(B)(A)
Definitions.
For
purposes of determining an individual's nursing-facility (NF) based level of
care, the following definitions apply unless a term is otherwise defined in a
specific rule:
(1) "Active Treatment" means a
continuous treatment program including aggressive, consistent implementation of
a program of specialized and generic training, treatment, health services and
related services for individuals with mental retardation and/or other
developmental disabilities that are directed toward the
following:
(a) The acquisition of the behaviors
necessary for the individual to function with as much self determination and
independence as possible; and
(b) The prevention or deceleration
of regression or loss of current optimal functional status.
(2)(1)
"Activity of daily living (ADL)" means a personal or self-care task that
enables an individual to meet basic life needs.
For
purposes of this rule, the term "ADL" includes the following defined
activities:
(a) "Bathing" means the ability of
an individual to cleanse one's body by showering, tub, or sponge bath, or any
other generally accepted method.
(b) "Dressing" means the ability of an
individual to complete the activities necessary to dress oneself and includes
the following two components:
(i) Putting on
and taking off an item of clothing or prosthesis; and
(ii) Fastening and unfastening an item of
clothing or prosthesis.
(c) "Eating" means the ability of an
individual to feed oneself. Eating includes the processes of getting food into
one's mouth, chewing, and swallowing, and/
or the ability to use and self-manage a feeding tube.
(d) "Grooming" means the ability of an
individual to care for one's appearance and includes the following three
components:
(i) Oral hygiene;
(ii) Hair care; and
(iii) Nail care.
(e) "Mobility" means the ability of an
individual to use fine and gross motor skills to reposition or move oneself
from place to place and includes the following three components:
(i) "Bed mobility" means the ability of an
individual to move to or from a lying position, turn from side to side, or
otherwise position the body while in bed or alternative sleep
furniture;
(ii) "Locomotion" means
the ability of an individual to move between locations by ambulation or by
other means; and
(iii) "Transfer"
means the ability of an individual to move between surfaces, including but not
limited to, to and from a bed, chair, wheelchair, or standing
position.
(f)
"Toileting" means the ability of an individual to complete the activities
necessary to eliminate and dispose of bodily waste and includes the following
four components:
(i) Using a commode, bedpan,
or urinal;
(ii) Changing
incontinence supplies or feminine hygiene products;
(iii) Cleansing self; and
(iv) Managing an ostomy or
catheter.
(3)(2) "Adverse level of
care determination" means a determination that an individual does not meet the
criteria for a specific level of care.
(4)(3) "Alternative form"
means a form that is used in place of and contains all of the data elements of,
the JFS 03697
ODM
03697, "Level of Care Assessment" (rev.
4/2003) to request a level of care determination from the
Ohio department of job and family services
(ODJFS)
Ohio department of medicaid (ODM)
or its designee.
(5)(4) "Assistance" means
the hands-on provision of help in the initiation and/ or completion of a task.
(6)(5)
"Authorized representative" has the same meaning as in rule
5101:1-37-01
5160-1-33 of the Administrative Code.
(7) "CBDD" means a county board of
developmental disabilities as established under Chapter 5126. of the Revised
Code.
(8)(6) "Current diagnoses"
means a written medical determination by the individual's attending physician,
whose scope of practice includes diagnosis, listing those diagnosed conditions
that currently impact the individual's health and functional
abilities.
(9)(7) "Delayed
face-to-face
in-person visit" means an in-person visit that occurs
within a specified period of time after a desk review has been conducted that
includes the elements of a long-term care consultation, in accordance with
Chapter 173-43 of the Administrative Code, for the purposes of exploring home
and community-based services (HCBS) options and making referrals to the
individual as appropriate.
(10)(8) "Desk review"
means a level of care determination process that is not conducted in
person.
(9)
"Developmental disabilities level of care" means the level
of care as described in rule
5123-8-01 of the Administrative
Code.
(11) "Developmental delay" means
that an individual age birth through five has not achieved developmental
milestones as expected for the individual's chronological age as measured,
documented, and determined by qualified professionals using generally accepted
diagnostic instruments or procedures.
(12) "Face-to-face" means an
in-person level of care assessment and determination process with the
individual for the purposes of exploring nursing facility services or HCBS
options and making referrals to the individual as appropriate, that is not
conducted by a desk review only.
(13) "Habilitation" in accordance
with 42 U.S.C. 1396n(c)(5) as in effect December 27, 2005, means services
designed to assist individuals in acquiring, retaining, and improving the
self-help, socialization, and adaptive skills necessary to reside successfully
in home and community-based settings.
