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April 20, 2022, 07:35 EDT

Chapter 11: Appendix B: Nursing Facility Criteria for Services (NF)

The pre-admission screening process pre-authorizes a continuum of Long-Term-Care Services available to an individual under the Virginia Medical Assistance Program. Medicaid-funded Long-Term-Care Services may be provided in either a nursing facility or community-based care setting.

 

The criteria for assessing an individual’s eligibility for Medicaid payment of Nursing Facility Care consist of two components:

 

  1. Functional capacity [the degree of assistance an individual requires to complete activities of daily living (ADLs)]; and
  2. Medical or nursing needs.

In order to qualify for Medicaid payment for Nursing Facility Care, an individual must meet both functional capacity requirements and have a medical condition that requires ongoing medical or nursing management. An exception may be made when the individual does not meet the functional capacity requirement but does have a health condition that requires the daily direct services of a Licensed Nurse that cannot be managed on an outpatient basis.

The criteria for assessing an individual’s eligibility for Medicaid payment of Community- Based Care consist of three components:

 

  1. Functional capacity (the degree of assistance an individual requires to complete ADLs);
  2. Medical or nursing needs; and
  3. The individual’s risk of nursing home placement in the absence of Community- Based Waiver Services.

 

In order to qualify for either Medicaid-funded Nursing Facility Care or Community-Based Care, the individual must meet the same criteria.

 

Nursing facility pre-admission screening are performed by teams, composed of agencies contracting with the Department of Medical Assistance Services (DMAS), to authorize Medicaid funded long-term care. The authorization for Medicaid-funded long-term care must be rescinded by the nursing facility or community-based care provider or by DMAS at any point that the individual is determined to no longer meet the criteria for Medicaid-funded long-term care. Medicaid-funded Long-Term-Care Services are covered by the Program for individuals, whose needs meet the criteria established by program regulations. Authorization of appropriate Non- Institutional Services shall be evaluated before actual nursing facility placement is considered.

Prior to an individual’s admission, the nursing facility must review the completed pre-admission screening forms to ensure that appropriate nursing facility admission criteria has been documented. The nursing facility is also responsible for documenting, upon admission and on an ongoing basis, that the individual meets and continues to meet nursing facility criteria. For this purpose, the nursing facility will use the Minimum Data Set (MDS). The post-admission assessment must be conducted no later than 14 days after the date of admission and promptly after a significant change in the resident’s physical or mental condition. If at any time during the course of the resident’s stay, it is determined that the resident does not meet nursing facility criteria as defined in the Virginia State Plan for Medical Assistance, (12 VAC 30-60-300) the nursing facility must initiate the discharge of such a resident. Nursing facilities must conduct a comprehensive, accurate, standardized, and reproducible assessment of each resident’s functional capacity and medical and nursing needs.

DMAS will conduct surveys of the assessments completed by nursing facilities to determine whether services provided to the residents meet nursing facility criteria and whether needed services are provided.

The community-based provider is responsible for documenting, upon admission and on an ongoing basis, that the individual meets the criteria for Medicaid-funded long-term care.

The criteria for nursing facility level of care under the Virginia Medical Assistance Program are contained herein. An individual’s need for care must meet these criteria before any authorization for payment by Medicaid will be made for either Institutional or Non-Institutional Long-Term- Care Services. The Pre-admission Screening (PAS) Team is responsible for documenting, on the state-designated assessment instrument, that the individual meets the criteria for nursing facility or community-based waiver services and for authorizing admission to Medicaid-funded long- term care.

Part I Pre-Admission Screening for Nursing Facility Care

Functional dependency alone is not sufficient to demonstrate the need for nursing facility care or placement. Individuals, who require the daily direct services of a licensed nurse that cannot be managed on an outpatient basis, may meet the nursing facility criteria when both the functional capacity of the individual and his/her medical or nursing needs meet the following requirements. Even when an individual meets nursing facility criteria, placement in a non-institutional setting shall be evaluated before actual nursing facility placement is considered. Individuals must be offered the choice between institutional and non-institutional settings.

Functional Capacity

Functional capacity must be documented on the Uniform Assessment Instrument (UAI), completed in a manner consistent with the definitions of ADLs and directions provided by DMAS for the rating of those activities. Individuals may be considered to meet the functional capacity requirements for nursing facility care when one of the following describes their functional capacity:

 

  1. Rated dependent in two to four of the ADLs, and also rated semi-dependent or dependent in Behavior Pattern and Orientation, and semi-dependent in Joint Motion or dependent in Medication Administration (12 VAC 30-60-303).
  2. Rated dependent in five to seven of the ADLs, and also rated dependent in Mobility.
  3. Rated semi-dependent in two to seven of the ADLs, and also rated dependent in Mobility and Behavior Pattern and Orientation.

