Fourth, a 7000 Hospital Exemption cannot be issued for an individual who is in a hospital psychiatric unit.

Transcription

1 Information for Lesson 6 Hospital Exemption Information (Formerly Convalescent Stays and Various Scenarios Involving Hospital Exemptions-) For the HENS (Hospital Exemption Notification System) website go to We have discussed Hospital Exemptions previously but this lesson will explore many different scenarios related to how a NF deals with it after a person is admitted under one of them. (This page is a review but it can't hurt to discuss again) Again, I suggest that you have a PASRR screen in hand while reading this Lesson Also, we mention RR/ID in this lesson. The RR/ID is the PASRR screen. I apologize if this is confusing but what you need to know is that the PASRR screen is called a Resident Review for codes 3-7 in section B of the screen. However, we often refer to it as a RR/ID (Resident Review Identification). I know these terms are often interchangeable. In this lesson we address code 3 for expired time limit for expired hospital exemption. When we mention state authority, we mean Kepro (for mental health issues- fax # ) and DODD- Department of Developmental Disabilities (For MR/DDfax # ) Okay, now that we got that out of the way, there are some important things to point out; (And some review from previous Lessons) First of all, it is important to note where each individual was residing prior to admission to the NF (Such as, Home, Assisted Living, Non Medicaid NF, Medicaid certified NF, etc). As we know from previous lessons that a 7000 hospital exemption can only be issued for an individual that was residing in the community prior to a hospitalization. Second, as we have discussed previously, a 7000 Hospital Exemption can only be issued when an individual has been admitted to the hospital. A Hospital Exemption cannot be issued for a person who is in the emergency room, or a hospital observation unit (The person must actually be admitted to the hospital). A Hospital Exemption cannot be issued for a person who is admitted to a Medicaid certified Nursing Facility directly from the community; such as their own home, an assisted living facility, etc. 1

2 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 issued a new 7000 Hospital Exemption. A Hospital Exemption can only be certified to a NF for an admission- not a readmission. Please check with the original NF to see how the person was admitted to the facility. Fourth, a 7000 Hospital Exemption cannot be issued for an individual who is in a hospital psychiatric unit. and Fifth, a 7000 Hospital Exemption cannot be issued for an individual who has had an adverse determination from the Ohio Mental Health Authority and/or Ohio Department of Developmental Disabilities within the previous 60 days. In this case either one or both of those agencies indicated that the individual could not either be admitted to a Medicaid certified NF or the individual had to be discharged from a Medicaid certified nursing facility. That said, now we will discuss many different Hospital Exemption scenarios. Hospital Exemption Scenarios (Formerly Listed as Convalescent Stays) 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 in Preadmission Review for clarification. The scenarios listed below are really only a point of reference when completing a 3622 for an expired Hospital Exemption. Important Terms/Forms Again, RR/ID refers to the PASRR screen (ODJFS 3622). In this lesson the majority are coded 3- Expired time limit for Hospital Exemption. The scenarios listed below do not assume that the NF's have requested extended stays. This is a new concept that began 12/1/09 and we will discuss it in Lesson 10. For an expired hospital exemption, the PASRR screen (known as RR/ID-Coded 3- Expired Time Limit for Hospital Exemption) is due by the 29 th day after the date of admission to the NF. This can be done by paper or you can complete it electronically in 2

3 HENS. Either way, a copy should be kept in the actual chart that is kept for the patient at the nurse's station at the nursing facility. Scenario A- An individual is admitted to a NF under a Hospital Exemption stay (Medicaid or Non Medicaid) payment), returns to the hospital (before Hospital Exemption 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, as well as every scenario when an individual is readmitted to the hospital from the NF within 30 days after admission to the NF under a 7000 Hospital Exemption, the days keep counting towards the Hospital Exemption while the individual is in the hospital. 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 or PASRR screen (all names for the same form) still needs to be completed by the 29th day after the original day of admission. However, when the form is completed for codes 3-7 of section B of the screen, it is known as an RR/ID. I know this can be confusing but we address the screen as the RR/ID in this lesson because we are exclusively discussing code 3 of section B which is Expired Hospital Exemption. 3. If the person is discharged from the hospital to a different NF, the original NF should forward the Hospital Exemption 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 Hospital Exemption Form. Scenario B- The patient is admitted to a NF under a valid 7000 Hospital Exemption 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 29 after the date of admission). 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 Hospital Exemption. Technically, the NF should complete the RR/ID by the 29 th day after admission even if the individual is in the hospital. If the NF completes the screen and it does not trigger for 3

