Okla. Admin. Code § 340:100-15-1

Current through Vol. 42, No. 7, December 16, 2024

Section 340:100-15-1 - Nursing facility services for members with intellectual disability or related condition

(a) The purpose of this Subchapter is to provide criteria by which Oklahoma Human Services, Developmental Disabilities Services, hereafter referred to as the Intellectual Disabilities (ID) Authority, determines the need for nursing facility services in contrast to other services and the need for specialized services for individuals with intellectual disabilities or related conditions. The provisions of this Subchapter apply to all Medicaid certified nursing facilities and to departmental staff responsible for evaluating individuals suspected of having intellectual disabilities or related conditions receiving or seeking to receive services in Medicaid certified nursing facilities.

(b) In order for the determination to be made that an individual with intellectual disabilities or related conditions needs services only available in a nursing facility but does not need specialized services, the individual must:

(1) require licensed nursing interventions at least once daily or require licensed nursing monitoring and observation on a frequent basis daily for maintenance of health or basic life support; and

(2) meets meet one or more of the following:

(A) be in a comatose state;

(B) require convalescent care;

(C) have a terminal illness;

(D) be at least 65 years of age, unless similar aging process characteristics are evident at age 50; or

(E) have a serious medical condition which requires on-going medical care and licensed nursing intervention services monitoring or observation. These conditions include but are not limited to:

(i) neurological disorders or malformations which includes muscle wasting diseases that are progressive, dementias, hydrocephalus, meningomyelocele, brain damage secondary to birth trauma, anoxia, cardiac arrest or other causes of cerebral anoxia that are severe enough to induce a comatose state. Cerebral or peripheral nerve damage secondary to central nervous system infection or trauma or other disorders or malfunctions inconsistent with normal functioning;

(ii) pulmonary disorder, with either congenital or acquired pulmonary disorders that leave the individual unable to adequately oxygenate, therefore, requiring respiratory support;

(iii) cardiac dysfunction or malformation which includes individuals with either congenital or acquired heart disease such as myocarditis, that are in persistent or intractable heart failure, have cardiac rhythms that are life threatening, are persistently cyanotic enough to require supplemental oxygen to survive or are otherwise liable to cardiac arrest, either primarily or secondarily. These individuals are identified by a physician as being unable to survive unless immediate skilled medical and nursing intervention is available;

(iv) circulatory dysfunction which includes individuals with either hypotension or hypertension with a central or unknown etiology that require frequent licensed nursing intervention or monitoring and medication or stimulation. It also includes individuals whose orthopedic or postural malformations require meticulous skin care;

(v) endocrine or metabolic disorder which includes individuals with hypothyroidism or hyperthyroidism, or diabetes with its associated problems including, but not limited to, circulation, skin care, infection, etc., aminoaciduria with secondary intellectual disabilities, glycogen storage disease or other abnormalities of lipid metabolism, and other genetic disorders limiting normal metabolism;

(vi) gastrointestinal disorder or malfunction which includes individuals with primary or secondary disorders of absorption of normal nutrients and vitamins that do not allow adequate calorie sustenance without supplementation by artificial means, those with congenital malformations of the gastrointestinal tract that require, despite surgical intervention, continuing supplementation with special diets and those whose nutritional requirements cannot be met without intravenous supplementation; or

(vii) renal and bladder dysfunction or malformation which includes individuals with severe polycystic kidney disease, hydronephrosis, those with kidney failure secondary to either congenital malformation, trauma or infection requiring frequent intravenous supplementation, and those in whom kidney or bladder malformations require surgical externalization with need for significant nursing and other management.

(c) The individual must be determined by the ID Authority to be unable to benefit from specialized service for intellectual disabilities or related conditions.

(d) It remains the responsibility of the nursing facility to provide services to improve the physical, mental, and psychosocial development of the individual.

(e) In order for the disposition to be made that an individual with intellectual disabilities or related conditions requires nursing facility services and specialized services, the individual must:

(1) meet the requirements in (b) of this Section; and

(2) be determined by the ID Authority to be able to benefit from specialized services for intellectual disabilities or related conditions.