 

The rating of functional dependencies on the pre-admission screening assessment instrument must be based on the individual’s ability to function in a community environment, not including any institutionally induced dependence. The following abbreviations shall mean:

I = independent                                   MH = mechanical help

d = semi-dependent                            HH = human help D = dependent

 

(1)

Bathing

 

(2)

Dressing

 

 

(a)

Without help

(I)

 

(a)

Without help

(I)

 

(b)

MH only

(d)

 

(b)

MH only

(d)

 

(c)

HH only

(D)

 

(c)

HH only

(D)

 

(d)

MH and HH

(D)

 

(d)

MH and HH

(D)

 

(e)

Performed by others

(D)

 

(e)

Performed by others

(D)

 

 

 

 

 

(f)

Is not performed

(D)

 

 

 

 

(3)

Toileting

 

(4)

Transferring

 

 

(a)

Without help day or night

(I)

 

(a)

(b)

Without help MH only

(I)

(d)

 

(b)

MH only

(d)

 

(c)

HH only

(D)

 

(c)

HH only

(D)

 

(d)

MH and HH

(D)

 

(d)

MH and HH

(D)

 

(e)

Performed by others

(D)

 

(e)

Performed by others

(D)

 

(f)

Is not preformed

(D)

 

 

 

 

 

 

 

 

 

(5)

Bowel Function

 

(6)

Bladder Function

 

 

(a)

Continent

(I)

 

(a)

Continent

(I)

 

(b)

Incontinent less than weekly

(d)

 

(b)

Incontinent less than weekly

(d)

 

(c)

External/In- dwelling device/ Ostomy Self Care

(d)

 

(c)

External device, Self Care

(d)

 

(d)

Incontinent weekly or more

(D)

 

(d)

In-dwelling catheter, Self Care

(d)

 

(e)

Ostomy, not Self Care

(D)

 

(e)

(f)

Ostomy Self Care Incontinent, weekly or more

(d)

(D)

 

 

 

 

 

(g)

External device, not Self Care

(D)

 

 

 

 

 

(h)

In-dwelling catheter, not Self Care

(D)

 

 

 

 

 

(i)

Ostomy, not Self Care

(D)

 

 

 

 

(7)

Eating/Feeding

 

(8)

Behavior                     Pattern and Orientation

 

 

(a)

(b)

(c)

(d)

Without help MH only HH only MH and HH

(I)

(d)

(D)

(D)

 

(a)

Appropriate or Wandering/ Passive less than weekly + Oriented

(I)

 

(e)

(f)

(g)

Spoon fed

Syringe or tube fed

fed by I.V. or clysis

(D)

(D)

(D)

 

(b)

Appropriate or Wandering/Passive < weekly + Disoriented, Some Spheres

(I)

 

 

 

 

 

(c)

Wandering/Passive Weekly or more + Oriented

(I)

 

 

 

 

 

(d)

Appropriate or Wandering/Passive < weekly + Disoriented, All Spheres

(d)

 

 

 

 

 

(e)

Wandering/Passive weekly some or more + Disoriented, All Spheres

(d)

 

 

 

 

 

(f)

Abusive/Aggressive/ Disruptive < weekly + Oriented or Disoriented

(d)

 

 

 

 

 

(g)

Abusive/Aggressive/ Disruptive weekly or more + Oriented

(d)

 

 

 

 

 

(h)

Abusive/Aggressive/ Disruptive + Disoriented, All Spheres

(D)

 

(9)

Joint Motion (NF)

 

(10)

Mobility

 

 

(a)

(b)

(c)

(d)

(e)

Within normal limits Limited motion Instability, corrected Instability, uncorrected Immobility

(I)

(d)

(I)

(D)

(D)

 

(a)

Goes outside without

help

(I)

 

(b)

Goes outside, MH only

(d)

 

(c)

Goes outside, HH only

(D)

 

(d)

Goes outside, MH and HH

(D)

 

 

 

 

 

(e)

Confined, moves about

(D)

 

 

 

 

 

(f)

Confined, does not move about

(D)

 

 

 

 

(11)

Medication Administration (NF)

 

(12)

Medication Administration (ACR)

 

 

(a)

(b)

(c)

 

(d)

No medications

(I)

 

(a)

(b)

 

(c)

Without assistance Administered/ monitored by lay person Administered/ monitored by professional staff

(I)

(D)

 

(D)

 

Self-administered, monitored < weekly Administered/ Monitored by lay persons Administered/ monitored by Licensed/Professional Nurse

(I)

(D)

 

(D)

 

 

 

 

 

 

 

 

 

(13)

Behavior Pattern

 

(14)

Instrumental     Activities                            of

Daily Living (ACR)

 

(a)

Appropriate

(I)

 

(a)

Meal Preparation

 

 

(b)

Wandering/ passive, less than weekly

(I)

 

 

  1. No help needed
  2. Needs help

Housekeeping

  1. No help needed
  2. Needs help

Laundry

  1. No help needed
  2. Needs help

Money Management

  1. No help needed
  2. Needs help

(D)

 

(c)

Wandering/ passive, weekly or more

(d)

 

(b)

 

 

 

(D)

 

(d)

Abusive/ aggressive/ disruptive, less than weekly

(D)

 

(c)

 

 

 

(D)

 

 

 

 

(d)

 

 

(e)

Abusive/ aggressive/ disruptive, weekly or more

(D)

 

 

 

(D)

 

 

 

 

Medical and Nursing Needs

An individual with medical or nursing needs is an individual whose health needs require medical or nursing supervision or care above the level that could be provided through assistance with ADLs, medication administration, and general supervision and is not primarily for the care and treatment of mental diseases. Medical or nursing supervision or care beyond this level  is required when any one of the following describes the individual’s need for medical or nursing supervision:

 

  1. The individual’s medical condition requires observation and assessment to assure evaluation of the person’s need for modification of treatment or additional medical procedures to prevent destabilization, and the person has demonstrated an inability to self-observe or evaluate the need to contact skilled medical professionals; or

 

  1. Due to the complexity created by the person’s multiple, interrelated medical conditions, the potential for the individual’s medical instability is high or medical instability exists; or

 

