210 R.I. Code R. 210-RICR-50-00-5.6

Current through December 3, 2024

Section 210-RICR-50-00-5.6 - Nursing Facility (NF) Needs-based Level of Care Determinations

5.6.1Overview

Under Rhode Island law, any health care institution licensed as a NF and certified for Medicare and Medicaid is authorized to provide skilled nursing and custodial care. Many facilities in the State also have the authority and capacity to offer subacute care, typically in the form of rehabilitation services, limited skilled nursing, and/or hospice care.

5.6.2NF Service Classifications

A. The NF service classifications are designed to provide service options that reflect the scope and intensity of the beneficiary's need for the level of care typically provided in a nursing facility.

1. Highest need -- Beneficiaries in this classification have access to all the Medicaid LTSS covered services they need at home, in the community, or in a nursing facility, in accordance with their plan of care.

2. High need -- Beneficiaries in the high classification have needs that can be met safely and effectively at home or in a community-based Medicaid certified LTSS setting such as an assisted living or shared living residence. Accordingly, these beneficiaries have access to the full array of State Plan and Section 1115 demonstration waiver home and community based services required to meet their needs as specified in the person-centered individual plan of care.

B. To determine the level of care and appropriate service classification, agency representatives review the materials provided from the sources identified in § 5.4 of this Part and, as appropriate, the most current Minimum Data Set (MDS) Tool for NF care. To make the final determination of care needs, the results of this review are mapped against the needs-based and institutional level of care criteria.

5.6.3Application of NF Needs-Based Criteria

A. The NF level of care determination focuses on health status and functional abilities as well as social and environmental factors and the availability of personal supports. The needs-based criteria reflect both best practices across the state and the prevailing standards of care within the LTSS community in Rhode Island.

1. Functional criteria [DOT]The functional disability criteria focus on the scope of a person's need for assistance with Activities of Daily Living (ADLs) such as bathing, toileting, dressing, transferring, ambulation, eating, personal hygiene, medication management, and bed mobility. To determine the scope of need, agency representatives consider the extent to which the level of assistance a person requires falls into one of the following categories:

a. Total dependence (All Action by Caregiver): The person does not participate in any part of the activity.

b. Extensive Assistance (Talk, Touch, & Lift): The person performs part of the activity, but caregiver provides physical assistance to lift, move, or shift individual.

c. Limited Assistance (Talk and Touch): The person is highly involved in the activity but receives physical guided assistance that does not require lifting of any part of him or her.

2. Health Status Criteria [DOT]The needs-based health status criteria for a NF level of care deal with cognitive, behavioral and physical impairments and chronic conditions that require extensive personal care and/or skilled nursing assessment, monitoring and treatment on daily basis.

B. Persons with highest need for a NF level of care have the choice of obtaining services in a NF or HCBS setting.

1. Needs-based criteria [DOT] A person is determined to have highest need when the results of the functional/clinical assessment indicate he or she:

a. Requires extensive assistance or total dependence with at least one of four specific ADLs [DOT] toileting, bed mobility, eating, or transferring and limited assistance with at least one other ADL; or

b. Has one (1) or more unstable medical, behavioral, cognitive, psychiatric or chronic recurring conditions requiring nursing assistance, care and supervision daily; or

c. Lacks awareness of needs or has a moderate impairment with decision-making skills AND has one (1) of the following symptoms/conditions, which occurs frequently and is not easily altered: wandering, verbally aggressive behavior, resisting care, physically aggressive behavior, or behavioral symptoms requiring extensive supervision; or

d. Requires skilled nursing assessment, monitoring, and care daily for at least one of the following conditions or treatments: Stage 3 or 4 skin ulcers, ventilator, respirator, IV medications, naso-gastric tube feeding, end stage disease, parenteral feedings, 2nd or 3rd degree burns, suctioning, or gait evaluation and training; or

e. Requires skilled nursing assessment, monitoring, and care on a daily basis for one or more unstable medical, behavioral or psychiatric conditions or chronic or reoccurring conditions related, but not limited to, at least one of the following: dehydration, internal bleeding, aphasia, transfusions, vomiting, wound care, quadriplegia, aspirations, chemotherapy, oxygen, septicemia, pneumonia, cerebral palsy, dialysis, respiratory therapy, multiple sclerosis, open lesions, tracheotomy, radiation therapy, gastric tube feeding, behavioral or psychiatric conditions that prevent recovery.