4 mental illness and/or MR/DD, it should be placed on the patient s chart with the Hospital Exemption Form. The NF can report the expired Hospital Exemption 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 (Remember from our previous lessons, the screen goes to fax # or DODD fax# ) 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 Hospital Exemption form, 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 Hospital Exemption), the new NF can complete the RR/ID. The original NF should forward the Hospital Exemption Form 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 Hospital Exemption Form or the original NF received an invalid Hospital Exemption. The receiving NF should complete a RR/ID and code it 6- 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 6-If the screen triggers for mental illness and/or 4

5 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 Hospital Exemption form to Preadmission review (unless Preadmission review already has verification in their system). The Hospital Exemption 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 Hospital Exemption Form is obtained from the original NF, the screen should be coded 3- expired time limit for Hospital Exemption. If the Hospital Exemption form cannot be obtained from the original NF, the screen should be coded 1- and a PAS can be requested from Preadmission Review if the person is returning the same NF. It should be coded 6, if the person is going to a new NF and no PAS is issued. 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 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 do not pay for bed hold days. Scenario C- An individual is admitted to the NF from the hospital under a valid Hospital Exemption (Non Medicaid or Medicaid). The individual is still residing in the NF on the 29 th day after the date of admission. The RR/ID triggers for mental illness and/or 5

6 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 has to discharge this individual from their census. 4. The hospital used to be able to apply for another Hospital Exemption (previously convalescent stay) for the individual to go to a different NF or back to the same NF. However, with the new rules, this loophole has been closed. If the individual is transferring to a different NF or returning to the same NF a PAS should be requested. Since it triggered for further review previously, it will most likely need it again. The new PASRR screen would be coded a 1-Ohio Resident Seeking Nursing Facility Admission. The paperwork (Medical information and PASRR screen-coded 1) should be forwarded to Preadmission Review and they will fax for further review. Scenario D- An individual is admitted to a NF from the hospital under a valid Hospital Exemption (Non Medicaid or Medicaid). The individual is still residing in the NF on the 29 th day after the date of admission. 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). 2. The resident received a No NF- No Specialized Service Determination from the state authority(ies) (This is called an adverse PAS Determination). 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 within the given time frame listed on the determination. 6

7 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 and is only sending the person to the hospital because it cannot locate a placement for the person, the long-term care ombudsman should be contacted. A new 7000 Hospital Exemption cannot be requested on the person. With the new PASRR rules, if the person receives an adverse determination (remember, an adverse determination means that the state authority issued a determination that the individual either could not be admitted to a Medicaid certified NF or could not remain in a Medicaid certified NF) from state authority the individual cannot receive a new hospital exemption within 60 days of the adverse determination. A PAS must be requested for a new admission. If the Individual received a No NF- No Specialized Services determination and the NF started a required 30 day discharge, the individual can return to the NF from the hospital and continue to reside there until a proper discharge is provided. Scenario E- An individual is admitted to a NF from the hospital under a valid Hospital Exemption (Non Medicaid or Medicaid). The individual is readmitted to the hospital before the Hospital Exemption has expired. The individual transfers to a different NF from the hospital under Medicaid payment. 1. The individual is hospitalized before the Hospital Exemption has expired. 2. The individual transfers to a different NF from the hospital under Medicaid by the 29th day after the original day of admission. 3. A LOC is required to pay the new NF. 4. Since the resident review (3622- coded-3- expired time limit for Hospital Exemption) is not due as yet, the hospital should request the Hospital Exemption form from the original admission to the NF. If the original NF is unable to locate the Hospital Exemption form, the hospital can complete a PASRR and code it 1- Ohio Resident seeking Nursing Facility Admission. Either the Hospital Exemption form or screen coded 1 should be forwarded with a current transfer form to Preadmission Review so a 7

