(1) INTRODUCTION. All individuals who are
candidates for admission to a Medicaid-certified nursing facility must be
assessed to evaluate their service needs and preferences and must receive
information about community-based, alternative services, and resources that can
meet the individual's service needs and are safe, least restrictive, and
potentially less costly than comparable nursing facility services.
PRE-ADMISSION SCREENING. A pre-admission
screening (PAS) as defined in OAR 411-070-0005
is required for potentially
Medicaid eligible individuals who are at risk for nursing facility services.
(A) An assessment;
(B) The determination of an individual's
service eligibility for Medicaid-paid long term care or post-hospital extended
care services in a nursing facility;
(C) The identification of individuals who can
transition to community-based service settings;
(D) The provision of information about
community-based services and resources to meet the individual's needs;
(E) Transition planning
assistance as needed.
(b) PAS is conducted in conjunction with the
individual and any representative designated by the individual.
(c) The PAS assessment shall be conducted by
a case manager or other qualified SPD or AAA representative using SPD's Client
Assessment and Planning System (CA/PS) tool, and other standardized assessment
tools and forms approved by SPD.
(d) A PAS may be completed based on
information obtained by phone or fax only to authorize Title XIX post-hospital
benefits in a nursing facility when short-term nursing facility services are
needed. A face-to-face assessment including the discussion of alternative
community-based services and resources shall be completed within seven days of
the initial, short term nursing facility service approval.
(e) Payment for nursing facility services may
not be authorized by SPD until PAS has established that nursing facility
services are required based on the individual's service needs and Medicaid
financial eligibility has been established.
(3) PRIVATE ADMISSION ASSESSMENT. A private
admission assessment (PAA) is required for individuals with private funding who
are referred to Medicaid-certified nursing facilities established by ORS
410.545 and OAR chapter 411,
SCREENING AND RESIDENT REVIEW. A pre-admission screening and resident review
(PASRR) as described in OAR 411-070-0043
is required for individuals,
regardless of payment source, with either mental illness or developmental
disabilities who need nursing facility services.
RESIDENT REVIEW. Title XIX regulations
require utilization review and quality assurance reviews of Medicaid residents
in nursing facilities. The reviews carried out by the authorized utilization
review organization must meet these requirements:
(a) Staff associated with SPD are required to
maintain service plans on all SPD residents in nursing facilities. The
frequency of their service plan update shall vary depending on such factors as
the resident's potential for transition to home or community-based care and
federal or state requirements for resident review.
(b) Authorized representatives of SPD or the
authorized utilization review organization must have immediate access to SPD
residents and to facility records. "Access" to facility records means the right
to personally read charts and records to document continuing eligibility for
payment, quality of care, or alleged abuse. SPD or the authorized utilization
review organization representative must be able to make and remove copies of
charts and records from the facility's property as required to carry out the
(c) SPD or
the authorized utilization review organization representatives must have the
right to privately interview any SPD residents and any facility staff in
carrying out the above responsibilities.
(d) SPD or the authorized utilization review
organization representatives must have the right to participate in facility
staffings on SPD residents.
Or. Admin. R.
PWC 847(Temp), f. & ef.
7-1-77; PWC 859, f. 10-31-77, ef. 11-1-77; AFS 40-1979, f. 10-31-79, ef.
11-1-79; AFS 58-1981, f. & ef. 9-1-81; Renumbered from 461-017-0060 by Ch.
784, OL 1981 & AFS 69-1981, f. 9-30-81, ef. 10-1-81; SSD 2-1983, f. 3-4-83,
ef. 4-1-83; SPD 9-2006, f. 1-26-06, cert. ef. 2-1-06; SPD 12-2007, f. 8-30-07,
cert. ef. 9-1-07; SPD 15-2009, f. 11-30-09, cert. ef.
Stat. Auth.: ORS
Stats. Implemented: ORS