Evaluation and Assessment Measures for Title XIX Recipients and Applicants

PURPOSE: This rule sets the requirements for the periodic evaluation and assessments of residents in long-term care facilities in relationship to evaluation and assessment processes, level of care needed by individuals, and appropriate placement of individuals in order to receive this care. The rule also includes the algorithm utilized for the department’s Home and Community Based Services program for its level-of-care determination. The rule includes a second level-of-care determination to be utilized from October 31, 2021, until the funding from the American Rescue Plan Act (temporary enhanced federal medical assistance percentage) has been expended. PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) For purposes of this rule only, the following definitions shall apply: (A) Applicant—any resident or prospective resident of a certified long-term care facility who is seeking to receive inpatient Title XIX assistance; (B) Certified long-term care facility—any long-term care facility which has been approved to participate in the inpatient program and receives Title XIX funding for eligible recipients; (C) Initial assessment forms—the forms utilized to collect information necessary for a level-of-care determination pursuant to 19 CSR 30-81.030 and designated Forms DHSSDRL-109 (10-20), Nursing Facility Level of Care Assessment and DHSS-DRL-110 (1020), Level One Nursing Facility PreAdmission Screening for Mental Illness/Intellectual Disability or Related Condition, included herein; (D) Inpatient Title XIX assistance—Title XIX payments for intermediate or skilled nursing care in a certified long-term care facility; (E) Level-of-care assessment—the determination of level-of-care need based on an assessed point count value for each category cited in subsection (4)(B) of this rule; (F) Level-of-care determination—the decision whether an individual qualifies for longterm care facility care; (G) Long-term care facility—a skilled nursing facility (SNF), an intermediate care facility (ICF), or a hospital which provides skilled nursing care or intermediate nursing care in a distinct part or swing bed under Chapter 197, RSMo; (H) Pro re nata (PRN)—medication or treatment ordered by a physician to be administered as needed, but not regularly scheduled; (I) Recipient—any resident in a certified long-term care facility who is receiving inpatient Title XIX assistance; (J) Redetermination of level-of-care—the periodic assessment of the recipients’ continued eligibility and need for continuation at the previously assigned level of care. Periodic assessment includes, but is not limited to, the following: 1. Assessment of new admissions to a long-term care facility; 2. Assessment of a change in mental and/or physical status for a resident who is being readmitted to a long-term care facility after transfer to an acute care facility, and the previous DA-124 A/B or C forms do not reflect the resident’s current care needs; and 3. Assessment of DA-124 forms as requested by the Department of Social Services, Family Support Division; (K) Reevaluation of level-of-care—the periodic assessment of the recipients’ continued eligibility and need for continuation at the previously assigned level of care. Periodic assessment includes, but is not limited to, the following: 1. Assessment of new admissions to a long-term care facility; 2. Assessment of a change in mental and/or physical status for a resident who is being readmitted to a long-term care facility after transfer to an acute care facility, and the previous DHSS-DRL-109 (10-20), Nursing Facility Level of Care Assessment or DHSSDRL-110 (10-20), Level One Nursing Facility Pre-Admission Screening for Mental Illness/Intellectual Disability or Related Condition forms do not reflect the resident’s current care needs; and 3. Assessment of DHSS-DRL-109 (1020), Nursing Facility Level of Care Assessment or DHSS-DRL-110 (10-20), Level One Nursing Facility Pre-Admission Screening for Mental Illness/Intellectual Disability or Related Condition forms as requested by Department of Social Services, Family Support Division; (L) Resident—a person seventeen (17) years or older who by reason of aging, illness, disease, or physical or mental infirmity receives or requires care and services furnished by a long-term care facility and who resides in, is cared for, treated, or accommodated in such long-term care facility for a period exceeding twenty-four (24) consecutive hours; and (M) The department—Department of Health and Senior Services. (2) Initial Level-of-Care Determination Requirements. (A) In accordance with 42 CFR sections 456.370 and 483.104, the department or its designated agents, or both, will conduct a review and assessment of the evaluations made by the attending physician for an applicant in or seeking admission to a long-term care facility. The review and assessment shall be conducted using the criteria in section (5) of this rule. (B) The initial level-of-care determination shall be completed for the following: 1. All applicants prior to or on admission to a long-term care facility; and 2. When an applicant or recipient has been discharged from a long-term care facility for more than sixty (60) days. (C) A referring individual shall fill out and submit electronically using the department’s online database system available at: https://health.mo.gov/seniors/nursinghomes/pasrr.php. the required documentation contained in forms DHSS-DRL-109 (1020), Nursing Facility Level of Care Assessment and DHSS-DRL-110 (10-20), Level One Nursing Facility Pre-Admission Screening for Mental Illness/Intellectual Disability or Related Condition. (D) The department shall complete the assessment within ten (10) working days of receipt of all documentation required by section (5) of this rule unless further evaluation by the State Mental Health Authority is required by 42 CFR 483.100 to 483.138. (E) The department shall provide written notice to the individual or referring entity if Level II screening is referred to the Department of Mental Health. The referring entity shall notify the applicant or recipient of the results of the screening. (3) Level-of-Care Reevaluation Requirements. (A) The level-of-care reevaluation is applicable for recipients who are eligible for placement in a long-term care facility. The level-of-care reevaluation shall be completed for the following: 1. When a significant change