8 LOC can be issued. If it is a screen coded 1, a PAS will also be need to be issued. 5. If the Hospital Exemption is located, the original NF should forward the Hospital Exemption form to the new NF. 6. Again, if the original NF locates the Hospital Exemption Form, the new NF will need to complete a RR/ID completed by the 29th day after the original day of admission to the original NF. If it triggers for mental illness or MR/DD, it should be forwarded to the appropriate state authority with the Hospital Exemption Form. Commentary about above situation: Preadmission Review (PAR) is supposed to receive all of the Hospital Exemption 7000 forms as well as the NF. Preadmission Review may have already entered the 7000 form in their system. However, some PAR sites receive more requests than others and depending on how soon the individual returned to the hospital from the NF the 7000 may not have been entered in the system as yet. Whenever, a NF resident is admitted to a hospital from a NF, it is advantageous for the hospital worker to check with the NF for the PAS requirement. You never know when you might need it. Scenario F- An individual is admitted to a NF under a valid Hospital Exemption (Non Medicaid or Medicaid). The individual is readmitted to the hospital before 29 days and then transfers to a different NF from the Hospital to a different NF (NonMedicaid). 1. The NF resident is readmitted to the hospital (let s say on the 11 th day after admission). 2. She is discharged from the hospital to a different NF under Non Medicaid Payment (let s say on the 19 th from the original date of admission to the NF). 3. The original NF should forward the Hospital Exemption Form to the new NF. Again, if the NF cannot locate it, the receiving NF can complete a RR/ID and code it 6 (NF Transfer- No Previous PASRR Record). 4. If the Hospital Exemption is received, the new NF completes a RR/ID (by the 29 th day after the date of admission to the Previous NF- Remember the days keep counting even during a hospitalization) and codes it a 3-expired time limit for Hospital Exemption. 5. The RR/ID should be placed in the residents chart with the Hospital Exemption Form. If the receiving NF obtains the Hospital Exemption Form from the original NF, the NF can report an expired Hospital Exemption to Preadmission Review by forwarding a 8

9 cover sheet that indicates expired Hospital Exemption and a demographics page with contact information. 6. If it triggers for mental illness and/or MR/DD the screen and the Hospital Exemption Form should be forwarded to the appropriate state authority(ies). Scenario G- An individual is admitted to a NF under a valid Hospital Exemption (Non Medicaid or Medicaid). The individual would like to transfer to a different Medicaid certified NF under Non Medicaid payment before the 29 days have expired. 1. The individual would like to transfer to another nursing facility before the 29 days have expired under Non Medicaid. 2. The original NF should forward the Hospital Exemption 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 Hospital Exemption). 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 29 th day as yet the receiving NF can forward to the state authority by the 29 th day from date of 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 Hospital Exemption (Non Medicaid or Medicaid payment). The individual would like to transfer to another NF before the 29 th after the date of admission under Medicaid payment. 1. The individual would like to transfer to another NF before the 29 days have expired under Medicaid payment. 2. The original NF will need to forward the Hospital Exemption along with documentation for a LOC (3697 or MDS with physician certification statement, additional data elements page, physician orders and at least a pending Medicaid number) to Preadmission Review. 3. Since it is not time for the resident review, it does not have to be completed as yet. However, the receiving NF will need to complete the RR/ID by the 29th day from the admission date to the original NF. Again, if it triggers for mental illness or MR/DD, it needs to be forwarded to the state authority with the transfer form and medical information. 9

