PASRR/LOC Process: The Basics and Beyond-Admission and Readmission Requirements for Ohio Medicaid Nursing Facilities

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1 PASRR/LOC Process: The Basics and Beyond-Admission and Readmission Requirements for Ohio Medicaid Nursing Facilities Although the information discussed in this document only applies to Medicaid certified nursing facilities, it is helpful to hospitals, assisted living facilities, home health care agencies, group homes and any other entity that helps to facilitate Medicaid Certified Nursing Facility placements. Although several years have gone into planning this course, there is no guarantee that the information contained in this document is completely accurate. Please check with your local Preadmission Review department for clarification. Since there are 12 different agencies which administer this program in Ohio, you are likely to get some difference in opinion. Information contained herein has been provided from review of 5101: , 5101: , 5101: , 5101: , 5101: , 5101: , 5101:3-3-06, 5101: , 5101:3-3-08, 5101:3-3-14, 5101:3-3-15, and 5101: of the Ohio Administrative Code (As well as clarification with individuals who work in Preadmission Review). The diagnoses listed in this document are taken from The Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition- Text Revision- DSM-IV-TR. Published by The American Psychiatric Association- Washington DC-Copyright 2000 ** Plase take your time in reviewing the following information. Please do not copy, distribute or use the following information for training purposes. The information contained herein is copyright material. All Rights Reserved Ltd ( )

2 Information for Lesson 1 PASRR is the process by which Preadmission Review screens individual applicants for indications of serious mental illness and/or mental retardation or developmental disabilities prior to admission to Medicaid certified NF s (Nursing Facilities). It is required for all admissions to Medicaid certified NF s regardless of the individual s payment source. PASRR is a federal mandate from the OBRA 1987 nursing home reform act. Every state must implement the PASRR process. The law specifies that as of 1/1/1989, NF s must not admit any individual who triggers the PASRR screen (also known as ODJFS 3622) for mental illness and/or mental retardation/developmental disorder without an approval from the appropriate state authorities. For an individual who triggers for both severe mental illness (SMI) and MR/DD, each state authority (ODMH & ODMR/DD) must agree on the outcome. ** Any PASRR requirements must be met before a level of care (LOC) determination can be issued for an individual seeking Medicaid as their primary payment source. Level of Care (LOC) -A Level of care is a designation that is issued for an individual whose primary payer source is Medicaid. The criteria that go into issuing a LOC are based on an individual s physical and/or cognitive impairment. In order for Medicaid to pay for an individual to reside in a NF, the individual must meet at least Intermediate Level of Care (ILOC). The Purpose of PASRR (Preadmission Screening- Resident Review) is to identify nursing facility aplicants with serious mental illness and/or mental retardation/developmental disabilities so as to ensure that a nursing facility is the most appropriate placement to meet their identified needs. PASRR includes all requirements that must be met prior to and after Medicaid certified Nursing Facility admissions. PASRR requirements may also apply to home and community based waiver programs such as the PASSPORT waiver. PASRR relates to determinations regarding whether individuals who have serious mental illness (SMI) and/or MR/DD require the level of services provided by a NF. These determinations must be based on the same LOC (Level of Care) criteria as are set forth in chapter 5101:3-3 of

3 the Ohio administrative code. However, the PAS process is distinct from the LOC review process. (a) PAS/ID means Preadmission Screening Identification and refers to that part of Preadmission Screening and Resident Review (PASRR) process mandated by section 1919 (e) (7) of the Social Security Act, as amended, which must be met prior to any new admission to a NF (as specified in rule 5101: of the Ohio Administrative Code). The PASRR screen is also known as a Who requires a PAS? From OAC 5101: ALL numbered items below assume individual is being admitted to an Ohio Medicaid certified NF. 1. Individual who is not a resident of an Ohio NF (Medicaid Certified) immediately preceding current request for an admission to a Medicaid certified NF. 2. Individual who is being admitted directly from a community setting such as a home, apartment, assisted living facility, Non Medicaid NF, Hospital emergency room. 3. Individual who is being admitted to a Medicaid certified NF from an inpatient hospitalization, was in the community prior to hospital stay, and does not have a valid convalescent stay certified on the transfer form. 4. A former NF resident who was discharged to home and is now seeking a new admission to the NF. 5. An individual being admitted directly from another state to an Ohio NF. 6. A NF resident who has used their 30 bed hold days for the year and is in the community on a leave from the NF. 7. An individual who is receiving PASSPORT home care and is seeking admission to a NF. 8. A resident of an ICF/MR facility who is seeking NF admission. (b) RR means Resident Review and refers to that part of Pre-Admission Screening and Resident Review process mandated by section 1919 (e)(7) of the Social Security Act, as amended, which must be met in order to retain NF residents (see codes 3-7 in section B of the 3622) (as specified in rule 5101: of the Ohio Administrative Code). RR -Resident Review (General Rule) (There are exceptions and they will be discussed later). The NF is responsible for completing the Resident Reviews. The NF must