has occurred in the resident’s physical, mental, or psychosocial status for a resident diagnosed with mental illness and/or intellectual disability or related condition; or 2. As requested by Department of Social Services, Family Support Division or the Department of Mental Health. (B) A referring individual shall fill out and submit electronically using the department’s online database system available at: https://health.mo.gov/seniors/nursinghomes/pasrr.php. the required documentation contained in forms DHSS-DRL-109 (1020), Nursing Facility Level of Care Assessment and DHSS-DRL-110 (10-20), Level One Nursing Facility Pre-Admission Screening for Mental Illness/Intellectual Disability or Related Condition. (C) The department shall provide written notice to the individual or referring entity if Level II screening is referred to the Department of Mental Health. The referring entity shall notify the applicant or recipient of the results of the screening. (4) Level-of-Care Criteria for Long-Term Care Facility Care—Qualified Title XIX Recipients and Applicants. (A) Individuals will be assessed with the ultimate goal to achieve placement for these individuals in the least restrictive environment possible, yet enable them to receive all services required by their physical/mental condition. (B) The specific areas which will be considered when determining an individual’s ability or inability to function in the least restrictive environment are—behavioral, cognition, mobility, eating, toileting, bathing, dressing and grooming, rehabilitative services, treatments, meal preparation, medication management, and safety. (C) To qualify for intermediate or skilled nursing care, an applicant or recipient shall exhibit physical impairment, which may be complicated by mental impairment or mental impairment which may be complicated by physical impairment, severe enough to require intermediate or skilled nursing care. (5) Assessed Needs Point Designations Requirements. (A) Applicants or recipients will be assessed for level-of-care by the assignment of a point count value for each category cited in subsection (4)(B) of this rule. (B) Points will be assessed for the amount of assistance required, the complexity of the care, and the professional level of assistance necessary, based on the level-of-care criteria. (C) For individuals seeking admission to a long-term care facility on or after July 15, 2021, the applicant or recipient will be determined as eligible for Title XIX-funded longterm care services if he or she is determined to need care with an assessed point level of eighteen (18) points or above, using the assessment procedure as required in this rule. (D) For individuals seeking admission to a long-term care facility on or after July 15, 2021, an applicant with less than eighteen (18) points will be determined as ineligible for Title XIX-funded long-term care services, unless the applicant qualifies as otherwise provided in subsection (5)(E) of the rule. (E) An applicant or recipient will be considered eligible for inpatient Title XIX assistance regardless of the total point count if the applicant or recipient is unable to meet physical/mental requirements for residential care facility (RCF) and assisted living facility (ALF) residency as specified by section 198.073, RSMo. In order to determine if an applicant or recipient is unable to meet RCF and ALF residency, the following criteria shall be applied: 1. For RCF residency an applicant or recipient shall be physically and mentally capable of negotiating a normal path to safety. In order to meet this requirement, an applicant or recipient, without staff assistance, must be able to reach and go through a required exit door to the outside building by— A. Responding to verbal direction or the sound of an alarm; B. Being prepared to leave the facility within five (5) minutes of being alerted of the need to evacuate; C. If using a wheelchair, the resident shall be able to transfer into the wheelchair and propel it or reach the assistive device, and open all doors without staff assistance; and D. If using another assistive device, such as a walker or cane, they shall be able to reach and utilize the assistive device without staff assistance. 2. For ALF residency, the applicant or recipient cannot be admitted or retained if they meet the following criteria: A. Exhibit behaviors that present a reasonable likelihood of serious harm to himself or herself or others; B. Require physical restraints; C. Require chemical restraints; D. Require skilled nursing services as defined in subsection 198.073.4, RSMo for which the facility is not licensed or able to provide; E. Require more than one (1) person to simultaneously physically assist the resident with any activity of daily living, with the exception of bathing and transferring; or F. Is bedbound or similarly immobilized due to a debilitating or chronic condition. (F) Points will be assigned to each category, as required by subsection (4)(B) of this rule, in multiples of three (3) according to the following requirements: 1. Behavioral is defined as the applicant or recipient’s repeated behavioral challenges that affect their ability to function in the community. The applicants or recipients who exhibit uncontrolled behavior that is dangerous to themselves or others must be transferred immediately to an appropriate facility. Determine if the applicant or recipient: receives monitoring for a mental condition, exhibits one (1) of the following mood or behavior symptoms: wandering, physical abuse, socially inappropriate or disruptive behavior, inappropriate public sexual behavior or public disrobing, resists care or exhibits one (1) of the following psychiatric conditions: abnormal thoughts, delusions, hallucinations. The applicant or recipient can receive up to nine (9) points in this category. The applicant or recipient will receive— A. Zero (0) points if assessed with a stable mental condition and no mood or behavior symptoms observed and no reported psychiatric conditions; B. Three (3) points if assessed with a stable mental condition monitored by a physician or licensed mental health professional at least monthly or behavior symptoms exhibited in the past, but not currently present or psychiatric conditions exhibited in the past, but not recently present; C. Six (6) points if assessed with an unstable mental condition monitored by a physician or licensed mental health professional at least monthly, or behavior symptoms are currently exhibited, or psychiatric conditions are recently exhibited; or D. Nine (9) points if assessed with an unstable mental condition monitored by a physician or licensed mental health professional at least monthly and behavior symptoms are currently exhibited or psychiatric conditions are currently exhibited. 