2. Exceptions -- Otherwise Medicaid LTSS-eligible persons who do not meet the needs-based criteria may be deemed to have the highest need for a NF level of care if an agency representative determines there is a critical need for Medicaid LTSS in a nursing facility due to special circumstances. These special circumstances must adversely affect the person's health and safety and be related to one of the following:

a. Loss of primary caregiver, due to hospitalization, debilitating illness, or death of a spouse, caretaker sibling, or adult child;

b. Loss of living situation, due to a fire, flood, foreclosure, or sale of principal residence as the result of the inability to afford to maintain housing;

c. A principal treating health care practitioner, or prior to ending an acute care hospital stay, a discharge planner indicates, based on a functional/clinical assessment, that the health and welfare of the applicant/beneficiary is at imminent risk if services are not provided or if services are discontinued;

d. The applicant/beneficiary met the highest NF level of care criteria on or before June 30, 2015 and chose to receive Medicaid LTSS at home or in a community-setting and the beneficiary reports he or she has experienced a failed placement that, if continued, may pose health or safety risks; or

e. The beneficiary was admitted to a hospital from a NF and is being discharged to the same or another NF upon discharge within any given forty (40) day period.

C. Persons with a high level of need for the NF level of care have a choice of HCBS service options but are restricted from receiving Medicaid LTSS in a NF.

1. Needs-based criteria -- Beneficiaries are deemed to have a high need for a NF level of care when one of the following is met:

a. Require at least limited assistance daily with at least two of the following ADLs: bathing/personal hygiene, dressing, eating, toilet use, walking or transferring; or

b. Require skilled teaching or rehabilitation daily to regain functional ability in at least one of the following: gait training, speech, range of motion, bowel or bladder control; or

c. Have impaired decision-making skills requiring constant or frequent direction to perform at least one of the following: bathing, dressing, eating, toilet use, transferring, or personal hygiene; or

d. Exhibit a need for a structured therapeutic environment, supportive interventions, and/or medical management to maintain health and safety.

2. Exceptions [DOT]

a. An LTSS applicant who is currently receiving non-LTSS Medicaid coverage may qualify for HCBS expedited eligibility as set forth in Part 50-00-1 of this Title pending completion of a full determination of level of care for a period of no more than ninety (90) days.

b. An applicant for Medicaid LTSS who is not a current beneficiary may qualify for HCBS expedited eligibility upon completion of a preliminary assessment by a treating health care practitioner indicating that absent immediate access to this limited package of services, the applicant must be admitted to a health care institution.

c. An LTSS applicant who is a current Medicaid beneficiary who has received expedited eligibility for a period of ninety (90) days may be deemed to meet the high level of care if:

(1) A full level of care of determination has not been completed by the end of the expedited eligibility period; and

(2) The applicant meets the financial eligibility requirements for an LTSS eligibility pathway identified in Subchapter 00 Part 1 of this Chapter; and

(3) The applicant's treating health care practitioner indicates that the discontinuation of HCBS will adversely affect the applicant's health and safety and/or require immediate admission into a NF or hospital.

5.6.4LTSS Preventive Services

LTSS Preventive Need. Beneficiaries who meet the needs-based criteria for the LTSS preventive level of care are eligible for a limited range of home and community-based services and supports along with the full range of IHCC group benefits they are entitled to receive. The goal of preventive services is to optimize health to delay or avert institutionalization or more extensive and intensive home and community-based care. Rules pertaining to the LTSS preventive level of need are located in Part 40-05-1 of this Title.

5.6.5Transitions to HCBS

Nursing facilities are required to refer to EOHHS any LTSS beneficiary who expresses a preference to obtain LTSS at home or in a community-based setting. Specifically, a Medicaid beneficiary is entitled to receive transition counseling if responding affirmatively to MDS Section Q, question 0500.This question asks whether the beneficiary wants to talk to someone about the possibility of leaving the facility and returning to live and receive services in the community. Agency representatives also pro-actively identify beneficiaries who may be interest in HCBS options. The team reviews functional and clinical data, including utilization, to identify possible candidates for a transition.

5.6.6Reassessment of NF Level of Care Needs

A. All Medicaid LTSS beneficiaries are re-assessed at set intervals after placement and at least annually to determine whether they are receiving the appropriate level of services in the most appropriate setting. A level of care re-evaluation is conducted when the findings of the reassessment indicate that the beneficiary's needs have changed to such an extent that more intensive or specialized service options may be required.

