Services Financing and the Office of Aging and Adult Services, LR 482130 (8/1/2022).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.