2. Cognition is defined as the applicant or recipient’s performance in remembering, making decisions, organizing daily self-care activities, as well as understanding others and making self- understood. Determine if the applicant or recipient has an issue in one (1) or more of the following areas: cognitive skills for daily decision making, memory or recall ability (short-term, procedural, situational memory), disorganized thinking/awareness, mental function varies over the course of the day, or ability to understand others or to be understood. The applicant or recipient can receive up to eighteen (18) points in this category. The applicants or recipients with “no discernable consciousness, coma” are presumed to meet nursing facility level of care. The applicant or recipient will receive— A. Zero (0) points if assessed with no issues with cognition and no issues with memory, mental function, or ability to be understood or to understand others; B. Three (3) points if assessed as displaying difficulty making decisions in new situations or occasionally requires supervision in decision making and has issues with memory, mental function, or ability to be understood or to understand others; C. Six (6) points if assessed as displaying consistent unsafe or poor decision making requiring reminders, cues, or supervision at all times to plan, organize, and conduct daily routines, and has issues with memory, mental function, or ability to be understood or understand others; or D. Nine (9) points if assessed as rarely or never has the capability to make decisions or displaying consistent unsafe or poor decision making or requires total supervision requiring reminders, cues, or supervision at all times to plan, organize, and conduct daily routines, and rarely or never understood by or able to understand others. 3. Mobility is defined as the amount of assistance needed by the applicant or recipient to move from one (1) place or position to another. Determine the applicant or recipient’s primary mode of locomotion and the amount of assistance the applicant or recipient needs with: locomotion—how one moves walking or wheeling, if wheeling how much assistance is needed once in the chair, or bed mobility—transition from lying to sitting, turning, etc. The applicant or recipient can receive up to eighteen (18) points in this category. The applicants or recipients who score in the “totally dependent on others to move or those that are bedbound” are presumed to meet nursing facility level of care. The applicant or recipient will receive— A. Zero (0) points if assessed as independently mobile, in that the applicant or recipient requires no assistance for transfers or mobility or only has set up or supervision needed; B. Three (3) points if assessed as requiring limited or moderate assistance, in that the applicant or recipient performs more than fifty percent (50%) of tasks independently; or C. Six (6) points if assessed as requiring maximum assistance, in that the applicant or recipient needs assistance from two (2) or more individuals or more than fifty percent (50%) weight-bearing assistance or totally dependent for bed mobility. 4. Eating is defined as the amount of assistance needed by applicant or recipient to eat and drink, including special nutritional requirements or a specialized mode of nutrition. Determine the amount of assistance the applicant or recipient needs with eating and drinking. Includes intake of nourishment by other means [e.g. tube feeding or total parenteral nutrition (TPN)]. Determine if the participant requires a physician ordered therapeutic diet. The applicant or recipient can receive up to eighteen (18) points in this category. The applicants or recipients “totally dependent on others to eat” are presumed to meet nursing facility level of care. The applicant or recipient will receive— A. Zero (0) points if assessed as independent in dietary needs, in that the applicant or recipient requires no assistance to eat and has no physician ordered diet; B. Three (3) points if assessed as requiring minimum assistance, in that the applicant or recipient requires physician ordered therapeutic diet, or set up, supervision, or limited assistance is needed with eating; C. Six (6) points if assessed as requiring moderate assistance with eating, in that the applicant or recipient performs more than fifty percent (50%) of tasks independently; or D. Nine (9) points if assessed as requiring maximum assistance with eating, in that the applicant or recipient requires an individual to perform more than fifty percent (50%) for assistance. 5. Toileting is defined as the amount of assistance needed by the applicant or recipient to complete all tasks related to toileting including the actual use of the toilet room (or commode, bedpan, urinal), transferring on/off the toilet, cleansing self, adjusting clothes, managing catheters/ostomies, and managing incontinence episodes. The applicant or recipient can receive up to nine (9) points in this category. The applicant or recipient will receive— A. Zero (0) points if assessed as requiring no assistance, or requires only set up or supervision needed; B. Three (3) points if assessed as requiring limited or moderate assistance, in that applicant or recipient performs more than fifty percent (50%) of tasks independently; C. Six (6) points if assessed as requiring maximum assistance, in that applicant or recipient needs two (2) or more individuals, or more than fifty percent (50%) weightbearing assistance; or D. Nine (9) points if assessed as requiring total dependence on others. 6. Bathing is defined as the amount of assistance needed by the applicant or recipient to complete a full body shower or bath. Determine the amount of assistance the applicant or recipient needs with bathing. Bathing includes: taking a full body bath/shower and the transferring in and out of the bath/shower. The applicant or recipient can receive up to six (6) points in this category. The applicant or recipient will receive— A. Zero (0) points if assessed as no assistance required, or requiring only set up or supervision needed; B. Three (3) points if assessed as requiring limited or moderate assistance, in that applicant or recipient performs more than fifty percent (50%) of tasks independently; or C. Six (6) points if assessed as requiring maximum assistance, in that the applicant or recipient requires two (2) or more individuals, more than fifty percent (50%) weightbearing assistance, or total dependence on others. 