4 initiate the RR/ID by completing the PASRR Identification Screen (ODJFS 3622) upon identification of the individual s significant change in condition and no later than the expiration for the categorical determination (such as the expired convalescent stay, the expired respite stay, expired emergency stay, or NF Resident No PAS on record). PAS- Preadmission Screening- In Ohio, a PAS is issued by one of the 12 PASSPORT sites. For a list of specific information for each PASRR site, go to Area Agency PAS- (General Rules)- There are exceptions and they will be discussed later. If a PAS is issued for an individual, and that individual is admitted to a Medicaid certified NF, the PAS is effective as long as the individual continues to reside in the Medicaid certified NF. If a PAS is issued for an individual and that individual does not go directly into a Medicaid certified NF, the PASRR rules currently do not have a time limit as to how long the PAS remains acceptable to use. Preadmission Review sites we spoke with indicate that if it is not used, it is good for up to a year. 1. While residing in the Medicaid certified NF, the individual may be admitted to the hospital and return to the NF multiple times and the PAS will still be effective. 2. The individual can transfer from one Medicaid certified NF to another Medicaid certified NF multiple times and the PAS will continue to remain effective. 3. However, if at any time, the individual is discharged to the community (i.e. their home, apartment, assisted living facility or anyplace other than a hospital or Medicaid certified NF) the chain is broken and a new PAS will need to be issued prior to admission to a Medicaid certified NF. Role of Preadmission Review The Preadmission Review department is responsible for issuing the PAS Result and LOC. In Ohio, the Area Agencies on Aging have a contract with both the Ohio Dept of Aging (ODA) and Ohio Dept of Jobs and Family Services to perform the Preadmission Review process for all individuals seeking admission to Medicaid certified nursing facilities. Preadmission review also issues LOC s (levels of care) for NF residents converting to Medicaid vendor payment, and LOC s for NF residents transferring from one Medicaid certified NF to another. There are 12 Preadmission Review

5 departments in OHIO. Each site covers a certain territory of specific counties in OH. Each site has its own specific hours (generally 9AM -5PM or 8:30AM -4:30PM, etc- Monday thru Friday). However, there are after hours coverage hours on the weekend. You can view a schedule of after hour coverage at Extended Preadmission Review Hours. ADMISSION VS. READMISSION ADMISSION- An individual was not residing in a Medicaid certified Nursing Facility (NF) prior to admission. The individual was residing in their own home, assisted living, or other community residence. This individual require a PAS. READMISSION- An individual was residing in a NF prior to returning to the NF (e.g. The individual was residing in a Medicaid certified NF and is admitted to the hospital for some type of care. The person either returns to the same NF or transfers to a different Medicaid certified NF). This individual should already have a PAS requirement. For admission purposes, every time a person is discharged to the community (The NF actually discharges the person off of their census), the PAS process will need to start over again. If the person is to be admitted again from the community, it will be considered a new admission and a new PAS will need to be obtained from Preadmission Review. Under the PASRR rules, a NF cannot discharge a resident to the hospital (meaning the person does not need a new PAS requirement if they go from the NF to the hospital and either return to the same NF or go to a different NF). There is an exception this rule. It is discussed in the convalescent stay information.

6 Information for Lesson 2 Community to NF Placement-Medicaid payment (normal placement) For Respite Stays as well as Long Term Placements 1. Requires a Level of Care assessment. A nurse or social worker from the PASSPORT agency will need to complete an assessment. The assessor completes an ODJFS and an ODJFS A referral for a NF placement can be made by anyone to the PASSPORT site. The referral can be phoned in to PASSPORT Site or faxed (If Faxed, the request needs to be clearly specified as a NF placement Medicaid payment with additional information such as demographic information (address/phone number, social security number, Medicaid Number if available, contact information, diagnoses, medications). 2. A Medicaid application Medicaid Application is completed before or during the assessment. 3. After the assessment, the assessor verifies the individual s diagnoses & medications with the individual s physician. 4. The 3697 is faxed to the physician for his/her signature. 5. If the PASRR (ODJFS 3622) does not trigger for mental illness or MR/DD, then further review is not required. 6. If the PASRR does trigger for mental illness and/or MR/DD, the individual s 3697 and the 3622 (all 3 pages) are forwarded to the appropriate state agency for further review. If the state agency issues an adverse determination, a PAS and LOC cannot be issued and the individual cannot be admitted to the NF. 7. Preadmission Review at the PASSPORT agency is the department that issues the paperwork for admission. Community to NF Placement Medicaid Payment-Emergency Admission 1.The individual s health and safety are at risk and an immediate placement is needed. The reason for the emergency placement needs to be clearly stated. 2. The person helping to initiate the placement can complete an ODJFS and ODJFS The physician will need to sign and date the cert. statement at the bottom of page 1 on the At least a pending Medicaid number is also needed.