(f) In order for the disposition to be made that an individual with intellectual disabilities or related conditions does not need nursing facility services but does need specialized services the individual must;

(1) be able to benefit from a program of specialized services for intellectual disabilities or related conditions, and

(2) not meet the criteria for nursing facility services identified in Oklahoma Administrative Code (OAC) 340:100-15-3.

(g) Long term residents meeting the criteria listed in (a) of this Section are offered a choice of remaining in the facility or of receiving services in an alternative appropriate setting.

(h) Short term residents meeting the criteria listed in (a) of this Section may not be considered appropriate for continued placement and must be discharged.

(i) The ID Authority does not make advance categorical dispositions that specialized services are needed. Such determinations are based on an extensive individualized evaluation to determine the exact nature of the specialized services that are needed. The ID Authority does make categorical determinations that nursing facility level of care is needed in the categories listed in (1) and (2) of this subsection.

(1) Individuals with a terminal illness as defined for hospice purposes are granted a categorical determination for nursing facility level of care and a negative specialized services determination by the ID Authority. Hospice criteria include late stage disease process with a life expectancy of six months or less and must be physician referred and certified.

(2) Individuals requiring convalescent care or extended hospital discharge as certified by a physician that are likely to require 30-calendar days are granted a categorical determination for nursing facility level of care and a negative specialized services determination by the ID Authority.

(j) Each individual has a unique prescriptive plan of specialized services based on professional assessments. The plan addresses identified needs and enhancement of independence. Assessments address self-care skills, communication skills, motor and mobility skills, and educational, recreational and leisure skills. The plan includes:

(1) behavioral objectives stated in measurable terms directed at skill acquisition;

(2) identification of additional services and supports necessary for skill acquisition to occur such as:

(A) adaptive, corrective, orthotic, mobility, and other types of equipment and devices;

(B) specific nursing care plan objectives relative to significant medical condition;

(C) Identification of persons responsible for service needs external to the facility such as vocational services or counseling; and

(3) specific methods, strategies, or steps relative to the behavioral objectives to ensure consistency of training;

(4) identification of persons responsible for training, obtaining and maintaining equipment, and providing health related services; and

(5) methods of data collection.

(k) The plan must be monitored by a designated nursing facility staff member on a monthly basis to ensure that training of behavioral objectives is occurring in a consistent manner and progress is being shown, necessary equipment is available and in good repair, all significant health issues are being addressed, and necessary modifications to the plan occur as needed.

(l) For individuals with both an intellectual disability or related condition and mental illness, individuals with dual diagnoses, a joint disposition is required from the ID Authority and Mental Illness Authorities. The Mental Illness Authority is administered through the Oklahoma Department of Mental Health and Substance Abuse Services. This disposition is based on independent assessment information from both authorities. The disposition determines which authority assumes responsibility for serving the individual or if the individual is served by both.

(m) Any individual believed to have been adversely affected by a preadmission screening and resident review disposition made in the context of either a preadmission screening or a resident review may appeal that disposition consistent with OAC 317:35-19-16.

(1) Special case determinations may be required for individuals with intellectual disabilities or a related condition(s) who would benefit from nursing facility level of care due to unusual circumstances other than medical needs.

(2) To make a special case determination ID Authority staff must:

(A) consider all factors including:

(i) the individual circumstances presented;

(ii) the individual's mental and emotional support needs;

(iii) all available assessment information;

(iv) any other relevant information; and

(v) availability of other formal and informal supports; and

(B) provide written specific rationale in support of the exception noting the unique and individualized circumstances of the case.

Okla. Admin. Code § 340:100-15-1

Added at 11 Ok Reg 4119, eff 6-21-94 (emergency); Added at 12 Ok Reg 1761, eff 6-12-95

Amended by Oklahoma Register, Volume 40, Issue 22, August 1, 2023, eff. 9/15/2023