10 8. Q&A for Hospital Exemptions- Formerly Convalescent Stays 1. Question: An individual is residing in a Medicaid certified NF. He was admitted to the NF directly from the hospital under a valid Hospital Exemption. He is readmitted to the hospital from the NF. He is due to be discharged to a new Medicaid certified NF. Can the person have or does the person need a new Hospital Exemption to go to the new NF? Answer: No, a new Hospital Exemption cannot be issued. The Hospital Exemption from original NF admission follows him to the next NF. If the previous NF did not complete a PASRR screen (because it wasn't time for them to complete it), then the new NF should complete it and code 3-expired time limit for hospital exemption. If it triggers for further review, then it should be forwarded to the proper state authority for either/both mental illness or MR/DD. 2. Question: A person is in the ER (Emergency Room) at a hospital (Prior to the ER the person was at home). Can a Hospital Exemption be certified on a transfer form for the individual to be admitted to a Medicaid certified NF from the ER? Answer: Again, an individual can only receive a Hospital Exemption when she is admitted as an inpatient at a hospital. 3. Question: An individual transfers from one Medicaid certified NF to another Medicaid certified NF. The individual arrives with paperwork which the previous NF believed was a valid Hospital Exemption and a PASRR screen that was completed and coded 3-expired time limit for Hospital Exemption. However, at closer look, the individual was admitted to the previous NF from a Hospital Clinical decision unit (An Observation unit but not actually admitted). What should the receiving NF do at this point? Answer: The new rules indicate that the receiving NF should complete a PASRR screen when they realize that the individual arrived from another Medicaid NF without a proper PASRR requirement. The screen should be coded 6- (No Previous PASRR 10

11 Records). If the screen triggers for mental illness or MR/DD, it should be faxed to the appropriate state authority. 4. Question: An individual was residing in the community. She is admitted to a hospital for an inpatient stay and discharged to a Medicaid certified NF from the hospital on 5/4/15 under a valid Hospital Exemption. She is readmitted to the hospital on 5/26/15 and remains in the hospital on the 29 th day from the original admission to the NF (June 2, 2015) and will be discharged to a new NF. Who is responsible for completing the RR/ID (PASRR screen)? Answer: The new rules indicate that more entities are capable of completing a Resident Review (PASRR Screen) (Such as a hospital worker). However, the NF that the individual was residing at could complete the PASRR screen if the resident is in the hospital on the 29 th after the original admission to the NF. Also, if the receiving NF obtains the Hospital Exemption form from 5/4/15 admission, the receiving NF can complete the screen and code it 3-Expired Time Limit for Hospital Exemption. If the receiving NF cannot obtain the 5/4/15 Hospital Exemption form, the screen can be coded 6. Also, there is still an option that if the proper paperwork can not be obtained from the original NF, they can request that the hospital submit to Preadmission Review for a PAS. In any case, if the screen triggers for mental illness or MR/DD, it should be forwarded the appropriate state authority. The state authority should be informed that the individual is in the hospital. 5. Question: An individual is residing in the community. She is admitted to a hospital. She is discharged to a Medicaid certified NF under a Hospital Exemption. The individual returns to the hospital and is in the hospital when the Hospital Exemption expired. The NF completes the RR/ID (PASRR Screen) and the screen triggers for mental illness. Should the NF forward the RR/ID to Kepro (Ohio Department of Mental Health contract agency) even though the individual is in the hospital? Answer: The NF can/should forward to Kepro. It is always very important to keep the hospital worker informed of the current status of the PAS requirement of the individual. 6. Question: An individual is residing in the community. She is admitted to a hospital. She is discharged to a Medicaid certified NF under a Hospital Exemption. The individual remains in the NF past the 29 th day after admission. The NF completes the 11

12 RR/ID by the 29th day after admission and it does not trigger for mental illness or MR/DD. The individual is readmitted to the hospital (medical floor only) and is discharged to a different NF under Non Medicaid payment. What is the responsibility of the original NF? Answer: The original NF should forward the Hospital Exemption form from original admission to the NF and the PASRR screen that they completed. This is the individual's PAS requirement and should follow the person to the next NF. 7. Question: An individual is residing in the community. She is admitted to a hospital. She is discharged to a Medicaid certified NF under a Hospital Exemption. The NF completes the RR/ID in a timely manner and it triggers for mental illness. The NF forwards the screen to Kepro for further review in a timely manner. ODMH issues a determination of No NF Need- Needs to be admitted to a hospital psychiatric unit. The individual is admitted to a hospital psychiatric unit. Is the individual allowed to be admitted to the NF or a new NF under Hospital Exemption? Answer: The new rules specify that if an individual receives and adverse PAS determination within 60 days, a new Hospital Exemption cannot be issued. A PAS must be applied for to be admitted to a Medicaid certified NF. 8. Question: An individual is admitted to a Medicaid certified NF from the hospital. The individual was residing in the community prior to the hospitalization. The NF does not receive a valid Hospital Exemption from the hospital and a PAS was not issued for the admission. What should the NF do as soon as possible? Answer: If it is still the same day of admission, the NF can ask the hospital to have it completed so that it is valid. If it is past the day of admission, the NF can still ask the hospital if a valid form was completed on the date of admission as maybe the hospital completed it but forgot to forward it to the NF. It cannot be completed after the date of admission to the NF. If the NF cannot obtain a valid form, it should submit to Preadmission review for a PAS as soon as possible. The NF should forward medical information, and a PASRR screen to Preadmission Review for the request. 9. Question: An individual is admitted to a Medicaid certified NF under a Hospital Exemption. The individual is readmitted to the hospital from the NF on the 10th day after admission to the NF. The individual is going to be transferred to a new NF from the hospital. The original NF cannot locate the Hospital Exemption. What happens now? 12

