Understanding
Pre-Admission
Review
Requirements
Presented by the
Area Agency on Aging Dist. 7, Inc.
1
Revised 9-27-13
DISCLAIMER
The materials
contained herein
DO NOT SUPERCEDE
Ohio Administrative
Code (OAC)
It is the Nursing
Facility’s responsibility
To know and comply
with OAC rules.
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Revised 9-27-13
OHIO ADMINISTRATIVE CODE (OAC)
FOR ADMISSIONS TO AND
CONTINUED PLACEMENT IN
MEDICAID-CERTIFIED NURSING
FACILITIES:
OAC 5101:3-3-14 Preadmission screening (PAS) and resident review (RR)
definitions
OAC 5101:3-3-15.1 Preadmission screening (PAS) requirements for
individuals seeking admission to nursing facilities (NFs).
OAC 5123:2-14-01 Preadmission screening and resident review for nursing
facility applicants and nursing facility residents with
mental retardation and/or other developmental
disabilities
OAC 5122-21-03
Preadmission screening and resident review (PASRR)
for nursing facility applicants with serious mental illness.
OAC 2101:3-3-15.2 Resident review (RR) requirements for individuals
residing in nursing facilities (NFs).
OAC 5101:3-3-15 Process and timeframes for a level of care
determination for nursing facility-based level of care
programs
OAC 5101:3-3-05 Level of care definitions
OAC 5101:3-3-06 Criteria for the protective level of care
OAC 5101:3-3-08 Criteria for nursing facility-based level of care
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Revised 9-27-13
PAS Rules
OAC 5101:3-3-15.1
The intent of Pre-Admission Screening (PAS) is to
identify nursing facility applicants who have
serious mental illness (SMI) and/or mental
retardation or developmental disabilities (MR/DD)
to ensure that a nursing facility is the most
appropriate placement to meet their needs.
The nursing facility benefits from the PAS review
process: This process prevents inappropriate
placement into NFs for individuals who need
special treatment for MH or MR/DD issues. For
example, the NF applicant may have violent
tendencies and need hospitalization (specialized
services) to get medications adjusted.
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Revised 9-27-13
Who is subject to PAS?
EVERYONE
entering a
Medicaid-certified nursing facility
NO MATTER WHAT THEIR PAY SOURCE
is required to
meet the PAS requirements
PRIOR TO ADMISSION.
The PAS requirements can be met three ways:
1.
2.
3.
A COMPLETED PAS form (JFS 3622) and supportive
documentation is faxed to Desk Review PRIOR to NF
admission AND it DOES NOT require further review for
SMI or MR/DD; or
Desk Review sends the request for further review and
ODMH and/or DODD approves NF placement PRIOR
to NF admission; or
The individual qualifies for a Hospital Exemption and
the NF received a COMPLETED hospital exemption
form (JFS 7000) OR by electronic receipt of the
Hospital Exemption using HENS (the Hospital
Exemption Notification System) PRIOR to NF
admission.
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Revised 9-27-13
Hospital Exemption
Formerly known as Convalescent Exemption
To qualify for the Hospital Exemption
ALL the following criteria must be met:
1. The individual must be coming to the NF directly from
the hospital where s/he was an inpatient (not ER,
Swing bed or observation bed);
2. The individual must require services from the NF for
the same condition that was treated in the hospital;
3. The individual must require less than 30 days of care
in the NF as certified in writing (signed and dated no
later than date of discharge) by the attending
physician at the hospital (not nurse practitioner or
other health care provider);
4. The individual must be coming from an Ohio Hospital
or be an Ohio resident at the time of hospital
admission;
5. The individual must not have received an adverse
PAS or RR determination within the last 60 days;
6. The NF and the PAA must receive a completed form
JFS 7000 OR notification in HENS from the discharging
hospital.
7. The individual is not discharged to the NF from a
Psych Unit of a hospital or a Psych Hospital (see next
page).
NOTE: A new Hospital Exemption will not be issued if consumer reenters the hospital during the exemption period.