7 4. If a physician is not available to sign the cert. statement, a PAS can be issued. If a recent signed/dated physician completed history & physical (with diagnoses and medications) can be obtained, it can be forwarded to Preadmission Review with a PASRR Screen. The reviewer at Preadmission Review can issue a PAS and send for a LOC at the NF soon after admission. As long as the PAS is issued and the individual meets at least Intermediate LOC (Assist with 2 Activities if daily living such as bathing, grooming, dressing,etc or 24 hour supervision due to a cognitive disorder like dementia) the LOC will be issued back to the date of admission after all the paperwork is completed. 5. If the individual requires further review for the emergency admission, Preadmission Review will forward the paperwork to the appropriate state authority. Preadmission Review must wait for an approval from the state agency before anything is issued for the admission. 6. If approved by the State Authority, they will issue the determination. It allows for a seven-day stay. If the individual is still residing in the NF on the 7 th day after admission, the NF must complete another code it 4 (expired time limit for emergency admission and forward it with admitting medical information to the State Authority. They will determine if the individual can continue to reside in the NF. Community to NF Placement Non Medicaid (normal placement) This applies to individuals admitted under Hospice payment as well 1. A signed/dated history and physical is needed (or equal documentation with diagnoses/medications which is signed/dated by physician or verified with physician (e.g. verbal order obtained from Dr. Smith/Susie Jones, LSW, date obtained). 2. An ODJFS needs to be completed. If it triggers for mental illness and/or MR/DD, then it will be forwarded to the appropriate agency with the medical information for further review. 3. An LTCC assessment needs to be considered. There is a series of questions that should be completed LTCC Worksheet. The form can be faxed to the Preadmission Review site. Preadmission will decide if a LTCC assessment should be completed based on the answers received. It takes the place of the UPAR assessment. Hospice patients are exempt from the LTCC assessment). There are 8 other total exemptions from the assessment. Some other exemptions include; Admission to a facility that is

8 a Home for the Aged, Admission to a NF under a contract for continuing care, Admission to a Non Medicaid certified NF, NF to NF transfer, Enrolled in a HCBS waiver (like PASSPORT), NF resident being actively case managed (Like by a Medicare case manager). 4. The Preadmission Review worker will then issue the PAS results to the NF. If further review is needed, Preadmission Review will need to wait for an approval from the state authority before the PAS results are issued. Community to NF placement- Non Medicaid- (emergency placement) Includes admissions from hospital emergency rooms 1. A signed/dated history and physical is needed (or equal documentation with diagnoses/medications which is signed/dated by the physician or verified with the physician (e.g. verbal order with Dr.. Smith/Susie Jones, LSW, 10/18/07). 2. A reason for emergency placement is needed (e.g. loss of caregiver). 3. If the individual requires further review, the Preadmission Review worker will fax the medical information and to the appropriate state authority. If approved, the PAS is issued for a 7 day placement. If the individual is still residing in the NF on the 7 th day after admission, the NF will need to complete a another code it 4-expired time limit for emergency admission and forward the screen with medical information to the appropriate state authority. The state authority will send a reviewer out to the NF to complete a full evaluation and then the state authority will determine if the individual can continue to reside in the NF. Community to NF placement- Non Medicaid (Respite stay) 1. The same medical information is required as in the normal placement. Submit it with completed PASRR screen 3622 to Preadmission Review. 2. A respite stay (considered respite stay if the intended stay in the NF is 14 days or less) must be indicated on the cover sheet of the request faxed to Preadmission Review. This person requires a PAS. 3. If the individual requires further review, the Preadmission Review worker will fax the medical information and PASRR (ODJFS 3622) screen (all three pages of the screen) to the appropriate state authority. If approved, the

9 PAS is issued for a fourteen-day respite stay. If the individual is still residing in the NF on the 14 th day after admission, the NF will need to complete another PASRR screen (code it 5- Expired time limit for respite stay) and forward that screen with medical information to the appropriate state authority. The state authority will send a reviewer to the NF to complete a full evaluation and then determine if the individual can continue to reside in the NF. Information for Lesson 3 Community to Hospital to NF-Medicaid Payment >30 stay in NF 1. NF must obtain a PAS and a LOC from the hospital prior to admission to guarantee Medicaid payment. 2. The hospital will submit a PASARR screen and a transfer form to Preadmission Review. 3. The transfer form must include the individual s diagnoses, medications, ADL s (Activities of daily living) which include oral care, bathing, dressing, grooming, toileting, transfers, ambulation, and medication administration) and individual s demographics (which includes community address, social security number, Medicaid #, etc). 4. This medical documentation must include a physician certification for the need for inpatient NF services. The certification statement indicates that the physician has reviewed the information contained in the documents forwarded to Preadmission Review and to the best of their knowledge the information is a true and accurate reflection of the patient s condition. An example of this statement is listed at the bottom of page 1 of the ODJFS A LOC (level of care) must be specified (either SLOC- Skilled level of Care or ILOC- Intermediate level of Care). For a LOC, the certification must be signed by a physician (either MD or DO) only. 5. The NF must wait for review results from Preadmission Review with a PAS and LOC before admitting the individual. 6. If the PASRR triggers for mental illness or MR/DD, the Preadmission Review must wait for an approval from the state authority before issuing the PAS and LOC. In any case, the NF should not admit the individual until receiving all the necessary paperwork.