13 Answer: If the Hospital Exemption form cannot be located. I would check with the hospital that sent the individual to the NF. If the hospital is unable to come up with it. Preadmission Review may be able to provide it. If it cannot be located a PAS may be requested by the hospital or the receiving NF can complete a new screen and code 6 upon admission. 10. Question: An individual is residing in the community. He is admitted to the hospital and needs rehab in a NF. The individual is a admitted to the NF under Medicare payment. The admission coordinator at the NF does not look closely at the Hospital Exemption form and it is not valid (example; it was signed by a nurse and not an Md or DO) and a PAS was not issued. The individual is readmitted to the hospital from the NF. While the individual is in the hospital, the NF realizes that it does not have a valid PAS. The individual is due to return the same NF still under Medicare. What can be done about the PAS requirement? Answer: Again, in this instance, the hospital can submit to Preadmission review for a PAS or the NF can submit to Preadmission review for a PAS even while the person is in the hospital. 11. Question: Similar to previous questions-an individual is residing in the community. He is admitted to the hospital and needs rehab in a NF. The individual is admitted to the NF under Medicare payment. The admission coordinator at the NF does not look closely at the transfer form and it does not have a valid Hospital Exemption and a PAS is not issued. The individual is readmitted to the hospital from the NF. While the individual is in the hospital, the NF realizes that it does not have a valid PAS. The individual is due to transfer to a different NF under Medicaid payment. What can be done about the PAS requirement so that a LOC can also be issued? Answer: In this instance, a PAS will need to be issued for a LOC to be issued. 12. Question: An individual is residing in the community. He is admitted to a hospital and discharged to a NF under a valid Hospital Exemption. The NF completes the PASRR screen in a timely fashion and submits to Kepro within the time frame as the screen triggers for mental illness. The state issues a determination of No NF Need- No Specialized Services Need. What should the NF do at this point? Answer: It should be indicated on the determination page that the NF has 30 days to arrange for an appropriate discharge for the person. The determination can also be 13

14 appealed by signing it and forwarding it to the address listed on the form. 13. Question: An individual is residing in the community. He is admitted to a NF under a valid Hospital Exemption under Medicaid. The NF completes the PASRR screen in a timely fashion and submits to DODD within time frame as the screen triggers for mental retardation. The state issues a determination of No NF Need- No Specialized Services Need (This is called an Adverse Determination). Within two days of the determination being received by the NF, the individual suffers a CVA and is hospitalized. The individual will need to return to a NF under Medicaid payment for therapy. Can the individual return to the NF? Answer: Since an adverse determination was recently issued, a new PASRR screen will need to be completed and coded 1- NF Applicant. This screen will need to be forwarded to DODD with current medical information. If approved for NF placement, Preadmission review will be able to issue a LOC for NF placement. 14. Question: An individual is residing in the community. He is admitted as an inpatient to a hospital. He is discharged to a NF under a Hospital Exemption under Medicaid payment. The NF completes the PASRR screen in a timely fashion and submits to Kepro within time frame as the screen triggers for mental illness. The state issues a determination of No NF Need- No Specialized Services Need (Adverse Determination). Within two days of the determination being received by the NF, the individual suffers a CVA and is hospitalized. The individual will need to return to a NF under Medicare payment for therapy. What happens in this case regarding a PAS requirement? Answer: Again, since he received an adverse determination within the past 60 days a new PASRR will need to be completed and coded 1- NF applicant. It should be forwarded to ODMH with current medical information. If approved, Preadmission review can issue a PAS for admission to the NF. Or, Preadmission review can be bypassed- If approved, the individual can continue to reside in the NF. If not, it can either be appealed or the NF can start a discharge. 15. Question: An individual is residing in the community. He is admitted to the hospital and is discharged to a NF under Medicare with a valid hospital exemption. On the tenth day after admission, his daughter contacts the NF and would like the individual transferred to a NF closer to where she lives. Medicare will continue to pay for care at 14