(14)(10)
"ICF-MR"
"ICF-IID" means an intermediate care facility for
persons with mental retardation
individuals with intellectual disabilities as defined in
section 5124.01 of the Revised
Code.
(15) "ICF-MR-based level of care"
means the levels of care as described in rules 5101:3-3-07, 5101:3-3-15.3, and
5101:3-3-15.5 of the Administrative Code.
(11)
"Immediate need"
means an individual has a need that may result in substantial harm or decline
in functioning if waiver services and supports are not received within thirty
calendar days.
(12)
"In-person" means a level of care assessment and
determination process conducted in the physical presence of the individual for
the purposes of exploring nursing facility services or HCBS options and making
referrals to the individual as appropriate, that is not conducted by a desk
review only.
(16)(13) "Individual"
means a medicaid recipient or person with
pending
applying for medicaid
eligibility.
(17)(14) "Instrumental
activity of daily living (IADL)" means the ability of an individual to complete
community living skills.
For the purposes of this
rule, the term "IADL" includes the following defined activities:
(a) "Community access " means the ability of
an individual to use available community services and supports to meet one's
needs and includes the following three components:
(i) "Accessing transportation" means the
ability to get and use transportation.
(ii) "Handling finances" means the ability of
an individual to manage one's money
and does not
include transportation. Handling finances includes all of the
following:
(a) Knowing where money
is;
(b) Knowing how to get
money;
(c) Paying bills;
and
(d) Knowing how to get and use
benefits and services, including but not limited to:
(i) Health benefits and insurance;
(ii) Social benefits; and
(iii) Home utilities.
(iii) "Telephoning" means the
ability to make and answer telephone calls or use technology to connect to
community services and supports.
(b) "Environmental management" means the
ability of an individual to maintain the living arrangement in a manner that
ensures the health and safety of the individual and includes the following
three components:
(i) "Heavy chores" means the
ability to move heavy furniture and appliances for cleaning, turn mattresses,
and wash windows and walls; and
(ii) "House cleaning" means the ability to
make beds, clean the bathroom, sweep and mop floors, dust, clean and store
dishes, pick up clutter, and take out trash;
(iii) "Yard work and/or maintenance" means the ability to care for the
lawn, rake leaves, shovel snow, complete minor home repairs, and
paint.
(c) "Meal
preparation" means the ability of an individual to prepare or cook food for
oneself.
(d) "Personal laundry"
means the ability of an individual to wash and dry one's clothing and household
items by machine or by hand.
(e)
"Shopping" means the ability to obtain or purchase one's necessary items.
Necessary items include, but are not limited to, groceries, clothing, and
household items. Shopping does not include handling finances or accessing
transportation.
(18)(15) "Less than
twenty-four hour support" means that an individual requires
needs the
presence of another person, or the presence of a remote monitoring device that
does not require
need the individual to initiate a response, during a
portion of a twenty-four hour period of time.
(19)(16) "Level of care
determination" means an assessment and evaluation by
ODJFS
ODM or its
designee of an individual's physical, mental, social, and emotional status,
using the processes described in
rules 5101:3-3-15,
5101:3-3-15.3, and 5101:3-3-15.5
rule
5160-3-14 of the
Administrative Code, to compare the criteria for all of the possible levels of
care as described in rules
5101:3-3-06 to
5101:3-3-08
5160-3-06 to 5160-3-08 of the
Administrative Code, and make a decision about whether an individual meets the
criteria for a level of care.
(20)(17) "Level of care
validation" means the verification process for ODJFS
ODM or its
designee that includes verifying the preadmission
screening and resident review criteria have been met for an individual as well
as reviewing and enteringto review and
enter an individual's current level of care in the electronic records
of the individual that are maintained by
ODJFS
ODM.
(21)(18) "Long-term
services and supports" means institutional or community-based medical, health,
psycho-social, habilitative, rehabilitative, or personal care services that may
be provided to medicaid-eligible individuals.
(22) "Major life area" has the same
meaning as in rule 5101:3-3-07 of the Administrative Code.
(23) "Manifested" means a condition
is diagnosed and interferes with the individual's ability to develop or
maintain functioning in at least one major life area.
(24)(19) "Medication
administration" means the ability of an individual to prepare and
self-administer all forms of over-the-counter (OTC) and prescription medication.