  1. The individual requires at least one ongoing medical/nursing service. The following is a non-exclusive list of medical/nursing services which may, but need not necessarily, indicate a need for medical or nursing supervision or care:
    1. Application of aseptic dressings;
    2. Routine catheter care;
    3. Respiratory therapy;
    4. Supervision for adequate nutrition and hydration for individuals who show clinical evidence of malnourishment or dehydration or have a recent history of weight loss or inadequate hydration which, if not supervised, would be expected to result in malnourishment or dehydration;
    5. Therapeutic exercise and positioning;
    6. Routine care of colostomy or ileostomy or management of neurogenic bowel and bladder;
    7. Use of physical (e.g., side rails, poseys, locked wards) or chemical restraints;
    8. Routine skin care to prevent pressure ulcers for individuals who are immobile;
    9. Care of small uncomplicated pressure ulcers and local skin rashes;
    10. Management of those with sensory, metabolic, or circulatory impairment with demonstrated clinical evidence of medical instability;
    11. Chemotherapy;
    12. Radiation;
    13. Dialysis;
    14. Suctioning;
    15. Tracheostomy care;
    16. Infusion therapy; and
    17. Oxygen.

Even when an individual meets nursing facility criteria, provision of services in a non- institutional setting shall be considered before nursing facility placement is sought (Statutory Authority 32.1-325 Code of Virginia).

 

Summary of Pre-admission Screening Criteria for Nursing Facility Care

An individual shall be determined to meet the nursing facility criteria when:

  1. The individual has both limited functional capacity and requires medical or nursing management according to the requirements of the Pre-admission Screening Criteria for Nursing Facility Care; or

 

  1. The individual is rated dependent in some functional limitations but does not meet the functional capacity requirements, and the individual requires the daily direct services or supervision of a licensed nurse that cannot be managed on an outpatient basis (e.g., clinic, physician visits, home health services) (12 VAC 30-60-303).

 

An individual shall not be determined to meet nursing facility criteria when one of the following specific care needs solely describes his/her condition:

 

  1. An individual who requires minimal assistance with ADLs, including those persons whose only need in all areas of functional capacity is for prompting to complete the activity;

 

  1. An individual who independently uses mechanical devices such as a wheelchair, walker, crutch, or cane;

 

  1. An individual who requires limited diets such as a mechanically altered, low-salt, low-residue, diabetic, reducing, and other restrictive diets;

 

  1. An individual who requires medications that can be independently self-administered or administered by a caregiver;

 

  1. An individual who requires protection to prevent him/her from obtaining alcohol or drugs or to address a social or environmental problem;

 

  1. An individual who requires minimal staff observation or assistance for confusion, memory impairment, or poor judgment; or

 

  1. An individual whose primary need is for behavioral management, which can be provided in a community-based setting (Statutory Authority 32.1-325 Code of Virginia).

 

EVALUATION TO DETERMINE ELIGIBILITY FOR MEDICAID PAYMENT OF NURSING FACILITY OR COMMUNITY-BASED CARE WAIVER SERVICES

 

Once the PAS Team has determined whether or not an individual meets the nursing facility criteria, the PAS Team must determine the most appropriate and cost-effective means of meeting the needs of the individual. The PAS Team must document a complete assessment of all the resources available for that individual in the community (i.e., the immediate family, other relatives, other community resources, and other services in the continuum of long-term care, which are less intensive than Nursing Facility Level-Of-Care Services). The PAS team shall be responsible for pre-authorizing Medicaid-funded long-term care according to the needs of each individual, and the support required to meet those needs.

Authorization of Nursing Facility Services

The PAS Team shall not authorize Medicaid-funded nursing facility services for any individual who does not meet nursing facility criteria. The PAS Team shall authorize Medicaid-funded nursing facility care for an individual who meets the nursing facility criteria only when services in the community are either not a feasible alternative or the individual or individual’s representative rejects the PAS Team’s plan for community services. The PAS Team must document that the option of community-based alternatives has been explained, the reason community-based services were not chosen, and have this document signed by the individual or individual’s primary caregivers.

Authorization of Community-Based Care Services

The PAS Team shall authorize Community-Based Waiver Services only for an individual who:

  • Meets the nursing facility criteria and is at risk of nursing facility placement (within a month or less) without waiver services. Waiver services are offered to such an individual as an alternative to avoid nursing home admission.

 

Federal regulations which govern Medicaid-funded facility and community-based services require that services only be offered to individuals who would otherwise require institutional placement in the absence of Home- and Community-Based Services. The determination that an individual would otherwise require placement in a nursing facility is based upon finding that the individual’s current condition and available support are insufficient to enable the individual to remain in the home and, thus, the individual is at risk of institutionalization if community-based care is not authorized. The determination of the individual’s risk of nursing facility placement shall be documented either on the state-designated PAS assessment or in a separate attachment for every individual authorized to receive Community-Based Waiver Services.

 

Federal regulations require an evaluation of the need for the level of care provided in a nursing facility or an ICF/MR (Intermediate Care Facility for the Mentally Retarded) when there is a reasonable indication that a recipient might need the services in the near future (i.e., a month or less) unless he/she receives Home- or Community-Based Services [42 CFR § 441.302 (c) (1)].