15 the next NF. What should the forwarding NF provide to the receiving NF with regard to a PAS requirement? Answer: The NF should forward the Hospital exemption to the next NF. It is not time for the PASRR screen to be completed and coded 3- expired time limit for Hospital Exemption as yet. The receiving NF should complete by the 29th day from admission to original NF. 16. Question: An individual is residing in the community. He is admitted to the hospital and is discharged to a NF under Medicare with a Hospital Exemption. The NF completes the PASRR screen in a timely manner. After five weeks, the individual would like to transfer to a different NF. Medicare will still pay for care at the next NF. The sending NF provides the Hospital Exemption Form and PASRR screen to the receiving NF. Within a few days of the individual being admitted to the NF, it is discovered that the individual has a diagnosis of mild Mental Retardation and it was not addressed on the screen that the original NF completed. What should be done? Answer: The receiving NF should complete a PASRR screen and code it 7-significant change in condition and fax it to DODD with medical information as soon as it is discovered. 17. Question: An individual is residing in the community. He is admitted to the hospital and is discharged to a NF under Medicare with a valid Hospital Exemption. The hospital transfer form does not specify a primary diagnosis and the individual is diagnosed with both schizophrenia and dementia. Does this really matter any more when completing the PASRR screen? Answer: The rules still indicate that a primary diagnosis should be specified. However, when completing the current PASRR screen you would still need to address both the dementia (section C) and the schizophrenia (Section D). The NF should check with this individual's physician and have the doctor specify a primary diagnosis in writing or a verbal order can be taken with the physician re: the primary diagnosis. 18. Question: An individual is residing in the community. He is admitted to the hospital and is discharged to a NF under Medicare with a valid Hospital Exemption. Within three 15

16 weeks, the individual would like to transfer to a different NF. He is not skilled anymore and a LOC will be needed to pay the receiving NF. What needs to be provided to Preadmission Review to obtain a LOC? Answer: Since it has been only three weeks, the valid Hospital Exemption is the only paperwork required. The PASRR screen is not due until the 29th day after admission and the receiving NF should complete by that date. The rest of the information needed is 1 An MDS, 2. Physician orders, 3. A signed/dated physician certification statement, and 4. Additional data elements page, or just a completed ODJFS 3697 form. 19. Question: An individual is residing in the community. He is admitted to the hospital and is discharged to a NF under Medicare with a valid Hospital Exemption. The NF completes the paperwork and submits to Preadmission Review for an expired hospital exemption. The PASRR screen that is completed does not trigger for mental illness or MR/DD. During this time, the individual would like to transfer to a different NF under Non Medicaid. Does the NF have to wait for paperwork from Preadmission Review prior to transferring the individual to a different NF? Answer: No, this question gets asked a lot, but the individual does not have to wait for anything from Preadmission review prior to transferring. The original NF needs to forward the valid Hospital Exemption and PASRR screen that the NF completed. 20. Question: An individual is residing in the community. He is admitted to the hospital and is discharged to a NF under Medicare with a valid Hospital Exemption. The NF completes the PASRR screen. The screen triggers for mental illness and the paperwork is forwarded to Kepro. During this time, the individual would like to transfer to a different NF under Non Medicaid. Does the NF have to wait for paperwork from Kepro prior to transferring the individual to a different NF? Answer: Again as in previous question, it is up to the receiving NF. If they would like to take this person they have to be aware of the possibility that the state authority may deny continued NF placement for this person. 21. Question: An individual is residing in the community. He is admitted to the hospital 16