7. Dressing and grooming is defined as the amount of assistance needed by the applicant or recipient to dress, undress, and complete daily grooming tasks. Dressing may also include specialized devices such as prosthetics, orthotics, etc. The applicant or recipient can receive up to six (6) points in this category. The applicant or recipient will receive— A. Zero (0) points if assessed as requiring no assistance, or requiring only set up or supervision needed; B. Three (3) points if assessed as requiring limited or moderate assistance, in that applicant or recipient performs more than fifty percent (50%) of tasks independently; or C. Six (6) points if assessed as requiring maximum assistance, in that applicant or recipient requires two (2) or more individuals, more than fifty percent (50%) of weightbearing assistance, or total dependence on others. 8. Rehabilitative services is defined as the restoration of a former or normal state of health through medically-ordered therapeutic services either directly provided by or under the supervision of a licensed qualified professional. Rehabilitative services include physical therapy, occupational therapy, speech therapy, cardiac rehabilitation, and audiology. If ordered by the physician, each resident must have an individually planned and implemented program with written goals and response/progress documented. Points will be determined by intensity of required services and the applicant’s or recipient’s potential for rehabilitation as determined by the rehabilitation evaluation. The applicant or recipient will receive— A. Zero (0) points if assessed as requiring no ordered rehabilitative services; B. Three (3) points, if assessed as requiring minimal-ordered rehabilitative services of one (1) time per week; C. Six (6) points if assessed as requiring moderate-ordered rehabilitative services of two (2) or three (3) times per week; or D. Nine (9) points if assessed as requiring maximum-ordered rehabilitative services of four (4) times per week or more. 9. Treatments are defined as a physician ordered medical care or management that requires additional hands on assistance. The scoring for treatments will be zero (0) or six (6). The applicant or recipient with the identified treatments will receive six (6) points. The applicant or recipient will receive— A. Zero (0) points if no treatments are ordered by the physician; or B. Six (6) points if assessed as requiring one (1) or more of the physician ordered treatments requiring daily attention by a licensed professional. These treatments could include: catheter/ostomy care, alternate modes of nutrition (tube feeding or TPN), suctioning, ventilator/respirator, and wound care (skin must be broken). 10. Meal preparation is defined as the amount of assistance needed to prepare a meal based on the applicant’s or recipient’s capacity to complete the task. This includes planning, assembling ingredients, cooking, and setting out the food and utensils. The applicant or recipient can receive up to six (6) points in this category. The applicant or recipient will receive— A. Zero (0) points if assessed as requiring no assistance, or requiring only set up or supervision needed; B. Three (3) points if assessed as requiring limited or moderate assistance, in that applicant or recipient performs more than fifty percent (50%) of tasks; or C. Six (6) points if assessed as requiring maximum assistance in that the individual performs more than fifty percent (50%) of tasks for the applicant or recipient, or requires total dependence on others. 11. Medication management is defined as the amount of assistance needed by the applicant or recipient to safely manage their medication regimen. Assistance may be needed due to a physical or mental disability. Determine the amount of assistance the applicant or recipient needs to safely manage their medications. The applicant or recipient can receive up to six (6) points in this category. The applicant or recipient will receive— A. Zero (0) points if assessed as requiring no assistance; B. Three (3) points if assessed as requiring setup help needed or supervision needed, or requires limited or moderate assistance, in that applicant or recipient performs more than fifty percent (50%) of tasks; or C. Six (6) points if assessed as requiring maximum assistance, in that the individual performs more than fifty percent (50%) of tasks for the applicant or recipient, or requires total dependence on others. 12. Safety is defined as the identification of a safety risk associated with vision impairment, falling, problems with balance, past institutionalization, and age. Determine if the applicant or recipient exhibits any of the following risk factors: vision impairment, falling, or problems with balance - balance is moving to standing position, turning to face the opposite direction, dizziness, or unsteady gait. The applicant or recipient can receive up to eighteen (18) points in this category. After determination of a preliminary score, institutionalization and age will be considered to determine the final score. Three (3) points can be added to the accumulated score if the applicant or recipient is aged seventy-five (75) years or older and/or has been institutionalized in the last five (5) years in a long-term care facility, mental health residence, psychiatric hospital, inpatient substance abuse, or settings for persons with intellectual disabilities and only to the specified points category listed. The applicants or recipients who score eighteen (18) points are presumed to meet nursing facility level of care. The applicant or recipient will receive— A. Zero (0) points if assessed with no difficulty or some difficulty with vision, and no falls in the last ninety (90) days, and no recent problems with balance; B. Three (3) points if assessed with severe difficulty with vision (sees only lights and shapes), or has fallen in the last ninety (90) days, or has current problems with balance, or has a preliminary score of zero (0) and is aged seventy-five (75) years or older or has been institutionalized; C. Six (6) points if assessed with no vision or has fallen in the last ninety (90) days and has current problems with balance, or assessed with a preliminary score of zero (0) and is aged seventy-five (75) years or older and has been institutionalized, or assessed with a preliminary score of three (3) points and is aged seventy-five (75) years or older or has been institutionalized; D. Nine (9) points if assessed with a preliminary score of six (6) points and has been institutionalized; or E. Eighteen (18) points if assessed with a preliminary score of six (6) points and is aged seventy-five (75) years or older or assessed with a preliminary score of three (3) points and is aged seventy-five (75) years or older and has been institutionalized. (6) Level of Care Determination for Home and Community Based Services Program. The department uses level of care determination for Home and Community Based Services (HCBS). The department utilizes the InterRAI Home Care Assessment System (HC), © InterRAI. Questions are scored within the InterRAI assessment using an algorithm, included herein. The HCBS assessment process is outlined in 19 CSR 15-7.021, 19 CSR 15-8.200, and 13 CSR 70-91.010. (7) Dual level-of-care assessments to be performed to determine level-of-care need from October 31, 2021, until the date that all of the temporary enhanced federal medical assistance percentage funds from the American Rescue Plan Act of 2021 are expended. (A) The department is eligible to receive an additional ten percent (10%) enhanced federal medical assistance percentage for home and community based services provided from April 1, 2021, through March 31, 2022, through the American Rescue Plan Act of 2021. This funding will allow the department to determine level-of-care need under the department’s previous scoring system directly prior to the department’s level-ofcare transformation which takes effect on October 31, 2021, through formal rulemaking. Therefore, if an individual does not qualify for level of care under the current level-ofcare assessment as set forth in sections (5) and (6) of this rule from October 31, 2021, until the date that all of the temporary enhanced federal medical assistance percentage funds from the American Rescue Plan Act of 2021 are expended, then individuals shall also be assessed using a level-of-care assessment as set forth in section (8) of this rule. An individual may qualify for level-ofcare need under either of these level of care assessments from October 31, 2021, until the date that all of the temporary enhanced federal medical assistance percentage funds from the American Rescue Plan Act of 2021 are expended. (8) Second level-of-care determination to be performed from October 31, 2021, until the date that all of the temporary enhanced federal medical assistance percentage funds from the American Rescue Plan Act of 2021 are expended. (A) Initial determination of level-of-care needs requirements. 1. For the purpose of making a determination of level-of-care need and in accordance with 42 CFR sections 456.370 and 483.104, the department or its designated agents, or both, will conduct a review and assessment of the evaluations made by the attending physician for an applicant in or seeking admission to a long-term care facility. The review and assessment shall be conducted using the criteria in subsection (8)(D) of this rule. 2. The department shall complete the assessment within ten (10) working days of receipt of all documentation required by subsection (8)(D) in this rule unless further evaluation by the State Mental Health Authority is required by 42 CFR 483.100 to 483.138. (B) Redetermination of level-of-care requirements. 1. Redetermination of level-of-care of individual recipients who are eligible for placement in long-term care facilities shall be conducted by the department through a review and assessment of the DA-124A/B (10-21) Initial Assessment – Social and Medical, DA-124C (10-21) Level One Nursing Facility Pre-Admission Screening for Mental Illness/Intellectual Disability or Related Condition, and DA-124C ATT (1021) Notice to Applicant included herein and any documentation provided by the resident’s attending physician. A referring individual shall fill out and submit the forms to the department at COMRU@health.mo.gov. (C) Level-of-care criteria for long-term care facility care-qualified Title XIX recipients and applicants. 1. Individuals will be assessed with the ultimate goal to achieve placement for these individuals in the least restrictive environment possible, yet enable them to receive all services required by their physical/mental condition. 2. The specific areas which will be considered when determining an individual’s ability or inability to function in the least restrictive environment are mobility, dietary, restorative services, monitoring, medication, behavioral, treatments, personal care, and rehabilitative services. 3. To qualify for intermediate or skilled nursing care, an applicant or recipient shall exhibit physical impairment, which may be complicated by mental impairment or mental impairment which may be complicated by physical impairment severe enough to require intermediate or skilled nursing care. (D) Assessed needs point designations requirements. 1. Applicants or recipients will be assessed for level-of-care by the assignment of a point count value for each category cited in paragraph (8)(C)2. of this rule. 2. Points will be assessed for the amount of assistance required, the complexity of the care, and the professional level of assistance necessary, based on the level-of-care criteria. If the applicant’s or recipient’s records show that the applicant’s or recipient’s attending physician has ordered certain care, medication or treatments for an applicant or recipient, the department will assess points for a PRN order if the applicant or recipient has actually received or required that care, medication, or treatment within the thirty (30) days prior to review and evaluation by the department. 