10 Community to Hospital to NF- Non Medicaid payment>30 day anticipated stay The NF must obtain a PAS prior to admission. The hospital will need to forward the PASRR screen and transfer form to Preadmission Review. Preadmission Review will complete a PAS Result. If the PASRR triggers for mental illness or MR/DD, the paperwork will be forwarded to the proper agency for further review and the NF must wait for an approval before admitting the individual. Also, Preadmission Review requires the new LTCC information. See LTCC ** If the individual is admitted to the NF from the hospital without obtaining a PAS result from Preadmission Review with a > 30 day stay indicated on the hospital transfer form, the NF must fax the hospital transfer form with a PASRR screen to Preadmission Review ASAP. Preadmission review will complete the PAS result. Again, if the individual triggers for Mental Illness or MR/DD, the paperwork will have to be faxed for further review. Also information from LTCC form LTCC must be completed. Community to Hospital to NF-Medicaid<30 Day anticipated stay 1.Convalescent stay < 30 days needs to be specified on the transfer form. 2. Physician (Currently MD or DO only) must sign/date. 3. The individual must be admitted directly from the hospital after receiving inpatient care from the hospital (which means the individual cannot have a valid convalescent stay from the hospital emergency room, from their own home, etc.). 4. The person must be discharged directly from the hospital to a Medicaid certified NF. If they make a stop at home or go to another hospital, etc., 5. If the individual is still residing in the NF on the 30TH day after admission to the NF, the NF must complete a (RR/ID) by the 30TH day after admission and code it 3- expired time limit for convalescent stay. The screen should be kept with transfer form that validates convalescent stay on the resident s chart. It is not necessary to report expired time limit information to Preadmission Review for individuals admitted to NF under Medicaid payment. 6. If the 3622 triggers for mental illness and/or MR/DD, the 3622 needs to be forwarded to the appropriate state authority by the 30TH day after admission with current medical information and the transfer form that certifies convalescent stay.

11 7. Fax for Ohio Mental Health Authority is 1-(866) Phone for Ohio Mental Health Authority is 1-(877) Fax for ODMR/DD is (614) Phone for ODMR/DD is (614) Community to Hospital to NF-Non Medicaid- <30 day anticipated length of stay Follow all the rules for Medicaid admission of <30 days length of stay, except. 1. Neither a LOC nor a PAS is needed for admission (However, it is extremely important that a convalescent stay (<30 day length of stay at NF) is indicated on the hospital transfer form and the physician must sign/date the transfer form. A verbal order is not allowed to validate a convalescent stay). 2. If the individual is still residing in the NF on the 30 th day after admission, the needs to be completed by the NF on or before the 30 th day after admission (coded 3). 3. The 3622 must be placed on the residents chart with the transfer form that validates the convalescent stay. 4. If the 3622 triggers for mental health or MR/DD, the screen must be forwarded to the proper state authority with current medical information. Fax for Ohio Mental Health Authority is 1-(866) Phone for Ohio Mental Health Authority is 1-(877) Fax for ODMR/DD is (614) Phone for ODMR/DD is (614) ODMR/DD fax is (614) The OAC RR/ID rules indicate that demographic information including a contact person/phone number is required to be reported to Preadmission Review- Usually a nursing facility demographics page is adequate (with contact information) as well as a Preadmission Review cover sheet which is checked expired time limit for expired convalescent stay. A LTCC worksheet should also be provided LTCC

12 Information for Lesson 4 NF to hospital to same NF (Medicaid) If the individual was residing in a NF and the NF already has a LOC, then a new LOC is not needed (unless of course the person is out of bed hold days-which will be discussed later- or the Medicaid was terminated by the Department of Job and Family Services). If the individual were not out of bed hold days, the NF would be billing for bed hold days while the individual is in the hospital. However, if the person is covered under a Medicaid HMO, the HMO does not pay for bed hold days. Each time the person goes from the NF to the hospital to the NF and returns under Medicaid HMO payment, a new LOC is needed. Also, it is possible that the individual is residing in the NF and is Non Medicaid payment. If they are admitted to the hospital and return to the NF under Medicaid, a LOC is needed. The hospital can fax a transfer form to Preadmission Review. Also, as usual the PASRR requirement will need to be established before a LOC can be issued. NF to Hospital to same NF-Non Medicaid The individual was residing in a Medicaid certified NF. The individual is admitted to a hospital and is going back to the same Medicaid certified NF under Non Medicaid payment. The hospital worker should not have to get involved in securing a PAS requirement since one should already be in place. If I were the hospital worker and the NF is requeting a PAS, I would have the NF worker contact a worker in Preadmission Review to discuss the situation. NF to Hospital to different NF (Medicaid) A LOC is needed-the hospital will need to submit a transfer form to

13 Preadmission Review. If Preadmission Review does not have a record of the PASRR requirement in the system, the Preadmission Review worker will request that the hospital discharge planner obtain from the NF and provide it. The original NF should also forward the PAS requirement to the new NF. The PAS requirement could be, 1. A PAS result 2. A Hospital Transfer Form with convalescent stay certified on it and a PASRR screen coded 3- Expired time limit for conv stay (If the resident has been in the NF for 30 days). 3. If this resident was admitted to the NF from another NF and the PAS requirement was not forwarded to the new NF, the receiving NF could have completed a PASRR screen and coded it 7- NF Resident - No PAS on Record. If the original NF cannot come up with the PAS requirement, the hospital discharge planner will need to complete a PASRR screen. It can be coded 1- NF applicant. Preadmission Review will then issue a PAS and LOC. However, if it triggers for mental illness or MR/DD, the paperwork will need to be forwarded to the proper state authority. Fax for Ohio Mental Health Authority is 1-(866) Phone for Ohio Mental Health Authority is 1- (877) Phone for ODMR/DD is (614) ODMR/DD fax is (614) Preadmission Review will need to wait for an approval from the state authority to issue a LOC. NF to Hospital to different NF (Non Medicaid) The individual was residing in a Medicaid certified NF. The individual is admitted to a hospital and is going to a different Medicaid certified NF under Non Medicaid payment. The hospital worker should check with the previous NF for the PAS requirement. If the previous NF is having difficulty coming up with a PAS requirement, the hospital worker should ask the previous NF how this individual was admitted to the NF. If it was from a hospital and it was a convalescent stay, the transfer form and PASRR screen the NF completed should be forwarded to the new NF. If the the person was admitted from the community to the previous NF, the NF should have received a PAS result from Preadmission Review. If the NF did not obtain a PAS, then a PAS can be requested from Preadmission Review while the individual is in the hospital. There is another possibility as well- If the