B. The reassessments for LTSS beneficiaries receiving the NF level of care proceed in accordance with the following:

1. Change in scope of need -- Beneficiaries determined to have a high need for a NF level of care at the time of an annual reassessment or an assessment done in conjunction with a change in health status are deemed to have the highest need if they meet any of the needs-based criteria established for highest need in §§5.6.2 and 5.6.3 of this Part.

2. Periodic reassessment of highest need [DOT] At the time a determination of highest need is made for a beneficiary who opts to reside in a nursing facility, agency representatives evaluate whether there is a possibility that the beneficiary's condition may improve within the succeeding two (2) month period. Based on this information, the agency representative notifies the beneficiary, any authorized representative(s) and the nursing facility, that NF care has been authorized and that the beneficiary's functional and health status will be re-evaluated in thirty (30) to sixty (60) days. At the time of reassessment, the LTSS eligibility specialist reviews all available information about clinical and functional status to determine whether a change in level of need and/or service options is required.

5.6.7Preadmission Screening/Resident Review (PASRR)

A. The PASRR is a federal requirement designed to: prevent the inappropriate placement of persons with serious mental or behavioral health conditions, intellectual disability or other developmental disability; and ensure that all NF applicants and residents regardless of payer source are identified, evaluated and determined to be appropriate for admission or continued stay and provided with specialized services (SS), if needed.

B. There are two levels to the PASRR:

1. Level I -- Completed prior to NF admission. The purpose is to identify: all NF applicants who possibly have developmental/ intellectual disabilities (DD/ID) and serious and persistent mental/behavioral health (MBH) conditions; and, on that basis, determine whether NF placement is appropriate and if Level II Preadmission Screening (PAS) (for specialized services) is warranted. An assessment to determine if NF placement if appropriate must be done in accordance with the criteria set forth in 42 C.F.R. 483.132(a).

a. In Rhode Island, BHDDH retains control and responsibility for PASRR, while certain PASRR responsibilities are delegated to EOHHS. For all persons seeking admission to a NF without regard to payer, an EOHHS agency representative completes the PASRR Level I determination based upon information submitted by appropriately licensed or certified health care providers who are qualified by knowledge and/or experience in working with this population. BHDDH conducts all PASRR Level II evaluations, in consultation with EOHHS.

2. Level II -- The purpose of Level II is to comprehensively evaluate the need for specialized services persons found to be appropriate for NF placement. There are two types of level II evaluations -- one for new applicants and one for resident reviews conducted on an "as needed" basis or when a person receiving specialized services experiences a change in condition --

a. Pre-Admission Screening Determination (PAS). The state agency responsible must determine if an applicant has a physical and/or behavioral health condition that requires the NF level of care and if the NF is required to provide any specialized services to meet needs identified on the PAS. PAS determinations must be made in writing within an annual average of seven (7) to nine (9) working days of referral. If the applicant is seeking readmission to the NF due to an exempt hospital discharge (convalescent stay) that subsequently requires more than thirty (30) days of a NF level of care, a PASRR resident review is used and the determination must be conducted within forty (40) days of admission.

b. Resident Review (RR). The State agency with PASRR authority for each NF resident must determine whether he or she continues to have the highest need for the level of services provided by a NF and whether or not specialized services authorized during the PAS should continue. Resident reviews for persons with ID/DD are conducted periodically and upon significant change; and for persons with MBH conditions when there is a significant change unless it is an exempted hospital discharge or other categorical determination.

C. Under federal law, PASRR responsibilities are delegated as follows:

1. EOHHS -- The Medicaid single state agency is responsible for the following:

a. Ensures that all requirements of federal law are met;

b. Develops written agreements with the BHDDH, in its role as a PASRR authority;

c. Assures that the PASRR authorities fulfill their statutory responsibilities;

d. Oversees NF compliance with any assigned PASRR functions established by the BHDDH in level II evaluations;

e Requires that no person be admitted to a Medicaid certified NF without a PASRR level I PAS;

f. Ensures any specialized services determined necessary in the PASRR evaluation process are made available;

g. Notifies the NF resident related of the outcome of the PASRR determination and indicates whether specialized services are needed, the placement options available to the person, and appeal rights (See 42 C.F.R. §§ 483.130(k), 483.130(l)).

h. Provides a system of appeals for persons affected by any PASRR determination; and

i. Withholds Medicaid payment for any person who is living with a developmental disability or serious mental/behavioral health condition who is admitted to a NF without PASRR Level II or who remains in a NF contrary to PASRR rules.