3. For individuals seeking admission to a long-term care facility on or after October, 31, 2021, the applicant or recipient will be determined to be qualified for long-term care facility care if he or she is determined to need care with an assessed point level of twentyfour (24) points or above, using the assessment procedure as required in paragraph (8)(D)7. of this rule. 4. For individuals seeking admission to a long-term care facility on or after October 31, 2021, an applicant with twenty-one (21) points or lower will be assessed as ineligible for Title XIX-funded long-term care in a long-term care facility, unless the applicant qualifies as otherwise provided in section (5), section (6), or paragraphs (8)(D)5. or 6. in this rule. 5. Applicants or recipients may occasionally require care or services, or both, which could qualify as long-term care facility services. In these instances, a single nursing service requirement may be used as the qualifying factor, making the individual eligible for long-term care facility care regardless of the total point count. The determining factor will be the availability of professional personnel to perform or supervise the qualifying care services. Qualifying care services may include, but are not limited to: A. Administration of levine tube or gastrostomy tube feedings; B. Nasopharyngeal and tracheotomy aspiration; C. Insertion of medicated or sterile irrigation and replacement catheters; D. Administration of parenteral fluids; E. Inhalation therapy treatments; F. Administration of injectable medications other than insulin, if required other than on the day shift; and G. Requirement of intensive rehabilitation services by a professional therapist at least five (5) days per week. 6. An applicant or recipient will be considered eligible for inpatient Title XIX assistance regardless of the total point count if the applicant or recipient is unable to meet physical/mental requirements for residential care facility (RCF) or assisted living facility (ALF) residency as specified by section 198.073, RSMo. 7. Points will be assigned to each category, as required by paragraph (8)(C)2. in this rule, in multiples of three (3) according to the following requirements: A. Mobility is defined as the individual’s ability to move from place to place. The applicant or recipient will receive— (I) Zero (0) points if assessed as independently mobile, in that the applicant or recipient requires no assistance for transfers or mobility. The applicant or recipient may use assistive devices (cane, walker, wheelchair) but is consistently capable of negotiating without assistance of another individual; (II) Three (3) points if assessed as requiring minimum assistance, in that the applicant or recipient is independently mobile once the applicant or recipient receives assistance with transfers, braces, or prosthesis application or other assistive devices, or a combination of these (example, independent use of wheelchair after assistance with transfer). This category includes individuals who are not consistently independent and need assistance periodically; (III) Six (6) points if assessed as requiring moderate assistance, in that the applicant or recipient is mobile only with direct staff assistance. The applicant or recipient must be assisted even when using canes, walker, or other assistive devices; and (IV) Nine (9) points if assessed as requiring maximum assistance, in that the applicant or recipient is totally dependent upon staff for mobility. The applicant or recipient is unable to ambulate or participate in the ambulation process, requires positioning, supportive device, application, prevention of contractures or pressure sores, and active or passive range of motion exercises; B. Dietary is defined as the applicant’s or recipient’s nutritional requirements and need for assistance or supervision with meals. The applicant or recipient will receive— (I) Zero (0) points if assessed as independent in dietary needs, in that the applicant or recipient requires no assistance to eat. The applicant or recipient has physician’s orders for a regular diet, mechanically altered diet, or requires only minor modifications (example, limited desserts, no salt or sugar on tray); (II) Three (3) points if assessed as requiring minimum assistance, in that the applicant or recipient requires meal supervision or minimal help, such as cutting food or verbal encouragement. Calculated diets for stabilized conditions shall be included; (III) Six (6) points if assessed as requiring moderate assistance, in that the applicant or recipient requires help, including constant supervision during meals, or actual feeding. Calculated diets for unstable conditions are included; and (IV) Nine (9) points if assessed as requiring maximum assistance, in that the applicant or recipient requires extensive assistance for special dietary needs or with eating, which could include enteral feedings or parenteral fluids; C. Restorative services are defined as specialized services provided by trained and supervised individuals to help applicants or recipients obtain and/or maintain their optimal highest practicable functioning potential. Each applicant or recipient must have an individual overall plan of care developed by the provider with written goals and response/progress documented. Restorative services may include, but are not limited to, applicant or recipient teaching program (self-transfer, self-administration of medications, self-care), range of motion, bowel and bladder program, remotivational therapy, validation therapy, patient/family program, and individualized activity program. The applicant or recipient will receive— (I) Zero (0) points if restorative services are not required; (II) Three (3) points if assessed as requiring minimum services in order to maintain level of functioning; (III) Six (6) points if assessed as requiring moderate services in order to restore the individual to a higher level of functioning; and (IV) Nine (9) points if assessed as requiring maximum services in order to restore to a higher level of functioning. These are intensive services, usually requiring professional supervision or direct services; D. Monitoring is defined as observation and assessment of the applicant’s or recipient’s physical and/or mental condition. This monitoring could include assessment of routine laboratory work, including, but not limited to, evaluating digoxin and coumadin levels, measurement and evaluation of blood glucose levels, measurement and evaluation of intake and output of fluids the individual has received and/or excreted, weights and other routine monitoring procedures. The applicant or recipient will receive— (I) Zero (0) points if assessed as requiring only routine monitoring, such as monthly weights, temperatures, blood pressures, and other routine vital signs and routine supervision; (II) Three (3) points if assessed as