14 sending NF is unable to come up with any type of proof of PAS, the receiving NF can complete a PASRR screen within 30 days of admission to the new NF and code it 7- No Previous PASRR records. If it triggers for mental illness and/or MR/DD the screen should be forwarded to the appropriate state authority with medical information. If all this fails and the receiving NF absolutely insists on a PAS result, Preadmission Review will issue a PAS. However, if it triggers for mental illness or MR/DD, it will have to go for further review while the individual is in the hospital. A LOC is not needed for the new NF. If the individual were paying privately at the previous NF, a LOC would not be needed until the individual would qualify for Medicaid to cover the cost of the NF. (Example) An individual is at a NF under private payment or private insurance, such as Medicare. The individual is admitted to the hospital for a qualifying 3day stay. The individual continues to qualify for skilled services under Medicare and is discharged to a different NF. Initially, the new NF does not need a LOC. However, once the Medicare time and private funds are used, the person will probably need to apply for Medicaid. Once the person qualifies for Medicaid, the local county Medicaid office will instruct the NF on a Medicaid effective date for the individual. The NF will then need to apply to Preadmission Review for a LOC. Information for Lesson 5 Placement to OH NF from a NF in another state 1. The receiving Ohio NF should obtain medical information (such as a recent physician completed history and physical that is signed/dated which includes the individual s diagnoses and medications) from the out of state facility. 2. The receiving Ohio NF should fax the medical information and a completed Ohio PASRR (ODJFS ) screen to the Preadmission Review site, which covers the county of the intended Nursing Facility. 3. Preadmission Review will issue a PAS result as long as there is no indication of mental illness or MR/DD.

15 4. If there is an indication of Mental Illness or MR/DD, the Preadmission Review worker will fax the paperwork to the Ohio Mental Health Authority (Ascend). The fax # is 1-(866) Phone for Ascend is 1-(877) The Preadmission Review worker will indicate that other state will need to have an evaluation by a mental health worker in that state (Called a Level II). This Level II evaluation should be faxed to at 1-(866) ODMH will complete a determination. The determination is forwarded to Preadmission review. If the person is granted approval for Ohio NF placement (It is usually for a 7 day stay). A PAS will be issued by a Preadmission review worker. If the individual is admitted to an Ohio NF and is still in the NF on the 7th day after admission, the NF completes a new screen and forwards to Ascend by the 7th day after admission. For an individual who triggers for MR/DD, the paperwork is forwarded to Preadmission Review, Preadmission review forwards to ODMR/DD. ODMR/DD issues a determination. Again, if approved the paperwork is issued by Preadmission Review. The NF is responsible for following up with ODMR/DD after the individual is admitted from out of state. In case where the screen triggers for mental illness or MR/DD and the person happens to be an Ohio resident, the paperwork (Medical information and PASRR screen) can be forwarded to Preadmission Review. Preadmission Review can forward the paperwork to the state authority and the state authority can issue a 7 day approval for NF placement (without going through a Level II from the other state). If the individual is still in the NF on the 7th day after admission, the NF should complete an RR/ID-coded 4- (expired time limit for emergency admission) and forward to the state authority with medical information. Preadmission Review will instruct the NF on this process should it occur. 5. If Medicaid is needed to the date of admission, an in person assessment is not required. The receiving NF can either complete an ODJFS 3697 and submit with a pending OH Medicaid number or wait until an MDS is completed and submit with physician orders, physician certification statement, pending Medicaid number and an additional data elements page. Direct placement to OH NF from a Hospital in another state. 1. The admitting NF should obtain medical information (such as a