 

CRITERIA FOR CONTINUED NURSING FACILITY CARE USING THE MINIMUM DATA SET (MDS)

 

Individuals may be considered appropriate for nursing facility care when one of the following describes their medical or nursing needs and functional capacity as recorded on the Minimum Data Set (MDS) of the Resident Assessment Instrument that is specified by the Commonwealth of Virginia:

  1. Functional Capacity:
    1. Rated dependent in two to four of the ADLs, and also rated semi-dependent or dependent in Behavior Pattern and Orientation, and semi-dependent in Joint Motion or dependent in Medication Administration. (12 VAC 30-60-303); or

 

    1. Rated dependent in five to seven of the ADLs, and also rated dependent in Mobility; or

 

    1. Rated semi-dependent in two to seven of the ADLs, and also rated dependent in Mobility and Behavior Pattern and Orientation.
  1. Medical or Nursing Needs:
    1. The individual has health needs that require medical or nursing supervision or care above the level, which could be provided through assistance with ADLs, medication administration, and general supervision and is not primarily for the care and treatment of mental diseases. (12 VAC 30-60-316 and 32.1-325 Code of Virginia)

Definitions to Be Applied When Completing the MDS (12 VAC 30-60-318)

  1. Activities of Daily Living (ADLs):
    1. Transfer [§E(1)(b)]: In order to meet this ADL, the individual must score a 1, 2, 3, 4, or 8 as described below:

 

      1. (0) Independent: No help or oversight OR help or oversight provided only 1 or 2 times during last 7 days.
      2. (1) Supervision: Oversight, encouragement, or cuing provided 3+ times during last 7 days OR supervision plus physical assistance provided 1 or 2 times during last 7 days.
      3. (2) Limited Assistance: Resident highly involved in activity; received physical help in guided maneuvering of limbs or other non-weight-bearing assistance 3+ times OR more help provided only 1 or 2 times during last 7 days.
      4. (3) Extensive Assistance: While resident performed part of activity over last 7-day period, help of following type or types was provided 3 or more times: weight-bearing support or full staff performance during part (but  not all) of last 7 days.

 

      1. (4) Total Dependence: Full staff performance of activity during entire 7 days.
      2. (8) Activity Did Not Occur During the Entire 7-day Period: Use of this code is limited to situations where the ADL activity was not performed and is primarily applicable to fully bed-bound residents, who neither  transferred from bed nor moved between locations over the entire 7-day period.

 

    1. Dressing [§E(1)(d)]: In order to meet this ADL, the individual must score a 1,  2, 3, 4, or 8 as described below:

 

      1. (0) Independent: No help or oversight OR help/oversight provided only 1 or 2 times during last 7 days.
      2. (1) Supervision: Oversight, encouragement, or cuing provided 3+ times during last 7 days OR supervision plus physical assistance provided 1 or 2 times during last 7 days.
      3. (2) Limited Assistance: Resident highly involved in activity; received physical help in guided maneuvering of limbs or other non-weight-bearing assistance 3+ times OR more help provided only 1 or 2 times during last 7 days.
      4. (3) Extensive Assistance: While resident performed part of activity over last 7-day period, help of following type or types was provided 3 or more times: weight-bearing support or full staff performance during part (but  not all) of last 7 days.
      5. (4) Total Dependence: Full staff performance of activity during entire 7 days.
      6. (8) Activity Did Not Occur During the Entire 7-Day Period: Use of this code is limited to situations where the ADL activity was not performed and is primarily applicable to fully bed-bound residents, who neither  transferred from bed nor moved between locations over the entire 7-day period.

 

    1. Eating [§E(1)(e)]: In order to meet this ADL, the individual must score a 1, 2,  3, 4, or 8 as described below:

 

      1. (0) Independent: No help or oversight OR help/oversight provided only 1 or 2 times during last 7 days.
      2. (1) Supervision: Oversight, encouragement, or cuing provided 3+ times during last 7 days OR supervision plus physical assistance provided 1 or 2 times during last 7 days.
      3. (2) Limited Assistance: Resident highly involved in activity; received physical help in guided maneuvering of limbs or other non-weight-bearing assistance 3+ times OR more help provided only 1 or 2 times during last 7 days.
      4. (3) Extensive Assistance: While resident performed part of activity over last 7-day period, help of following type or types was provided 3 or more times: weight-bearing support or full staff performance during part (but not all) of last 7 days.

 

      1. (4) Total Dependence: Full staff performance of activity during entire 7 days.
      2. (8) Activity Did Not Occur During the Entire 7-Day Period: Use of this code is limited to situations where the ADL activity was not performed and is primarily applicable to fully bed-bound residents, who neither  transferred from bed nor moved between locations over the entire 7-day period.

OR

      1. To meet this ADL, one of the following is checked:
        1. §L(4)(a) - Parenteral or intravenous.
        2. §L(4)(b) - Feeding tube.
        3. §L(4)(d) - Syringe (oral feeding).
    1. Toilet Use [§E(1)(f)]: In order to meet this ADL, the individual must score a 1, 2, 3, 4, or 8 as described below:

 

      1. (0) Independent: No help or oversight OR help/oversight provided only 1 or 2 times during last 7 days.
      2. (1) Supervision: Oversight, encouragement, or cuing provided 3+ times during last 7 days OR supervision plus physical assistance provided 1 or 2 times during last 7 days.
      3. (2) Limited Assistance: Resident highly involved in activity; received physical help in guided maneuvering of limbs or other non-weight-bearing assistance 3+ times OR more help provided only 1 or 2 times during last 7 days.
      4. (3) Extensive Assistance: While resident performed part of activity over last 7-day period, help of following type or types was provided 3 or more times: weight-bearing support or full staff performance during part (but  not all) of last 7 days.
      5. (4) Total Dependence: Full staff performance of activity during entire 7 days.
      6. (8) Activity Did Not Occur During the Entire 7-Day Period: Use of this code is limited to situations where the ADL activity was not performed and is primarily applicable to fully bed-bound residents, who neither  transferred from bed nor moved between locations over the entire 7-day period.