2. BHDDH -- As the State's mental health authority, BHDDH retains control and responsibility for PASRR and must make timely level II evaluations. In addition, BHDDH ensures that all PASRR level II findings are issued in the form of a written evaluative report which is provided to the applicant/resident and their legal guardian, the admitting or retaining NF, the attending physician and where applicable the discharging hospital of the applicant or resident; and arranges for the provision of specialized services when appropriate in the NF setting or alternative placement option.

3. Nursing facilities -- NFs are responsible for the maintenance of all PASSR forms within a person's record. In addition, to ensure documentation compliance, nursing facilities are required to maintain an active list of anyone within the PASRR MBH and DD/ID services. NFs must also:

a. Care planning. NFs must also consider the PASRR, other related assessments and treatment recommendations within the care planning process. During the resident's annual care planning process, the nursing facility must complete a full assessment and care plan update for anyone receiving PASRR-related services.

b. Immediate need. When there is a significant change in a resident's condition, a NF is required to initiate treatment to meet immediate needs and then begin a comprehensive reassessment. Treatment is geared to improvements when possible and prevention of avoidable decline, pending additional review and action by the State PASRR authorities. A comprehensive assessment must be completed by the 14th day after noting a significant change and the care plan must be revised accordingly within seven (7) days after its completion. The NF must also assure that any new or additional specialized services are provided pending a determination of whether a RR by the State is warranted during this twenty-one (21) day period.

c. Notice for Resident Review. If, upon completing an assessment and associated care plan update, the NF determines that a resident review is or might be necessary due to a significant change or other situation, the nursing facility must promptly provide LTSS clinical specialist and/or the BHDDH PASRR authority with proper written notification.

d. Interfacility Transfers. In cases of inter-facility transfers, the transferring NF is responsible for ensuring that PASRR evaluations accompany the resident when moved.

4. Specialized services for the NF population include:

a. Specialized Services for Behavioral Health Conditions

(1) Specialized services do not have to be provided by NFs. The term "Specialized Services" is equated with the level of care provided in psychiatric hospitals, or other intensive programs staffed with trained mental health professionals on a 24-hour/7-day basis. The patient's care follows the aggressive implementation of a treatment plan developed by an interdisciplinary team including a physician and other qualified mental health professionals and incorporates therapies supervised by these professionals. Treatment is aimed at diagnosing and reducing behavioral symptoms to improve the patient's level of functioning to a point that permits a reduction in intensity of services. While some of these services may be the same as those required to be provided by the nursing facility, it is the intensive level that sets these specialized services apart.

b. Specialized Services for Persons with Intellectual/Developmental Disabilities are provided in accordance with the following:

(1) Specialized services take the form of a continuous program of specialized and generic training, treatment, health care, and related services and supports that aggressively and consistently:

(AA) facilitates the acquisition of the behaviors necessary for the person to function with as much self-determination and independence as possible; and

(BB) promotes the prevention or deceleration of regression or loss of current optimal functional status. Specialized services do not include services to maintain generally independent beneficiaries who are able to function with little supervision or in the absence of a continuous specialized services program.

(2) BHDDH is responsible for the provision of specialized services that enhance the quality of life for persons with intellectual/developmental disabilities and maximize their potential for inclusion and participation in community life. The role of PASRR within this framework is to ensure and enhance the quality of care for persons with an I/DD who are residing in nursing facilities and to certify that a nursing facility is the most appropriate and least restrictive residential setting.

D. Exemptions to PASRR are identified in federal regulations at 42 C.F.R. §§ 483.100 through 483.138. In accordance with BHDDH's "advance group determination" wherein certain diagnoses and conditions that typically require NF admission are designated as exempt, the following classes are exempt from PASRR in Rhode Island: any person expected to be residing in a NF for less than thirty (30) days; any person in need of respite or emergency protective services; any person who has a terminal illness, severe or debilitating physical condition or illness, delirium, or dementia.

210 R.I. Code R. 210-RICR-50-00-5.6