Intravenous medication administration will be
considered a skilled nursing service for the purposes of determining NF-based
level of care, OTC and all other self-administered prescription medication will
not be considered a skilled nursing service.
(25)(20) "Need" means the
inability of an individual to complete a necessary and applicable task
independently, safely, and consistently. An individual does not have a need
when:
(a) The individual is not willing to
complete a task or does not have the choice to complete a task.
(b) The task can be completed with the use of
available assistive devices and accommodations.
(26)(21)
"Nursing facility (NF)" has the same meaning as in section
5111.20
5165.01 of the Revised
Code. A facility that has submitted an application packet for medicaid
certification to ODJFS
the Ohio department of health is considered to be in
the process of obtaining its initial medicaid certification
by the Ohio department of health and
shall
will be
treated as a NF for the purposes of this rule.
(27)(22) "NF-based level
of care" means the intermediate and skilled levels of care, as described in
rule 5101:3-3-08
5160-3-08 of the Administrative Code.
(28)(23)
"NF-based level of care program" means a NF, a home and community- based
services medicaid waiver that requires
uses a NF-based level of care, or other medicaid
program that requires
uses a NF-based level of care.
(29)(24)
"PASRR" means the preadmission screening and resident review requirements
mandated by section 1919(e)(7) of the Social Security Act and implemented in
accordance with rules 5101:3-3-14, 5101:3-3-15.1,
5101:3-3-15.2 and 5122-21-03 and 5123:2-14-01
5160-3-14, 5160-3-15.1, 5160-3-15.2, 5122-21-03, and
5123-14-01 of the Administrative Code.
(30)(25) "Physician" means
a person licensed under Chapter 4731. of the Revised Code or licensed in
another state as defined by applicable law, to practice medicine and surgery or
osteopathic medicine and surgery.
(31) "Psychiatrist" means a
physician licensed under Chapter 4731. of the Revised Code or licensed in
another state as defined by applicable law, to practice
psychiatry.
(32) "Psychologist" means, a person
licensed in Ohio as a psychologist or school psychologist, or licensed in
another state as a psychologist as defined by applicable law.
(33) The terms "psychologist," "the
practice of psychology," "psychological procedures," "school psychologist,"
"practice of school psychology," "licensed psychologist," "licensed school
psychologist," and "certificated school psychologist" have the same meanings as
in section 4732.01 of the Revised Code.
(34)(26)
"Skilled nursing services" means specific tasks that must
are, in
accordance with Chapter 4723. of the Revised Code, be provided by a licensed practical nurse (LPN) at
the direction of a registered nurse or by a registered nurse
directly.
(35)(27) "Skilled
rehabilitation services" means specific tasks that
must
are, in
accordance with Title 47 of the Revised Code,
be provided directly by a licensed or other
appropriately certified technical or professional health care personnel.
(36) "Sponsor" means an adult
relative, friend, or guardian of an individual who has an interest in or
responsibility for the individual's welfare.
(37) "Substantial functional
limitation" means the inability of an individual to independently, adequately,
safely, and consistently perform age-appropriate tasks as associated with the
major life areas and as referenced in paragraph (B) (4) of this rule, without
undue effort and within a reasonable period of time.
An individual who has access to and
is able to perform the tasks independently, adequately, safely, and
consistently with the use of adaptive equipment or assistive devices is not
considered to have a substantial functional limitation.
(38)(28) "Supervision"
means either of the following:
(a) Reminding
an individual to perform or complete an activity; or
(b) Observing while an individual performs an
activity to ensure the individual's health and safety.
(39)(29)
"Twenty-four hour support" means that an individual requires
needs the
continuous presence of another person throughout the course of the entire day
and night during a twenty-four hour period of time.
(40)(30) "Unstable medical
condition" means clinical signs and symptoms are present in an individual and a
physician has determined that:
(a) The individual's signs and
symptoms are outside of the normal range for that individual;
(b)(a)
The individual's signs and symptoms require
need extensive
monitoring and ongoing evaluation of the individual's status and care and there
are supporting diagnostic or ancillary testing reports that justify the need
for frequent monitoring or adjustment of the treatment regimen;
and
(c)(b) Changes in the
individual's medical condition are uncontrollable or unpredictable and may
require
need
immediate interventions
.; and
(d) A licensed health professional
must provide ongoing assessments and evaluations of the individual that will
result in adjustments to the treatment regimen as medically necessary. The
adjustments to the treatment regimen must happen at least monthly, and the
designated licensed health professional must document that the medical
interventions are medically necessary.