 

    1. Bathing [§E(3)(a)]: To meet this ADL, the individual must score a 1, 2, 3, 4, or 8 as described below:
      1. (0) Independent: No help provided.
      2. (1) Supervision: Oversight help only.
      3. (2) Physical Help Limited to Transfer Only.
      4. (3) Physical Help With Part of Bathing Activity.
      5. (4) Total Dependence.
      6. (8) Activity Did Not Occur During the Entire 7-Day Period: Use of this code is limited to situations where the ADL activity was not performed and is primarily applicable to fully bed-bound residents, who neither transferred from bed nor moved between locations over the entire 7-day period.

 

    1. Bladder Continence [§F(1)(b)]: In order to meet this ADL, the individual must score a 2, 3, or 4 in this category:
      1. (0) Continent: Complete control.
      2. (1) Usually Continent: incontinent episodes once a week or less.
      3. (2) Occasionally Incontinent: 2+ times a week but not daily.
      4. (3) Frequently  Incontinent:    Tended to be incontinent daily, but some control present (e.g., on day shift).
      5. (4) Incontinent: Had inadequate control; multiple daily episodes. OR
      6. To meet this ADL, one of the following is checked:
        1. §F(3)(b) - External catheter.
        2. §F(3)(c) - In-dwelling catheter.
    2. Bowel Continence [§F(1)(a)]: In order to meet this ADL, the individual must score a 2, 3, or 4 in this category:
      1. (0) Continent: Complete control.
      2. (1) Usually Continent: Control problems less than weekly.
      3. (2) Occasionally Incontinent: Once a week.
      4. (3) Frequently Incontinent: 2-3 times a week.
      5. (4) Incontinent: Had inadequate control all (or almost all) of the time. OR
      6. To meet this ADL, §F(3)(h) - Ostomy, is checked.
  1. Joint Motion [§E(4)]: In order to meet this category, at least one of the following must be CHECKED:
    1. (c) Contracture to arms, legs, shoulders, or hands.
    2. (d) Hemiplegia/hemiparesis.
    3. (e) Quadriplegia.
    4. (f) Arm: partial or total loss of voluntary movement.
    5. (g) Hand: lack of dexterity (e.g., problem using toothbrush or adjusting hearing aid).
    6. (h) Leg: partial or total loss of voluntary movement.
    7. (i) Leg: unsteady gait.
    8. (j) Trunk: partial or total loss of ability to position, balance, or turn body.

 

  1. Locomotion [§E(1)(c)]: In order to meet this ADL, the individual must score a 1, 2, 3, 4, or 8 in this category:

 

    1. (0) Independent: No help or oversight OR help or oversight provided only 1 or  2 times during last 7 days.
    2. (1) Supervision: Oversight, encouragement, or cuing provided 3+ times during last 7 days OR supervision plus physical assistance provided 1 or 2 times during last 7 days.
    3. (2) Limited Assistance: Resident highly involved in activity; received physical help in guided maneuvering of limbs or other non-weight-bearing assistance 3+ times OR more help provided only 1 or 2 times during last 7 days.
    4. (3) Extensive Assistance: While resident performed part of activity over last 7- day period, help of following type or types was provided 3 or more times: weight-bearing support or full staff performance during part (but not all) of last 7 days.
    5. (4) Total Dependence: Full staff performance of activity during entire 7 days.
    6. (8) Activity Did Not Occur During the Entire 7-Day Period: Use of this code is limited to situations where the ADL activity was not performed and is primarily applicable to fully bed-bound residents, who neither transferred from bed nor moved between locations over the entire 7-day period.

 

  1. Nursing Observation: In order to meet this category, at least one of the following special treatments, procedures, and skin conditions must be CHECKED:
    1. §N(4)(a) Open lesions other than stasis or pressure ulcers (e.g., cuts).
      1. Wound care or treatment (e.g., pressure ulcer care, surgical wound).
      2. Other skin care or treatment.
    2. §P(1)(a) Chemotherapy.
  1. Radiation.
  2. Dialysis.
  3. Suctioning.
  4. Tracheostomy care.
  5. Intravenous medications.
  6. Transfusions.
  7. Oxygen.
  8. Other special treatment or procedure.

 

 

 

 

  1. Behavior and Orientation: In order to meet this category, the individual must meet at least one of the categories for both behavior AND orientation.

 

    1. Behavior: To meet the criteria for behavior, the individual must meet at least one of the following:

 

      1. §H(1)(d) Failure to eat or take medications, withdrawal from Self Care or leisure activities (must be CHECKED).

OR

      1. One of the following is coded 1 (behavior of this type occurred less than daily) or 2 (behavior of this type occurred daily or more frequently):

 

        1. §H(3)(a) - Wandering (moved with no rational purpose, seemingly oblivious to needs or safety).
        2. §H(3)(b) - Verbally abusive (others were threatened, screamed at, cursed at).
        3. §H(3)(c) - Physically abusive (others were hit, shoved, scratched, sexually abused).
        4. §H(3)(d) - Socially inappropriate/disruptive behavior (made disrupting sounds, noisy, screams, self-abusive acts, sexual behavior or disrobing in public, smeared/threw food/feces, hoarding, rummaged through others’ belongings).

 

    1. Orientation: To meet this category, the individual must meet at least one of the following:

 

      1. §B(3)(d) - “Awareness that the individual is in a nursing facility” is NOT CHECKED.
      2. §B(3)(e) - “None of the memory/recall ability items are recalled” must be CHECKED.