16 signed/dated hospital transfer form which includes diagnoses and medications) from the out of state hospital. The medical information and Ohio PASRR screen should be forwarded to the Ohio Preadmission Review site, which covers the county of the intended Nursing Facility. It doesn t matter if the Ohio NF or the out of state hospital faxes the paperwork to Preadmission Review. 2.The paperwork is faxed to your Preadmission site. The Preadmission Review worker will forward it to Ascend. ODMH will indicate that they need to have an evaluation by a mental health worker in the state that the individual is currently residing. The evaluation should be forwarded to Ascend and ODMH will complete a determination. The determination is forwarded to Preadmission review. If the person is granted approval for Ohio NF placement (It is usually for a 7 day stay. A PAS will be issued by a Preadmission review worker. If the individual is admitted to an Ohio NF and is still in the NF on the 7th day after admission, the NF completes a new screen and forwards to ODMH by the 7th day after admission. For an individual who triggers for MR/DD, the paperwork is forwarded to Preadmission Review, Preadmission review forwards to ODMR/DD. ODMR/DD issues a determination. Again, if approved the paperwork is issued by Preadmission Review. The NF is responsible for following up with ODMR/DD after the individual is admitted from out of state. However, if the person is an Ohio resident, the paperwork (Medical information and PASRR screen) can be forwarded to Preadmission Review. Preadmission Review can forward the paperwork to the state authority and the state authority can issue a 7day approval for NF placement. If the individual is still in the NF on the 7 th day after admission, the NF should complete an RR/ID (PASRR screen)-coded 4- (expired time limit for emergency admission) and forward to the state authority with medical information. Preadmission Review will instruct the NF on this process should it occur. 3. If it is not a convalescent stay (per Ohio PASRR rule the individual must be an Ohio resident to receive a convalescent stay from an out of state hospital). Also, for additional clarification, review convalescent stay information. An individual who is a resident of another state cannot have a valid convalescent stay in an Ohio NF and must receive a PAS result from Preadmission Review prior to entering an OH NF.

17 4. As noted above, if the person is an Ohio resident, a convalescent stay can be issued by an out of state hospital. Ohio Preadmission Review would not need to be involved if a valid Convalescent stay is indicated on the hospital transfer form and the person is to be admitted to an Ohio NF under Non Medicaid payment. If the Ohio resident will be admitted to an Ohio NF from out of state hospital under a convalescent stay under Medicaid, Preadmission Review could issue a LOC as long as the person has a valid Ohio Medicaid # and a document such as 3697 or Hospital Referral Information Form (R.I.F.) is completed and a physician signs it. If it is not a convalescent stay situation, the medical information and PASRR screen should be forwarded to Preadmission Review. Preadmission Review will issue a determination prior to admission. Again, if it triggers for mental illness and/or MR/DD, follow instructions from #4 in (Out of State- In NF in other state). 5. If the person is not an Ohio resident and Medicaid is the primary payer source upon admission, Preadmission Review will issue a PAS for the admission. Once the person is admitted to the Ohio NF, the NF can resubmit the hospital transfer form with at least a pending Ohio Medicaid number. If the hospital transfer form does not have all the required information (physician certification statement, medications, diagnoses, activities of daily living), than that information needs to be provided as well (In the way of MDS, or Referral Information Form). Direct Placement to OH NF from the Community in another state (i.e. own home, apartment, assisted living, or any residence other than a Medicaid certified NF or a Hospital) 1. Medical information should be obtained (such as a recent H&P) and an Ohio PASRR should be completed. 2. The medical information and Ohio PASRR should be forwarded to Preadmission Review prior to admission. Preadmission Review will issue a PAS result to the NF. Again, if the PASRR triggers for mental illness and/or MR/DD, please review #4 (Out of state to Ohio NF-NF in other state). The Preadmission Review worker will assist in this circumstance. 3. If Medicaid is the primary payer source upon admission, a LOC

18 assessment needs to be completed by the local PASSPORT agency. The NF will need to inform the PASSPORT agency when the individual is admitted to the facility and the PASSPORT site will set up a LOC assessment. **For all admissions from out of state to OH NF s, the most important aspect is to obtain a PAS from Preadmission Review prior to admission. A PAS does not transfer from state to state. Each state has its own PASRR screen. Information for Lesson 6 Convalescent Stay Information First of all, it is important to note where each individual was residing prior to admission to the NF (e.g. Home, Assisted Living, Non Medicaid NF, Medicaid certified NF, etc). Secondly, a Convalescent stay can only be issued when an individual has been admitted to the hospital. A Convalescent stay cannot be issued for a person who is in the emergency room (The person must actually be admitted to the hospital). A Convalescent stay cannot be issued for a person who is admitted to a Medicaid certified Nursing Facility from the community; such as their own home, an assisted living facility, etc. Third, If the individual was residing in a Medicaid certified NF prior to a hospitalization and is then discharged from the hospital back to the same Medicaid certified Nursing Facility (NF) or to a different Medicaid certified NF, the individual cannot be readmitted to a NF under a Convalescent Stay (An exception to this rule is indicated in Scenario C). In general, Convalescent Stay can only be certified to the original NF upon original admission. Please check with the original NF to see how the person was admitted to the facility. Convalescent Stay Scenarios Warning- Please take your time when reviewing the following information. A lot of it is very confusing and there is often more than one answer depending on which reviewer or which PASSPORT agency you are dealing with at the time. If you are ever unsure, it is often best to contact a worker