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Revised 9-27-13
Hospital Exemption
Formerly known as Convalescent Exemption
Effective September 29, 2013:
An individual can no longer be admitted to a NF from a
hospital using the Hospital Exemption process when the
individual is transferred or directly admitted to a NF from a
hospital that is either of the following:
(A) A hospital that the Ohio Department of Mental Health
and Addiction Services (ODMHAS) maintains, operates,
manages or governs under Section 5119.14 of the Revised
Code for the care and treatment of mentally ill persons;
OR
(B)A free-standing hospital, or unit of a hospital, licensed by
ODMHAS under section 5119.33 of the Revised Code.
The NF is responsible for ensuring that all Hospital Exemption
criteria are met PRIOR to accepting the admission.
The NF must maintain proof of Hospital Exemption (JFS 7000
form) on the resident’s chart.
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Revised 9-27-13
Further Review for
SMI and MR/DD
OAC 5122-21-03
OAC 5123:2-14-01
When Further Review (aka Level II) is required for SMI and/or MRDD
the NF must not admit the individual until and unless ODMH and/or
DODD give approval to do so.
When further review is needed, Desk Review will determine if the
individual qualifies for a Categorical Determination or an
Individualized Determination:
The Individualized Determination is a lengthier process than the
Categorical Determination and takes longer to receive approval (or
denial) for the NF admission. However, it entails a more thorough
review of the individual’s circumstances and needs because it is
completed in-person by the local evaluators (DDM Ascend for SMI
and/or County Board of DD for MRDD).
If Desk Review determines the individual qualifies for a Categorical
Determination, the request will be faxed directly to the State
Authority (DDM Ascend and/or DODD) and approval (or denial) for
the NF admission is typically received much quicker, in some cases
the same day.
A Categorical Determination will be requested when:
1. The admission is for a respite stay of 14 days or less; or
2. The admission is because of an emergency situation; or
3. The individual is an out-of-state resident seeking placement in
an Ohio NF (must also have Level II from state of residence).
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Revised 9-27-13
Resident Review (RR)
Requirements
OAC 5101:3-3-15.2
The NF must perform RR for:
1.
2.
3.
Expired time limit for hospital exemption
 RR due by day 29
Expired time limit for emergency admission
(admission must take place within 24 hours of
ODMH/DODD determination)
 RR due by day 7
Expired time limit for a Respite admission
 RR due by day 14
For the above RRs, the NF may request approval for
continued NF placement for an unspecified period of time
or for a specified period of time. Also, the NF may request
an extension to a previously approved RR.
4.
5.
NF transfer (Ohio NF to different Ohio NF) or
readmission and there are no previous PASRR records
 RR due by day of admission
Significant change in condition (decline or
improvement)
 RR due within 72 hours of the significant change
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Revised 9-27-13
Res
Resident Review Process
1. The NF completes the PAS/RR form (JFS 3622)
a. The NF is responsible for ensuring the PAS/RR is
completed accurately and thoroughly.
2. The NF reviews the completed PAS/RR to determine if
the resident requires further review for SMI and/or
MRDD.
a. The NF is responsible for ensuring their
determination is accurate.
 If further review is NOT required: the PAS/RR and
supporting documentation is to be retained on the
resident’s chart.
 If further review is required for SMI: the NF faxes the
PAS/RR to DDM Ascend. (The NF should keep the
fax transmittal sheet as evidence.)
 If further review is required for MRDD: the NF faxes
the completed PAS/RR to DODD. (The NF should
keep the fax transmittal sheet as evidence.)
 If further review is required for both SMI and MRDD:
the NF faxes the PAS/RR to both DDM Ascend and
DODD. (The NF should keep the fax transmittal
sheet as evidence.)

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Revised 9-27-13
What happens if the PAS or RR is
not completed in compliance
with OAC rules?
For non-Medicaid residents:
 The NF will be out of compliance with their
Medicaid certification and may be cited by the
State for this infraction.
For Medicaid residents:
 The NF will be out of compliance with their
Medicaid certification and may be cited by the
State for this infraction; AND
 The NF will not be eligible to receive Medicaid
vendor payment until the date the PAS review or
RR is completed.
Example:
If an admission occurs on April 1st, but the PAS requirements
are not met until May 30th, the NF cannot receive Medicaid
vendor payment prior to May 30th.
If an individual is admitted under the Hospital Exemption on
July 1st, the RR is due by July 30th (day 29). If the RR is not
performed until a later date, Medicaid payment will be
suspended from the date the RR was due and until:
1. The NF completes the RR and accurately determines
further review is not required.