requiring minimal monitoring, in that the applicant or recipient requires periodic assessment due to mental impairment, monitoring of mild confusion, or both, or periodic assessment of routine procedures when the recipient’s condition is stable; (III) Six (6) points if assessed as requiring moderate monitoring, in that the applicant or recipient requires recurring assessment of routine procedures due to the applicant’s or recipient’s unstable physical or mental condition; and (IV) Nine (9) points if assessed as requiring maximum monitoring, which is intensive monitoring usually by professional personnel due to applicant’s or recipient’s unstable physical or mental condition; E. Medication is defined as the drug regimen of all physician-ordered legend medications, and any physician-ordered nonlegend medication for which the physician has ordered monitoring due to the complexity of the medication or the condition of the applicant or recipient. The applicant or recipient will receive— (I) Zero (0) points if assessed as requiring no medication, or has not required PRN medication within the thirty (30) days prior to review and evaluation by the department; (II) Three (3) points if assessed as requiring any regularly scheduled medication and the applicant or recipient exhibits a stable condition; (III) Six (6) points if assessed as requiring moderate supervision of regularly scheduled medications, requiring daily monitoring by licensed personnel; and (IV) Nine (9) points if assessed as requiring maximum supervision of regularly scheduled medications, a complex medication regimen, unstable physical or mental status, or use of medications requiring professional observation and assessment, or a combination of these; F. Behavioral is defined as an individual’s social or mental activities. The applicant or recipient will receive— (I) Zero (0) points if assessed as requiring little or no behavioral assistance. Applicant or recipient is oriented and memory intact; (II) Three (3) points if assessed as requiring minimal behavioral assistance in the form of supervision or guidance on a periodic basis. Applicant or recipient may display some memory lapses or occasional forgetfulness due to mental or developmental disabilities, or both. Applicant or recipient generally relates well with others (positive or neutral) but needs occasional emotional support; (III) Six (6) points if assessed as requiring moderate behavioral assistance in the form of supervision due to disorientation, mental or developmental disabilities, or uncooperative behavior; and (IV) Nine (9) points if assessed as requiring maximum behavioral assistance in the form of extensive supervision due to psychological, developmental disabilities, or traumatic brain injuries with resultant confusion, incompetency, hyperactivity, hostility, severe depression, or other behavioral characteristics. This category includes residents who frequently exhibit bizarre behavior, are verbally or physically abusive, or both, or are incapable of self-direction. Applicants or recipients who exhibit uncontrolled behavior that is dangerous to themselves or others must be transferred immediately to an appropriate facility; G. Treatments are defined as a systematized course of nursing procedures ordered by the attending physician. The applicant or recipient will receive— (I) Zero (0) points if no treatments are ordered by the physician; (II) Three (3) points if assessed as requiring minimal type-ordered treatments, including nonroutine and preventative treatments, such as whirlpool baths and other services; (III) Six (6) points if assessed as requiring moderate type-ordered treatments requiring daily attention by licensed personnel. These treatments could include daily dressings, PRN oxygen, oral suctioning, catheter maintenance care, treatment of stasis or pressure sore ulcers, wet/moist packs, maximist, and other such services; and (IV) Nine (9) points if assessed as requiring maximum type-ordered treatments of an extensive nature requiring provision, direct supervision, or both, by professional personnel. These treatments could include intratrachial suctioning, insertion or maintenance of suprapubic catheter, continuous oxygen, new or unregulated ostomy care, dressings of deep draining lesions more than once daily, care of extensive skin disorders such as advanced pressure sore or necrotic lesions, infrared heat, and other services; H. Personal care is defined as activities of daily living, including hygiene; personal grooming, such as dressing, bathing, oral and personal hygiene, hair and nail care, shaving; and bowel and bladder functions. Points will be determined based on the amount of assistance required and degree of assistance involved in the activity. The applicant or recipient will receive— (I) Zero (0) points if assessed as requiring no assistance with personal care, in that the applicant or recipient is an independent, self-care individual. No assistance is required with personal grooming; the applicant or recipient has complete bowel and bladder control; (II) Three (3) points if assessed as requiring minimal assistance with personal care, in that the applicant or recipient requires assistance with personal grooming, and/or exhibits infrequent incontinency (once a week or less); (III) Six (6) points if assessed as requiring moderate assistance with personal care, in that the applicant or recipient requires assistance with personal grooming, requiring close supervision or exhibits frequent incontinency (incontinent of bladder daily but has some control or incontinent of bowel two (2) or three (3) times per week), or a combination of these; and (IV) Nine (9) points if assessed as requiring maximum assistance with personal care, in that the applicant or recipient requires total personal care to be performed by another individual, and/or exhibits continuous incontinency all or most of the time; and I. Rehabilitation is defined as the restoration of a former or normal state of health through medically ordered therapeutic services either directly provided by or under the supervision of a qualified professional. Rehabilitation services include, but are not limited to, physical therapy, occupational therapy, speech therapy, and audiology. If ordered by the physician, each resident must have an individually planned and implemented program with written goals and response/progress documented. Points will be determined by intensity of required services