OR

      1. §B(4) - Cognitive skills for daily decision-making must be coded with a 2 (moderately impaired decisions poor; cue or supervision required) or 3 (severely impaired, never or rarely made decisions).

Part II Adult Specialized Care

  1. The resident must have long-term health conditions requiring close medical supervision, 24 hours of licensed nursing care, AND specialized services or equipment.

 

  1. The targeted adult population for needing specialized care includes individuals requiring mechanical ventilation or complex tracheostomies.
  2. To meet Specialized Care criteria, the individual must require at a minimum:
    1. Physician visits at least every seven (7) days. The initial Physician visit must be made by the Physician personally and subsequent required Physician visits after the initial visit may alternate between personal visits by the Physician and visits by a Physician Assistant or Nurse Practitioner;

 

    1. Licensed Nursing Services 24 hours a day [a registered nurse (RN) must be on the nursing unit on which the resident resides, 24 hours a day, whose sole responsibility is the designated unit];

 

    1. Respiratory Services provided by a licensed and board-certified Respiratory Therapist (these services must be available 24 hours a day); AND
    2. A coordinated multidisciplinary team approach to meet needs.
  1. In addition, the individual must meet one of the two following requirements:
    1. Require mechanical ventilation; OR
    2. Have a complex tracheostomy that meets all of the following criteria. The resident must:
      • Have a tracheostomy with the potential for weaning or documentation of attempts to wean with subsequent inability to wean;
      • Require nebulizer treatments followed by chest PT (Physiotherapy) at least 4 times per day or nebulizer treatments at least 4 times a day, provided by a Licensed Nurse or Licensed Respiratory Therapist;
      • Require pulse oximetry monitoring at least every shift due to demonstrated unstable oxygen saturation levels;
      • Require respiratory assessment and documentation every shift by a Licensed Respiratory Therapist or Trained Nurse;
      • Have a Physician’s order for oxygen therapy with documented usage;
      • Require tracheostomy care at least daily;
      • Have a Physician’s order for suctioning as needed; AND
      • Be deemed to be at risk to require subsequent mechanical ventilation.

Part III Pediatric/Adolescent Specialized Care Criteria

  1. The child must have ongoing health conditions requiring close medical supervision, 24 hours of licensed nursing supervision, AND specialized services or equipment. The recipient must be under age 21.

 

  1. The targeted children’s population for specialized care includes children requiring mechanical ventilation, children with communicable diseases requiring universal or respiratory precautions (excluding normal childhood diseases such as chicken pox, measles, strep throat, etc.), children requiring ongoing intravenous medication or intravenous nutrition administration, children requiring daily dependence on device- based respiratory or nutritional support (tracheostomy, gastrostomy, etc.), children requiring Comprehensive Rehabilitative Therapy Services, and children with terminal illness.
  2. The child must require at a minimum:
    1. Physician visits at least every seven (7) days. The initial Physician visit must be made by the Physician personally. Subsequent required Physician visits after  the initial visit may alternate between personal visits by the Physician and visits by a Physician Assistant or Nurse Practitioner;

 

    1. Skilled nursing services 24 hours a day (an RN must be on the nursing unit on which the child is residing, 24 hours a day, whose sole responsibility is that nursing unit);
    2. Coordinated multidisciplinary team approach to meet needs; and
    3. The nursing facility must coordinate with appropriate state and local agencies for the educational and habilitative needs of the child. These services must be age-appropriate and appropriate to the cognitive level of the child. Services must also be individualized to meet the specific needs of the child and must be provided in an organized and proactive manner. Services may include but are not limited to school, active treatment for mental retardation, habilitative therapies, social skills, and leisure activities. The services must be provided for a total of two (2) hours per day, at a minimum. Educational and Habilitative Services are not reimbursable by Medicaid.
  1. In addition, the child must meet one of the following requirements:
    1. Must require two out of three of the following Physical Rehabilitative Services: Physical Therapy, Occupational Therapy, or Speech Pathology Services; therapy must be provided at a minimum of six (6) therapy sessions (minimum of

15 minutes per session) per day, five (5) days per week; the child must demonstrate progress with the overall rehabilitative Plan of Care (POC) on a monthly basis; OR

    1. Must require special equipment such as mechanical ventilators, respiratory therapy equipment (that has to be supervised by a Licensed Nurse or Respiratory Therapist), a monitoring device (respiratory or cardiac), kinetic therapy, etc.; OR
    2. Children who require at least one of the following special services:
      1. Ongoing administration of intravenous medications or nutrition (i.e., TPN, antibiotic therapy, narcotic administration, etc.);

 

      1. Special infection control precautions (universal or respiratory precaution; this does not include hand-washing precautions only or isolation for normal childhood diseases such as measles, chicken pox, strep throat, etc.);

 

      1. Dialysis treatment that is provided within the facility (i.e. peritoneal dialysis);

 

      1. Daily respiratory therapy treatments that must be provided by a Skilled Nurse or a Respiratory Therapist;

 

      1. Extensive wound care requiring debridement, irrigation, packing, etc. more than two times a day (i.e., grade IV decubiti; large surgical wounds that cannot be closed; second or third degree burns covering more than 10% of the body);
      2. Ostomy care requiring services by a Licensed Nurse; and
      3. Care for terminal illness.