2. Ascend and/or DODD completes their further review
evaluation (or seven days after the RR was submitted,
whichever date is earliest).
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Revised 9-27-13
Medicaid Level of Care Criteria
OAC 5101:3-3-08 (ILOC/ SLOC)
OAC 5101:3-3-06 (PLOC)
Medicaid will only pay for an individual to be in a NF if they meet
an Intermediate or Skilled LOC. (NOTE: “Skilled LOC” refers to
Medicaid LOC criteria and is NOT related to “Medicare Skilled.”)
PLOC:
The individual
needs either:
Supervision of
one ADL or
supervision of
medication
administration
– AND –
assistance with 3
IADLs
ILOC:
The individual meets
PLOC – AND – one of
the following applies:
SLOC:
The individual meets
PLOC and ILOC
AND
* The individual needs
assistance with 2 ADLs
* The individual needs
assistance with one ADL
– AND - assistance with
medication
administration
The individual has an
unstable medical
condition
AND
Receives:
OR
less than 24 hour
support in order
to prevent harm
due to a
cognitive
impairment.
* The individual needs
at least one skilled
nursing service OR
skilled rehab service.
* 24 hour support in
order to prevent harm
due to a cognitive
impairment.
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Revised 9-27-13
*Skilled Nursing
services 7 days per
week
OR
*Skilled Rehab
services 5 days per
week
Process and timeframes for a
level of care determination or
nursing facility-based level of
care programs
OAC 5101:3-3-15
This section outlines the process to be followed
for:
1. Medicaid Admissions from the Community /
Non-Emergency
2. Medicaid Admissions from the Community /
Emergency Situation
3. Medicaid Admissions from the Hospital
4. Medicaid Admissions from a different Ohio
NF
5. Medicaid Admissions from out-of-state
6. Residents converting from other pay source
to Medicaid pay
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Revised 9-27-13
Medicaid Admissions from the
Community
Non-Emergency
1. The individual or his/her representative contacts the
PAA (PASSPORT Administrative Agency) to schedule
a LOC assessment. (Ask for the Resource Center.)
2. The PAA will perform the assessment within 5 days,
unless a later date is requested.
3. The Assessor will complete the PAS and LOC
documentation and forward it to Desk Review.
4. Desk Review will initiate Further Review if required.
5. Upon completion of the PAS and LOC determination,
Desk Review will notify the individual and his/her
representative and the admitting NF.
6. Desk Review will fax copies of the PAS, the LOC
assessment tool and the Review Results letter to the
admitting NF.
The NF can accept the admission after Desk Review sends
the Review Results letter indicating the process is complete.
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Revised 9-27-13
Medicaid Admissions from the
Community
Emergency Situation
1. The admitting NF calls Desk Review to explain the
need for emergency admission.
2. If Desk Review agrees that the situation does
constitute an emergency placement, the admitting
NF must fax to Desk Review:
a. The completed PAS/RR form (JFS 3622)
b. ODHS 3697 LOC assessment tool (or other
approved document)
c. A written statement describing the emergency
3. Desk Review will make a PAS determination and
initiate Further Review if required.
4. Desk Review will issue a LOC as appropriate once the
PAS determination is complete.
5. Once all determinations are complete, Desk Review
will fax the Review Results letter to the admitting NF.
6. A delayed assessment, if required, will be performed
by PAA certified staff within 90 days of the
determination date.
The NF is strongly encouraged to wait until Desk Review
issues the LOC before accepting the admission.
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Revised 9-27-13
Medicaid Admissions from the
Hospital
1. The hospital will fax to Desk Review a completed PAS
(or JFS 7000 for Hospital Exemption) and the ODHS
3697, or other approved document requesting a
LOC.
2. Desk Review will make a PAS and LOC determination
and initiate Further Review if required.
3. Desk Review will fax the Review Results letter to the
hospital. The hospital needs to fax the PAS to the NF.
4. Desk Review will fax the Review Results letter to the
admitting NF (if known).
5. A delayed assessment, if required, will be performed
by PAA certified staff within 90 days of the
determination date.
The NF is strongly encouraged to wait until Desk Review
issues the LOC before accepting the admission.
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Revised 9-27-13
Medicaid Admissions
Ohio NF to Ohio NF transfer
1. The discharging NF submits a completed ODHS 3697 (or
other approved document) to request LOC. The NF
should indicate clearly the request is for a NF transfer.