17 and is discharged to a NF under Medicare with a valid hospital exemption. The NF completes the PASRR screen by the 29 th day after the date of admission. The screen triggers for a developmental disability and the paperwork is forwarded to DODD. During this time, the individual would like to transfer to a different NF under Medicaid. Can a LOC be issued for a transfer to a different NF? Answer: In this circumstance, a LOC cannot be issued until an approval is received from the state authority. If an approval is not received, a LOC cannot be issued. The NF can either appeal this decision or start a discharge for the person. 22. Question: A LOC is issued for an admission from the hospital to a Medicaid certified NF under a Hospital Exemption. The individual is due to be discharged to the NF the same day the LOC is received. However, just before discharge he ends up having medical complications and needs to remain in the hospital for another 2 weeks. He is then discharged to the NF under the LOC that was issued. The LOC was dated 2 weeks ago. Is it still valid and then what date do I start counting when I plan on completing the PASRR screen? Answer: As long as the individual continues to need assistance as he did when the LOC was completed, it would remain effective for up to 30 days from the date it was issued. For when you should complete the PASRR screen for the expired Hospital Exemption, you should still complete it by the 29 th day after the date of admission to the NF. 23. Question: I am from a Medicaid certified NF. We receive an individual from the hospital under Medicare payment with a complete Hospital Exemption. The hospital social worker also completes a PASRR screens and forwards to us. Since the hospital worker completed it, do I also need to complete one by the 29 th day after the date of admission? Answer: The screen completed by the hospital worker does not take the place of the screen that you complete. You will still need to complete one by the 29 th day after the date of admission. 24. Question: I am an admissions coordinator at a Medicaid certified NF. Does the hospital need to complete a new Hospital Exemption each time a NF resident is readmitted to the hospital? Answer: No, a Hospital Exemption form is only issued when the individual is first admitted to the NF. He had to have been residing in the community prior to the 17

18 hospitalization. A Hospital Exemption cannot be issued if an individual was residing in a Medicaid certified NF prior to the hospitalization. 25. Question: I work in a Medicaid certified NF. I admitted an individual from the hospital two days ago. The hospital worker promised that she would provide the Hospital Exemption form but I have not received it as yet. What should I do if I do not get it soon? Answer: I would fax a request to Preadmission Review for a PAS (Medical information and a PASRR screen) as you have an individual in your NF without a PAS requirement. Also, if it is very soon after admission, Preadmission Review may still have it and can provide it to you (Although, they are not required to do so). 26. Question: I am a discharge planner completing a Hospital Exemption form. The individual that I am completing the form for has a diagnosis of MS (Multiple Sclerosis). Should I check yes on question 4 of section B and specify it as indicated? Answer: The 7000 Hospital Exemption form specifies that if the person has any type of developmental disability for which the onset occurred prior to age 22, the state authority wants the question checked yes and the developmental disorder listed. 27. Question: I am a nursing home admissions coordinator. A person has a mental health diagnosis listed on his hospital paperwork, but it is not indicated on the 7000 form that the hospital worker provided to me. Is this 7000 form invalid? Answer: The question should be checked Yes or No, however, if it is checked incorrectly or not at all it does not make it invalid. Sometimes not all of the diagnoses are available at the hospital. 28. A person is admitted to the hospital from the community. A 7000 Hospital Exemption Form is completed for him to be admitted to a Medicaid certified NF under Medicare Payment. Instead of going to the NF, the individual is discharged to home. After a few days, it is apparent that he needs to be in a NF. Can the 7000 Hospital Exemption be used for the person to be admitted to the NF directly from home? Answer: No, per the Ohio Administrative Rules, since the person did not go directly to the NF from the hospital, the 7000 Hospital Exemption form cannot be used for an admission to the NF from home. A PAS will need to be requested from Preadmission Review for admission to the Medicaid certified NF. 18