Part IV Traumatic Brain Injury (TBI) Unit

  • The resident must be at least 14 years old;
  • Meets minimal nursing facility criteria;
  • Physician’s diagnosis of TBI in the medical record;
  • In addition to the documentation required for nursing facility placement, the following is required:
    • Evaluation by a Neuropsychologist or Neurologist;
    • An annual evaluation by a Licensed Clinical Psychologist with expertise in neuropsychology or a Neurologist. If an individual is admitted and has not been evaluated by a Neuropsychologist or Neurologist in the past calendar year, an evaluation must be completed within the first 30 days of the individual’s stay;
    • Educational Services; AND
    • Documentation of coordination correspondence for Educational Services for the individual with the appropriate public school system, if the individual has not completed all the educational requirements for high school education as specified by the State Board of Education.

Part V Intermediate Care Facilities for Mentally Retarded Persons

  1. Utilization Control regulations require that criteria be formulated for guidance for appropriate levels of services. Traditionally, care for the mentally retarded has been institutionally based; however, this level of care need not be confined to a specific setting. The habilitative and health needs of the client are the determining issues.

 

  1. The purpose of these regulations is to establish standard criteria to measure eligibility for Medicaid payment. Medicaid can pay for care only when the individual is receiving appropriate services and when “active treatment” is being provided. An individual’s need for care must meet these criteria before any authorization for payment by Medicaid will be made for either Institutional or Waiver Rehabilitative Services for the mentally retarded.

 

  1. Care in facilities for the mentally retarded requires planned programs for habilitative needs and/or health-related services, which exceed the level of room, board, and supervision of daily activities.

 

Such cases shall be a combination of habilitative, rehabilitative, and health services directed toward increasing the functional capacity of the individual. Examples of services will include training in the ADLs, task-learning skills, socially acceptable behaviors, basic community living programming, or health care and health maintenance. The overall objective of programming shall be the attainment of the optimal physical, intellectual, social, or task-learning level which the person can presently or potentially achieve.

 

  1. The evaluation and re-evaluation for care in a facility for the mentally retarded are based on the needs of the individual, the reasonable expectations of the individual’s capabilities, the appropriateness of programming, and whether progress is demonstrated from the training and, in an institution, whether the services could reasonably be provided in a less restrictive environment.

DEFINITIONS

As used in these criteria, the following terminology is defined:

  • “NO ASSISTANCE” means no help is needed.
  • “PROMPTING/STRUCTURING” means prior to the functioning, some verbal direction and/or some re-arrangement of the environment is needed.
  • “SUPERVISION” means that a helper must be present during the function and provide only verbal direction, gesture prompts, and/or guidance.
  • “SOME DIRECT ASSISTANCE” means that a helper must be present and provide some physical guidance/support (with or without verbal direction).
  • “TOTAL CARE” means that a helper must perform all or nearly all of the functions.
  • “RARELY” means that a behavior occurs quarterly or less.
  • “SOMETIMES” means that a behavior occurs once a month or less.
  • “OFTEN” means that a behavior occurs 2-3 times a month.
  • “REGULARLY” means that a behavior occurs weekly or more.

PATIENT ASSESSMENT CRITERIA

  1. The patient assessment criteria are divided into broad categories of needs or services provided. These must be evaluated in detail to determine the abilities/skills, which will be the basis for the development of a POC. The evaluation process will demonstrate a need for programming an array of skills and abilities or health care services. These have been organized into seven major categories. The level of functioning in each category is graded from the most dependent to the least dependent. In some categories, the dependency status is rated by the degree of assistance required. In other categories, the dependency is established by the frequency of a behavior or ability to perform a given task.

 

  1. The resident must meet the indicated dependency level in TWO OR MORE of categories 1 through 7.
    1. Health Status - To meet this category:

(a.) Two or more questions must be answered with a 4, OR (b.) Question “J” must be answered “Yes.”

    1. Communication Skills - To meet this category:

Three or more questions must be answered with a 3 or a 4.

    1. Task Learning Skills - To meet this category:

Three or more questions must be answered with a 3 or a 4.

    1. Personal Care - To meet this category:

(a.) Question “A” must be answered with a 4 or a 5; OR (b.) Question “B” must be answered with a 4 or a 5; OR

(c.) Questions “C” and “D” must be answered with a 4 or a 5.

    1. Mobility - To meet this category:

Any one question must be answered with a 4 or a 5.

 

 

 

 

    1. Behavior - To meet this category:

Any one question must be answered with a 3 or a 4.

    1. Community Living - To meet this category:

(a.) Any two of the questions “B,” “E,” or “G” must be answered with a 4 or a 5; OR

(b.) Three or more questions must be answered with a 4 or a 5.

 

 

 

 

LEVEL OF FUNCTIONING SURVEY

 

  1. HEALTH STATUS

How often is nursing care or nursing supervision by a Licensed Nurse required for the following? (Key: 1=Rarely, 2=Sometimes, 3=Often, or 4=Regularly)

 

a.

Medication administration and/or

1

2

3

4

 

evaluation for effectiveness of a

 

 

 

 

 

medication regimen

 

 

 

 

b.

Direct services [i.e., care for lesions,

1

2

3

4

 

dressings, treatments, (other than

 

 

 

 

 

shampoos, foot powder, etc.)]

 

 

 

 

c.

Seizure control

1

2

3

4

d.

Teaching diagnosed disease control and

1

2

3

4

 

care, including diabetes

 

 

 

 

e.

Management of care of diagnosed

1

2

3

4

 

circulatory or respiratory problems

 

 

 

 

f.

Motor disabilities which interfere with

1

2

3

4

 

all Activities of Daily Living (bathing,

 

 

 

 

 

dressing, mobility, toileting, etc.)

 

 

 

 

g.

Observation for choking/aspiration

1

2

3

4

 

while eating, drinking

 

 

 

 

h.