2. Desk Review will make a LOC determination.
3. Desk Review will fax the Review Results letter to both
the discharging and admitting NFs (if both are known).
4. A delayed assessment, if required, will be performed by
certified PAA staff within 90 days of the determination
date.
Resident Review (RR) must be initiated immediately if the
discharging NF does not have PAS/RR records to forward to
the admitting NF.
The admitting NF should not accept the NF transfer until
Desk Review completes the LOC review to ensure the
resident continues meeting a NF LOC.
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Revised 9-27-13
Medicaid Admissions for
Out of State
Residents
1. The individual’s representative (hospital, NF, etc.) must
submit a PAS and LOC review request to Desk Review.
 If Further Review is required, the State where the
individual is located must perform their Further
Review process;
 Once the out-of-state Further Review is
completed, the individual’s representative will
forward those results to Desk Review.
 Desk Review will forward all appropriate
documentation to DDM Ascend and/or DODD.
 Desk Review will issue a Review Results letter to the
submitter and the admitting NF once the process is
completed and NF admission is approved.
2. If Further Review is not required Desk Review will send
the submitter and admitting NF the Review Results letter
indicating the PAS requirements are met and the LOC
has been issued.
The NF must ensure that all PAS requirements are met prior
to accepting the admission. The NF is strongly encouraged
to wait until Desk Review verifies LOC before accepting the
admission.
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Revised 9-27-13
NF Residents converting to
Medicaid Pay Source
1. The NF submits to Desk Review (by fax or mail) the
ODHS 3697 (or other approved form) requesting a LOC
review.
 Desk Review must verify that all PAS and/or RR
requirements have been met before making a
LOC determination.
2. Desk Review will make a LOC determination and will
establish the LOC effective date (the date Medicaid
will begin paying the NF).
 As long as all PAS/RR requirements were met within
the mandated timeframes, the LOC effective date
can be the date the other funding source
stopped.
3. Once the review is complete, Desk Review will fax a
Review Results letter to the NF.
4. A delayed assessment, if required, will be performed by
PAA certified staff within 90 days of the determination
date.
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Revised 9-27-13
ODHS 3697 Reference for page 4 (Systems Review)
EYES: Prosthesis / Blurring / Difficulty reading / Diplopia / Swelling / Jaundice /
Redness / Pain / Discharge / Loss of Vision / Glasses or contacts /
Glaucoma / Cataracts
EARS: Hearing Aid / Deafness / Diminished hearing / Tinnitus / Wax build-up /
Pain
MOUTH & THROAT: Dentures / Missing teeth / Broken teeth / Difficulty chewing
and/or swallowing / Gums (swollen, bleeding, receding) / Lesions /
Dry mouth / Coated tongue / Halitosis / Dysphasia / Loss of sense of
taste
NEUROLOGIC:
Quadriplegia / Paraplegia / Hemiplegia / Weakness of
grasp / Tremors / Frequent headaches / Fainting / Blackouts / Vertigo /
Convulsions / Sleep pattern disturbance / Loss of tactile sensation /
Expressive aphasia / Receptive aphasia
PULMONARY:
Abnormalities w/ sinus or w/ sense of smell / Dyspnea at rest
and/or w/ exertion / Persistent cough / Audible wheezing /
Tracheotomy / Expectorates (blood or sputum) / Cyanosis / Nosebleeds
/ Oxygen therapy (IPPB, cannula/mask, ventilator)
CARDIOVASCULAR AND CIRCULATORY:
Pain (chest, jaws, neck, arms) /
Pressure (chest, neck, arms) / Tightness (chest, neck, arms) / Irregular
heartbeat / Edema / Fainting / Blackouts / Convulsions / Vertigo / High
blood pressure / Dyspnea at rest and/or w/ exertion
MUSCULOSKELETAL:
Joints (swelling or stiffness) / Prosthesis / Gait
(unsteady or shuffling) / Frequent falls / Standing (limited or unable) /
Wheelchair bound / Bed bound / Contracture / Deformity
GASTROINTESTINAL:
Indigestion, nausea, vomiting / Fecal incontinence /
Recent change in bowel habits / Constipation / Diarrhea / Ostomy /
Abdominal pain / Recent weight gain or loss / Rectal bleeding
GENITOURINARY: Incontinent / Dribbling / Painful urination / Hematuria /
Nocturia / Catheter / Breast (lumps, pain, tenderness, discharge) /
Genital pain / Urine monitoring for glucose / Bleeding (vaginal, urethral)
SKIN: Oily / Dry / Discoloration / Jaundice / Bruises / Abrasions / Rash / Itching
/ Sores / Ulcers / Lumps / Moles / Poor turgor / Abnormalities w/ hair or
scalp
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Revised 9-27-13
Level of Care Data Elements
Desk Review must have the following information to issue a LOC:




















PAS/RR or evidence of Hospital Exemption
Client’s name on every page
Medicaid number or Pending number
Social Security number
Nursing Facility name (if transferring, need names of both
facilities)
Level of Care being requested (ILOC or SLOC)
LOC effective date being requested
County where Medicaid is active or pending
Individual’s representative, if applicable
Individual’s original date of admission (or planned admission
date
Estimated length of stay (short/long-term, unknown,
permanent, etc.)