19 in Preadmision Review for clarification. RR/ID refers to PASRR screen (ODJFS 3622) coded 3- Expired time limt for convalescent stay. Scenario A- An individual is admitted to a NF under a valid convalescent stay (Medicaid or Non Medicaid), returns to the hospital (before convalescent stay expires) say on the 18-day after admission to the NF, and is either readmitted to the same NF or goes to a different NF from the hospital under Non Medicaid. 1. In this scenario the days keep counting towards the Convalescent stay while the individual is in the hospital (as they always do). 2. If the individual either returns to the same NF (say on day 25 from the original admission date to the NF or goes to a different NF on day 25) the RR/ID (3622) still needs to be completed by the 30th day from the original admission. 3. If the person is discharged from the hospital to a different NF, the original NF should forward the transfer form with the convalescent stay to the new NF. 4. If the RR/ID triggers for mental illness or mental retardation, it should be forwarded to the appropriate state authority with the transfer form. Scenario B- The patient is admitted to a NF under a valid convalescent stay under Non Medicaid payment or Medicaid payment. The individual is readmitted back to a hospital from the NF and is in the hospital on the date that the RR/ID is due (day 30). This individual will either be going to a new NF from the hospital or going back to the same NF (Non Medicaid or Medicaid payment). There are multiple possibilities for this one. 1. The individual is going back to the same NF under Non Medicaid The NF will need to complete a 3622 and code it 3- expired time limit for convalescent stay. Technically, the NF should complete the RR/ID by the 30th day after admission even if the individual is in the hospital. If the NF completes the screen and it does not trigger for mental illness and/or

20 MR/DD, it should be placed on the patient s chart with the transfer form that validates the convalescent stay. The NF can report the expired convalescent stay to Preadmission Review when the person returns to the NF by faxing a cover sheet and a demographics page.. If it does trigger for mental illness or MR/DD the NF will need to forward it to the appropriate state authority even if the individual is still in the hospital. However, it is important to make the state aware that the person is currently in the hospital. 2. The individual is going back to the same NF under Non Medicaid. Prior to the hospitalization, the NF has already completed the RR/ID and it triggers for mental illness and/or MR/DD and the NF forwarded the RR/ID to the state authority. If a determination has not been received from the state authority as yet, the individual can return to the same NF from the hospital and wait for the determination from the state. The NF needs to contact the state authority and inform them of the patient s location. 3. The individual transfers to a different NF from the hospital under Non Medicaid. The original NF has already completed the RR/ID and it triggers for mental illness and/or MR/DD. The original NF has already forwarded the paperwork to the state authority. If the determination has not been received as yet,the individual can go to a different NF and wait for the determination from the state. The original NF should forward the transfer form with the convalescent stay, the RR/ID, and the proof that it was faxed to the state authority to the new NF. Again, it is important to contact the state authority and inform them of the patient s current location. 4. The individual transfers to a different NF from the hospital under Non Medicaid If the original NF did not complete the RR/ID (3622-coded 3- expired time limit for convalescent stay), the new NF can complete the RR/ID. The original NF should forward the transfer form with the valid convalescent stay to the receiving NF. If the screen triggers for mental illness and/or MR/DD the NF will have to forward it to the state authority in Columbus, 5. The patient is transferring to a different NF from the hospital under Non Medicaid. The original NF either cannot locate the transfer form with the

21 convalescent stay or the original NF received a transfer form without a valid convalescent stay. The receiving NF should complete a RR/ID and code it 7- No previous PASRR records. Or, if the receiving NF wants a PAS issued, the hospital can submit to Preadmission Review for a PAS. If the NF accepts the individual without a PAS and completes one coded 7-If the screen triggers for mental illness and/or MR/DD the screen should be forwarded to the state authority. If the screen does not trigger for mental illness and/or MR/DD, the screen should be kept in the resident s chart. It does not have to be forwarded to Preadmission Review unless the NF is requesting a LOC. 6. The patient is transferring to a new NF from the hospital under Medicaid. a. The original NF will need to forward a copy of the convalescent stay transfer form to Preadmission review (unless preadmission review already has verification in their system). The transfer form should also be forwarded to the hospital worker so it can be passed on to the new NF. b. If the original NF has already completed the RR/ID, it should be forwarded to Preadmission Review so they can verify it. It should also be forwarded on to the hospital worker so it can be forwarded to the new NF. c. If the original NF has already completed the RR/ID and it triggers for mental health and/or MR/DD and the NF has already faxed it to the state authority, a LOC cannot be issued until an approval is received from the state authority. d. If the NF did not complete a RR/ID, the hospital discharge planner can complete a RR/ID. If the transfer form with convalescent stay is obtained from the original NF, the screen should be coded 3- expired time limit for convalescent stay. If the convalescent transfer form cannot be obtained from the original NF, the screen should be coded 1- and a PAS can be requested from Preadmission Review. e. If the screen triggers for mental illness or MR/DD, the hospital worker will need to forward the RR/ID to the appropriate state authority. Preadmission Review cannot issue a LOC (level of care) until an approval is received from the state authority. 7. If the patient is returning to the same NF under Medicaid. Follow the

22 same basic steps as in #6 (above). If the individual is returning to the same NF under Medicaid, the person was either Non Medicaid at the NF prior to the hospitalization, out of bed hold days for the year, or the individual may have been covered under a Medicaid HMO which usually do not pay for bed hold days. Scenario C- An individual is admitted to the NF from the hospital under a valid convalescent stay (Non Medicaid or Medicaid). The individual is still residing in the NF on the 30 th day after admission. The RR/ID triggers for mental illness and/or MR/DD and the individual is readmitted to the hospital. 1. The original NF has already sent and received further review results from the state authority on a resident (Please remember that if the resident needed further review for both mental illness and MR/DD, you must wait for both determinations from each state authority before a decision can be made about the resident). 2. The resident received a No NF Need determination. However, the state authority indicated that the individual should be admitted to a psychiatric unit for stabilization. 3. The resident is admitted to a psychiatric unit of a hospital. The NF discharged the individual from their census. 4. The hospital can apply for another 30 day convalescent stay for the individual to go to a different NF or back to the same NF. Scenario D- An individual is admitted to a NF from the hospital under a valid convalescent stay (Non Medicaid or Medicaid). The individual is still residing in the NF on the 30 th day after admissions. The RR/ID triggers for mental illness and/or MR/DD and the individual is readmitted to the hospital from the NF. 1. The original NF has already sent and received further review results from the state authority on a resident (again, if it is a dual determination, both results must be received).