19 29. Question: I am a nursing home social worker. A resident was admitted to my NF under a hospital exemption. Within 10 days after admission, he is readmitted to a hospital psychiatric unit. Do I need to complete a PASRR screen coded-7 for significant change in condition? Answer: Yes, the resident review does need to be completed for an individual who is readmitted from a nursing facility to a hospital psychiatric unit every time this happens. The screen should be coded 7 and it should be forwarded to the state authority(ies) if it triggers. 30. Question: An individual is residing in a Medicaid certified NF. He was admitted under a Hospital Exemption under Medicaid payment. On day 28 from the original date of admission to the NF, the individual is readmitted to the hospital from the NF. The individual is ready to be discharged (on day 32) but prefers to be discharged to a different NF. Under Medicaid payment a new LOC is needed for the receiving NF. How can this be accomplished? Answer: Since it is over 30 days from the original admit date to the NF, the PASRR screen is due. The original NF or the hospital worker can complete a PASRR screen. The 7000 Hospital Exemption form should also be obtained. If the PASRR screen triggers for mental illness or MR/DD an approval from the state authority will have to be obtained prior to a LOC being issued. 31. Question: Similar to previous question- An individual is residing in a Medicaid certified NF. He was admitted under a Hospital Exemption under Medicaid HMO payment. A LOC is not needed as it is an HMO. On day 28 from the original date of admission from the hospital to the NF, the individual is readmitted to the hospital from the NF. The individual is ready to be discharged but prefers to be discharged to a different NF on day 32. The payment source will again be Medicaid HMO. A LOC is still not needed for the receiving NF. How can this be accomplished? Answer: Since it is over 30 days from the original admit date to the NF, the PASRR screen is due. The original NF or the hospital worker can complete a PASRR screen. The original hospital exemption should also be obtained. If the PASRR screen triggers for mental illness or MR/DD an approval from the state authority will have to be obtained but the individual can be admitted to the new NF under the HMO as long as the HMO approves and wait for determination from state authority. 19

20 Post Test Questions for Lesson 6 1. An individual is admitted to a Medicaid certified NF under a valid Hospital Exemption. Within ten days, she is readmitted to the hospital. She will be transferred to a different NF at discharge from the hospital. A new hospital exemption can be certified- True/False 2. An individual is admitted to a Medicaid certified NF under a valid 7000 Hospital Exemption form. On the tenth day after admission to the NF, the individual needs to be readmitted from the NF to the Hospital. You would continue to count the days that the individual is in the hospital toward the expiration of the Hospital Exemption. True/False 3. An individual is admitted to a Medicaid certified NF under a valid Hospital Exemption. If the individual is still residing in the NF (or the NF sent the individual to the hospital and he/she is in the hospital on the 29 th day after the date of admission to the NF) a worker at the NF should complete the PASRR screen for the individual on this day for an expired Hospital Exemption. However, it is possible for the hospital social worker to complete the screen if the person is in the hospital and the NF refuses to do so. True/False 4. A Hospital Exemption can only be certified for an admission to a NF, not a readmission (Based on the PASRR Rules that we discussed earlier in the course regarding the definition of an admission and a readmission)- True/False (Hint-This is a review question from previous lessons) 5. An individual receives an adverse PAS determination (Remember an adverse determination occurs when a person receives a determination from the state authority that does not allow the person to either enter a Medicaid certified NF or to remain in a Medicaid certified NF). He/she cannot have a 7000 Hospital Exemption issued for admission to a NF within 60 days after the adverse PAS determination. True/False 6. A 7000 Hospital Exemption form is completed for a person who is an inpatient at a hospital and the individual goes home instead of being discharged to a Medicaid certified NF. The 7000 Hospital Exemption can still be used for the person to be admitted to a Medicaid certified NF a week after discharge to home. True/False 7. A Hospital Exemption cannot be issued for a person who is in the emergency room, or a hospital observation unit (The person must actually be admitted to the hospital). True/False 20

21 8. The new rules indicate that the receiving NF should complete a PASRR screen when they realize that the individual arrived from another Medicaid NF without a proper PASRR requirement. The screen should be coded 6- (No Previous PASRR Records). If the screen triggers for mental illness or MR/DD, it should be faxed to the appropriate state authority. True/False 9. The RR/ID, 3622 or PASRR screen (all names for the same form) True/False 10. The 7000 Hospital Exemption form specifies that if the person has any type of developmental disability for which the onset occurred prior to age 22, the state authority does not want the question checked yes and the developmental disorder listed. True/False 21