Ohio Admin. Code 5160-3-08 - [Effective 7/1/2025] Criteria for nursing facility-based level of care

(A) The criteria for the intermediate level of care is met when:

(1) The individual's needs for long-term services and supports (LTSS) exceed the criteria for the protective level of care, as described in paragraph (A)(3) of rule 5160-3-06 of the Administrative Code;

(2) The individual's LTSS needs are less than the criteria for the skilled level of care, as described in paragraph (C) of this rule;

(3) The individual's LTSS needs do not meet the criteria for the developmental disabilities level of care or meets one of the following:

(a) The individual has been evaluated through an Ohio department of medicaid (ODM)-approved assessment tool and determined to have medical condition(s) or related need(s) necessitating an immediate need for support as determined by (ODM), or

(b) The individual receives a non-adverse level II pre-admission screening and resident review (PASRR) determination indicating the need for NF services .

(4)The individual needs a minimum of one of the following:

(a) Assistance with the completion of a minimum of two activities of daily living (ADL), as defined in rule 5160-3-05 of the Administrative Code and as described in paragraph (B) of this rule;

(b) Assistance with the completion of a minimum of one ADL as described in paragraph (B) of this rule, and assistance with medication administration;

(c) A minimum of one skilled nursing service or skilled rehabilitation service;

(d) Twenty-four hour support in order to prevent harm due to a cognitive impairment, as diagnosed by a physician or other licensed health professional acting within his or her applicable scope of practice, as defined by law ; or

(e) If the individual is age seventeen years or younger, the age-appropriate need for assistance with items described in paragraphs (A)(4)(a) and (A)(4) (b) of this rule will be assessed in accordance with the ODM-approved assessment guide.

(B) For the purposes of meeting the criteria described in paragraph (A)(4) of this rule, an individual age eighteen years or older who needs assistance with an ADL needs:

(1) Assistance with mobility in at least one of the following three components:

(a) Bed mobility;

(b) Locomotion; or

(c) Transfer.

(2) Assistance with bathing.

(3) Assistance with grooming in all of the following three components:

(a) Oral hygiene;

(b) Hair care; and

(c) Nail care.

(4) Assistance with toileting in at least one of the following four components:

(a) Using a commode, bedpan, or urinal;

(b) Changing incontinence supplies or feminine hygiene products;

(c) Cleansing self; or

(d) Managing an ostomy or catheter.

(5) Assistance with dressing in at least one of the following two components:

(a) Putting on and taking off an item of clothing or prosthesis; or

(b) Fastening and unfastening an item of clothing or prosthesis.

(6) Assistance with eating.

(C)The criteria for the skilled level of care is met when:

(1) The individual's LTSS needs exceed the criteria for the protective level of care, as described in paragraph (A)(3) of rule 5160-3-06 of the Administrative Code;

(2) The individual's LTSS needs exceed the criteria for the intermediate level of care as described in paragraph (A)(4) of this rule;

(3) The individual's LTSS needs exceed the criteria for the developmental disabilities level of care;

(4) The individual needs a minimum of one of the following:

(a) One skilled nursing service within the day on no less than seven days per week; or

(b) One skilled rehabilitation service within the day on no less than five days per week;and

(5) The individual has an unstable medical condition.

(D) When an individual has been previously determined to meet the criteria for the intermediate or skilled level of care and has been enrolled in a NF-based home and community-based services (HCBS) waiver and has maintained enrollment, failure to meet the criteria in paragraph (A)(3) of this rule will not be a sufficient reason alone to deny level of care at the annual reassessment.

(E)When an individual meets the criteria for a skilled level of care, as described in paragraph (C) of this rule, the individual may request placement in an intermediate care facility for individuals with intellectual disabilities (ICF-IID) that provides services to individuals who have a skilled level of care. When an individual with a skilled level of care requests placement in an ICF-IID they will need to meet the criteria for the developmental disabilities level of care.

Notes

Ohio Admin. Code 5160-3-08

Effective: 7/1/2025
Five Year Review (FYR) Dates: 1/14/2025 and 07/01/2030
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02, 5165.04
Prior Effective Dates: 07/01/1980, 11/10/1983, 10/01/1993 (Emer.), 12/31/1993, 07/01/2008, 03/19/2012