23 2. The resident received a No NF- No Specialized Service Determination from the state authority. 3. At this point, the NF must make the resident aware of the decision. The individual or (if the individual has a legal guardian) can appeal the decision. 4. If an appeal is made, the paperwork must be signed and forwarded to the appropriate agency. 5.If no appeal is made, the NF has 30 days to make an appropriate discharge for the resident. If the individual is admitted to the hospital and the NF makes an informed decision that it cannot adequately treat this individual when he/she is ready to be discharged from the hospital, the NF can discharge the resident of their census. If it appears that the NF is not making a fair determination, the long-term care ombudsman should be contacted. A new convalescent stay cannot be requested on the person. If the Individual received a No NF- No Specialized Services determination and the NF started a required 30day discharge, the individual can return to the NF from the hospital and continue to reside there until a proper discharge is provided. **However, if the individual is out of bed hold days, a new LOC cannot be issued. If this situation occurs the NF can complete a 3622 and code it 6 (significant change in condition) and forward it to the state authority for a new determination. If it is approved, a new LOC can be issued. Scenario E- An individual is admitted to a NF from the hospital under a valid convalescent stay (Non Medicaid or Medicaid). The individual is readmitted to the hospital before the convalescent stay has expired. The individual transfers to a different NF from the hospital under Medicaid payment. 1. The individual is hospitalized before the convalescent stay has expired. 2. The individual transfers to a different NF from the hospital under Medicaid before the 30 days from the original admission to the first NF. 3. A LOC is required to pay the new NF.

24 4. Since the resident review (3622- coded-3- expired time limit for convalescent stay) is not due as yet, the hospital should request the transfer form from the original admission to the NF (which certifies the convalescent stay). If the original NF is unable to locate the transfer form, the hospital can complete a PASRR and code it 1- No previous PASRR Records. Either the convalescent stay transfer form or screen coded 1 should be forwarded with a current transfer form to Preadmission Review so a LOC can be issued. If it is a screen coded 1, a PAS will also be issued. 5. If it is located, the original NF should forward the transfer form with the convalescent stay to the new NF. 6. Again, if the original NF locates the transfer form with convalescent stay, the new NF will need to complete a RR/ID by the 30th day from the admission date to the original NF. If it triggers for mental illness or MR/DD, it should be forwarded to the appropriate state authority with the transfer form that certifies the convalescent stay. Scenario F- An individual is admitted to a NF under a valid convalescent stay (Non Medicaid or Medicaid). The individual is readmitted to the hospital before 30 days and then transfers to a different NF (Non Medicaid) to a different NF. 1. She is readmitted to the hospital (let s say on the 11TH day after admission). 2. She is discharged from the hospital to a different NF under Non Medicaid Payment (let s say on the 19TH from the original date of admission to the NF). 3. The original NF should forward the transfer form, which validates the convalescent stay to the new NF. Again, if the NF cannot locate it, the receiving NF can complete a RR/ID and code it If the original transfer form with convalescent certification is received, the new NF completes a RR/ID and codes it a 3-expired time limit for convalescent stay.

25 5. The RR/ID should be placed in the residents chart with the transfer form that validates the convalescent stay. If the receiving NF obtains the transfer from with valid convalescent stay from the original NF, the NF can report an expired convalescent stay to Preadmission Review by forwarding a cover sheet that indicates expired convalescent stay and a demographics page with contact information. 6. If it triggers for mental illness and/or MR/DD the screen and transfer form with the convalescent stay certified on it should be forwarded to the appropriate state authority. Scenario G- An individual is admitted to a NF under a valid convalescent stay (Non Medicaid or Medicaid). The individual would like to transfer to a different Medicaid certified NF under Non Medicaid payment before the 30 days have expired. 1. The individual would like to transfer to another nursing facility before the 30 days have expired under Non Medicaid. 2. The original NF should forward the transfer form with valid convalescent stay to the receiving NF. 3. If it is determined prior to transfer that this individual will be a long-term resident of the receiving NF, the original NF can complete the RR/ID (coded 3-expired time limit for convalescent stay). If it triggers for mental illness and/or MR/DD, it could be forwarded to the state authority for further review or since it is not the 30 th day as yet the receiving NF can forward to the state authority by the 30 th day from admission to the initial NF. Even if the original NF forwards to the state authority, the individual can transfer to the receiving NF prior to the determination from ODMH or ODMR/DD. However, if the state authority determines that the consumer does not have a NF need, the NF will have to start a 30 day discharge. Scenario H- An individual is admitted to a nursing facility under a valid convalescent stay (Non Medicaid or Medicaid). The individual would like to transfer to another NF before the 30 days have expired under Medicaid payment. 1. The individual would like to transfer to another NF before the 30 days

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