Description of informal supports and their ability/inability to
provide care
Individual’s current setting (NF, Hospital, ER, Community, etc.)
List of all current diagnosis (one specified as primary)
Individual’s medications and treatments including PT, OT, ST
Individual’s mental and behavioral status
Description of the need for 24 hours supervision due to
cognitive impairment, if applicable
Individual’s ability or inability to perform each ADL/IADL
Status of individual’s medical condition (stable or unstable)
A statement signed and dated by a physician certifying that
the information contained in the LOC request is a true and
accurate reflection of the individual’s condition as of (LOC
effective date).
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Revised 9-27-13
Long Term Care
Consultations (LTCC)
OAC 173-43-01
Thru
OAC 173-43-04
These rules replaced:
OAC 5101:3-3-14 Assessment process for non-Medicaid
placements in Medicaid-certified nursing facilities.
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Revised 9-27-13
Long Term Care
Consultations (LTCC)
Hospitals and Nursing Facilities assist Desk Review with
identifying individuals who could benefit from a Long Term
Care Consultation (LTCC).
Some individuals are exempt from LTCC. Regardless of
whether the individual is exempt from the LTCC, s/he must
still meet all PAS requirements prior to NF admission.
Nursing Facilities are responsible for ensuring that all PAS
requirements are met prior to accepting a non-Medicaid
admission.
The PAS requirements can be met three ways:
1.
2.
3.
A COMPLETED PAS form (JFS 3622) and supportive
documentation is faxed to Desk Review PRIOR to NF
admission AND it DOES NOT require further review for
SMI or MR/DD; or
Desk Review sends the request for further review and
ODMH and/or DODD approves NF placement PRIOR
to NF admission; or
The individual qualifies for a Hospital Exemption and
the NF received a COMPLETED hospital exemption
form (JFS 7000) OR by electronic receipt of the
Hospital Exemption using HENS (the Hospital
Exemption Notification System) PRIOR to NF
admission.
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Revised 9-27-13
Important Phone, FAX and
Web sites
Area Agency on Aging, District 7
1-800-582-7277
www.aaa7.org
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Desk Review
Monday – Friday / 8:00 a.m. – 4:30 p.m.
Phone: 740-245-9123
FAX: 740-245-9148
HENS (Hospital Exemption Notification System)
www.hens.age.ohio.gov
Extended Desk Review FAX Availability
From 4:30 p.m. on the last business day of the week
through midnight Saturday…
In the event of a Monday holiday, the FAX machine
will be available until midnight Sunday.
FAX: 419-222-8262
Any complete PAS or LOC request that is faxed to Extended
Coverage will be processed within one (1) calendar day.
AAA7 Resource Center
Monday – Friday / 8:00 a.m. – 4:30 p.m.
Phone: 800-582-7277
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Revised 9-27-13
DDM Ascend / Ohio PASRR Quality Team Member
Phone: 877-431-1388
FAX: 866-299-0029
Ohio Dept of Mental Health (ODMH)
Phone: 614-466-1063
FAX: 614-485-9746
Ohio Dept. of Development Disabilities (DODD)
Phone: 614-728-9508
FAX: 614-995-4877
Ohio Dept. of Job & Family Services / FORMS
http://www.odjfs.state.oh.us/forms/inter.asp
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