La. Admin. Code tit. 50 § XXI-8107

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

Section XXI-8107 - Resource Assessment and Allocation Process

A. Each Community Choices Waiver applicant/participant shall be assessed using the uniform international resident assessment instrument (interRAI). This assessment provides researched and validated measures of an individual's functional status. The assessment is used to verify if an individual meets nursing facility level of care and generates a resource utilization group (RUG) score. This score is used to establish an individual's services and supports budget.

B. The RUG score assigns an individual to one of 23 distinct groups in seven major groupings. Individuals are assigned to a group based on a hierarchy and are assigned to the highest group for which they qualify. The following seven major groupings will be utilized to determine the waiver assistance needed to complete various activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

1. Special Rehabilitation. Individuals in this group had at least 120 minutes of rehabilitation therapy (physical, occupational and/or speech) within the seven days prior to the interRAI assessment.

2. Extensive Services. Individuals in this group received one or more of the following services and have an ADL index of 7 or more:

a. tracheostomy;

b. ventilator or respirator;

c. suctioning;

d. parenteral/IV feeding only;

e. combined oral and parenteral/tube feeding; or

f. IV medications.

3. Special Care. Individuals in this group must meet one of the following criteria:

a. have one of the following conditions or treatments and have an ADL index of 7 or greater:

i. stage 3 or 4 pressure ulcers and turning/positioning program;

ii. combined oral and parenteral/tube feeding or nasogastric feeding only and aphasia;

iii. fever with either vomiting, weight loss, dehydration, nasogastric tube or parenteral feeding, or pneumonia; or

iv. radiation therapy; or

b. have one of the following conditions and have an ADL index of 10 or greater:

i. cerebral palsy;

ii. multiple sclerosis;

iii. quadriplegia; or

c. are receiving one of the extensive care services (as listed in B.2 above)and have an ADL index of 6 or less.

d. - h.iv. Repealed.

4. Clinically Complex. Individuals in this group have one of the following conditions or treatments:

a. septicemia;

b. dehydration;

c. hemiplegia and an ADL index of 10 or greater;

d. pneumonia;

e. end-stage disease;

f. comatose (confirmed by totally dependent in the four ADLs used in the ADL index);

g. foot problems that limit/prevent walking;

h. gastrointestinal (GI) or genitourinary (GU) bleeding;

i. diabetes;

j. combined oral and parenteral/tube feeding or nasogastric tube feeding only;

k. chemotherapy;

l. dialysis;

m. transfusions;

n. oxygen therapy; or

o. one of the special care conditions or treatments listed in 3.a above and an ADL index of 6 or less.

5. Impaired Cognition. Individuals in this group have a cognitive performance scale of 3 or more and an ADL index of 10 or less.

6. Behavior Problems. Individuals in this group have one or more of the following behavior problems and an ADL index of 10 or less:

a. wandering;

b. verbally abusive;

c. physically abusive;

d. socially inappropriate/disruptive;

e. resists care;

f. sexually inappropriate;

g. hallucinations; or

h. delusions.

7. Physical Function. Individuals who did not meet the criteria for any of the previous categories.

C. Based on the RUG score, the applicant/participant is assigned to one of the distinct groups and is eligible for a set annual services budget associated with that group.

1. If the applicant/participant disagrees with their annual services budget, they or their responsible representative may request a fair hearing to appeal the decision.

2. The applicant/participant may qualify for an increase in the annual services budget amount upon showing that:

a. one or more responses on the assessment are recorded incorrectly (except for the responses in the identification information, personal intake and initial history, assessment date and reason, and/or signature sections); or

b. they need an increase in the annual services budget to avoid entering into a nursing facility.

D. Each Community Choices Waiver participant shall be re-assessed at least annually.

La. Admin. Code tit. 50, § XXI-8107

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Aging and Adult Services, LR 37:3518 (December 2011), Amended by the Department of Health, Bureau of Health Services Financing and the Office of Aging and Adult Services, LR 441896 (10/1/2018), Amended LR 491068 (6/1/2023).

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