OAR 411-070-0040: Screening, Assessment, and Resident Review

(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. (2) 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) PAS includes: (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; and (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 410.505 through 410.545 and OAR chapter 411, division 071. (4) PRE-ADMISSION 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. (5) 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 above responsibilities. (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.