Supervision of use of adaptive equipment

1

2

3

4

 

(i.e., special spoon, braces, etc.)

 

 

 

 

i.

Observation for nutritional problems

1

2

3

4

 

(i.e., undernourishment, swallowing

 

 

 

 

 

difficulties, obesity, etc.)

 

 

 

 

j.

Is age 55 or older, has a diagnosis

1

2

3

4

 

of a chronic disease, and has been in

 

 

 

 

 

an institution 20 years or more

 

 

 

 

 

 

 

 

  1. COMMUNICATION

How often does this person:

(Key: 1=Rarely, 2=Sometimes, 3=Often, 4=Regularly)

 

a.

Indicate wants by pointing, vocal noises,

 

 

 

 

 

or signs?

1

2

3

4

b.

Use simple words, phrases, or short sentences?

1

2

3

4

c.

Ask for at least 10 things using

 

 

 

 

 

appropriate names?

1

2

3

4

d.

Understand simple words, phrases, or

 

 

 

 

 

instructions containing prepositions (i.e.,

 

 

 

 

 

“on,” “in,” “behind,” etc.)?

1

2

3

4

e.

Speak in an easily understood manner?

1

2

3

4

f.

Identify self, place of residence, and

 

 

 

 

 

significant others?

1

2

3

4

  1. TASK LEARNING SKILLS

How often does this person perform the following activities?

(Key: 1=Rarely, 2=Sometimes, 3=Often, 4=Regularly)

 

a.

Pay attention to purposeful activities for

 

 

 

 

 

five minutes?

1

2

3

4

b.

Stay with a three-step task for more than 15

 

 

 

 

 

minutes?

1

2

3

4

c.

Tell time to the hour and understand time

 

 

 

 

 

intervals?

1

2

3

4

d.

Count more than 10 objects?

1

2

3

4

e.

Do simple addition or subtraction?

1

2

3

4

f.

Write or print 10 words?

1

2

3

4

g.

Discriminate shapes, sizes, or colors?

1

2

3

4

h.

Name people or objects when describing

 

 

 

 

 

pictures?

1

2

3

4

i.

Discriminate between “one,” “many,” or “a lot?”

1

2

3

4

 

 

 

 

  1. PERSONAL/SELF CARE

With what types of assistance can this person currently:

(Key: 1=No Assistance, 2=Prompting/Structuring, 3=Supervision, 4=Some Direct Assistance, 5=Total Care)

 

(a.)

Perform toileting functions (i.e., maintain

1

2

3

4

5

 

bladder and bowel continence, clean self, etc.)

 

 

 

 

 

(b.)

Perform eating/feeding functions (i.e.,

1

2

3

4

5

 

drink liquids, eat with spoon or fork,

 

 

 

 

 

 

etc.)

 

 

 

 

 

(c.)

Perform bathing function (i.e., bathe, run

1

2

3

4

5

 

bath, dry self, etc.)

 

 

 

 

 

(d.)

Dress self completely (i.e., including

1

2

3

4

5

 

fastening clothes, putting on clothes, etc.)

 

 

 

 

 

  1. MOBILITY

With what types of assistance can this person currently:

(Key: 1=No Assistance, 2=Prompting/Structuring, 3=Supervision, 4=Some Direct Assistance, 5=Total Care)

 

(a.)

Move (walk, wheel, etc.)

 

 

 

 

 

 

around environment?

1

2

3

4

5

(b.)

Rise from lying down to sitting positions,

1

2

3

4

5

 

sit without support?

 

 

 

 

 

(c.)

Turn and position in bed, roll over?

1

2

3

4

5

 

 

 

 

  1. BEHAVIOR

How often does this person: (Key: 1=Rarely, 2=Sometimes, 3=Often, 4=Regularly)

 

 

(a.)

Engage in self-destructive behavior?

1

2

3

4

(b.)

Threaten or do physical violence to others?

1

2

3

4

(c.)

Throw things, damage property, have temper outbursts?

1

2

3

4

(d.)

Respond to others in a socially unacceptable

1

2

3

4

 

manner (with undue anger, frustration,

 

 

 

 

 

or hostility)?

 

 

 

 

 

  1. COMMUNITY LIVING SKILLS

With what type of assistance would this person currently be able to:

(Key:      1=No Assistance, 2=Prompting/Structuring, 3=Supervision, 4=Some Direct Assistance, 5=Total Care)

 

 

a.

Prepare simple foods requiring no mixing

1

2

3

4

5

 

or cooking?

 

 

 

 

 

b.

Take care of personal belongings, room

1

2

3

4

5

 

(excluding vacuuming, ironing, clothes

 

 

 

 

 

 

washing/drying, and wet mopping)?

 

 

 

 

 

c.

Add coins of various denominations up to

1

2

3

4

5

 

one dollar?

 

 

 

 

 

d.

Use the telephone to call home, a doctor,

1

2

3

4

5

 

fire department, or police?

 

 

 

 

 

e.

Recognize survival signs/words (i.e.,

1

2

3

4

5

 

stop, go, traffic lights, police, men,

 

 

 

 

 

 

women, restrooms, danger, etc.)?

 

 

 

 

 

f.

Refrain from exhibiting unacceptable sexual

1

2

3

4

5

 

behavior in public?

 

 

 

 

 

g.

Go around cottages, wards, and buildings without

1

2

3

4

5

 

running away, wandering off, or becoming lost?

 

 

 

 

 

h.

Make minor purchases (i.e., candy, soft drinks,

1

2

3

4

5

 

etc.)?