and the applicant’s or recipient’s potential for rehabilitation as determined by the rehabilitation evaluation. The applicant or recipient will receive— (I) Zero (0) points if assessed as requiring no ordered rehabilitation services; (II) Three (3) points, if assessed as requiring minimal-ordered rehabilitation services of one (1) time per week; (III) Six (6) points if assessed as requiring moderate-ordered rehabilitative services of two (2) or three (3) times per week; or (IV) Nine (9) points if assessed as requiring maximum-ordered rehabilitative services of four (4) times per week or more. Page 1 of 4 SECTION D. ASSESSED NEEDS Date of the last consult completed by a physician or licensed mental health professional: Behavioral Symptoms (Check one box for each) Withdrawn/Depressed Suspicious/Paranoid Wanders Hallucinations/Delusions Abnormal Thought Process Aggressive (Physical/Verbal) Suicidal/Homicidal Ideation Restraints Sexually Inappropriate Controlled with Medications COMMENT: Stable mental condition AND no mood or behavior symptoms observed AND no reported psychiatric conditions Stable mental condition monitored by a physician or licensed mental health professional at least monthly OR behavior symptoms exhibited in past, but not currently present OR psychiatric conditions exhibited in past, but not recently present Unstable mental condition monitored by a physician or licensed mental health professional at least monthly OR behavior symptoms are currently exhibited OR psychiatric conditions are recently exhibited Unstable mental condition monitored by a physician or licensed mental health professional at least monthly AND behavior symptoms are currently exhibited OR psychiatric conditions are currently exhibited BEHAVIORAL: • Determine if the applicant or recipient: • Receives monitoring for mental condition • Exhibits one of the following mood or behavior symptoms - wandering, physical abuse, socially inappropriate or disruptive behavior, inappropriate public sexual behavior or public disrobing; resists care • Exhibits one of the following psychiatric conditions - abnormal thoughts, delusions, hallucinations None Min Mod Max COMMENT: 0 pts 3 pts 6 pts 9 pts ,1',&$7(7+(',$*126(65(/(9$1772$33/,&$17·6)81&7,21$/$1'256.,//('1856,1*1(('6 6(&7,21&5(&(170(',&$/,1&,'(176,(&9$685*(5<)5$&785(+($',1-85<(7&$1'*,9('$7(6 6(&7,21% &855(17/2&$7,21352326('3/$&(0(17 REASON FOR SUBMITTING APPLICATION: INDIVIDUAL’S CURRENT PHYSICAL LOCATION: NAME OF PROPOSED SKILLED NURSING FACILITY: FACILITY ID NUMBER: ADMIT DATE TO NF: DISCHARGE DATE FROM NF: STATE OF MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES 1856,1*)$&,/,7</(9(/2)&$5($66(660(17 MO 580-3350 (12-2020) DHSS-DRL-109 (10-20) 6(&7,21$ ,1',9,'8$/ 6,'(17,)<,1*,1)250$7,21 NAME (LAST, FIRST, MIDDLE INITIAL, SUFFIX) DATE OF BIRTH: DCN (MEDICAID NUMBER): SSN NUMBER: RACE: GENDER: See Attached All questions on this form must be answered- write N/A if not applicable. Blank areas will result in return of document and delay in payment. Page 2 of 4 MO 580-3350 (12-2020) DHSS-DRL-109 (10-20) COGNITION: • Determine if the applicant or recipient has an issues in one or more of the following areas: • Cognitive skills for daily decision making • Memory or recall ability (short-term, procedural, situational memory) • Disorganized thinking/awareness - mental function varies over the course of the day • Ability to understand others or to be understood Person Place Time Situation No issues with cognition AND no issues with memory, mental function, or ability to be understood/understand others Displays difficulty making decisions in new situations or occasionally requires supervision in decision making AND has issues with memory, mental function, or ability to be understood/understand others Displays consistent unsafe/poor decision making requiring reminders, cues or supervision at all times to plan, organize and conduct daily routines AND has issues with memory, mental function, or ability to be understood/understand others Rarely or never has the capability to make decisions OR displays consistent unsafe/poor decision making or requires total supervision requiring reminders, cues or supervision at all times to plan, organize and conduct daily routines AND rarely or never understood/able to understand others TRIGGER: No discernible consciousness, coma 0 pts 3 pts 6 pts 9 pts 18 pts COMMENT: 02%,/,7< • Determine the applicant or recipient's primary mode of locomotion • Determine the amount of assistance the applicant or recipient needs with: • Locomotion - how moves walking or wheeling, if wheeling how much assistance is needed once in the chair • Bed Mobility - transition from lying to sitting, turning, etc. DIET ORDERED BY PHYSICIAN: COMMENT: No assistance needed OR only set up or supervision needed Limited or moderate assistance needed, i.e. applicant or recipient performs more than 50% of tasks independently Maximum assistance needed, i.e. applicant or recipient needs two (2) or more individuals or more than 50% weightbearing assistance OR total dependent for bed mobility TRIGGER: Applicant or recipient is bedbound OR totally dependent on the others for locomotion EATING: • Determine the amount of assistance the applicant or recipient needs with eating and drinking. Includes intake of nourishment by other means (e.g. tube feeding or total parenteral nutrition (TPN). • Determine if the participant requires a physician ordered therapeutic diet. No assistance needed AND no physician ordered diet Physician ordered therapeutic diet OR set up, supervision, or limited assistance needed with eating Moderate assistance needed with eating, i.e. applicant or recipient performs more than 50% of the task independently Maximum assistance needed with eating, i.e. applicant or recipient requires an individual to perform more than 50% for assistance TRIGGER: Totally dependent on others 0 pts 3 pts 6 pts 9 pts 18 pts 0 pts 3 pts 6 pts 18 pts COMMENT: TOILETING: • Determine the amount of assistance the applicant or recipient needs with toileting. Toileting includes: the actual use of the toilet room (or commode, bedpan, or urinal), transferring on/off the toilet, cleansing self, adjusting clothes, managing catheters/ ostomies, and managing incontinence episodes. No assistance needed OR only set up or supervision needed Limited or moderate assistance needed, i.e. applicant or recipient performs more than 50% of tasks independently Maximum assistance needed, i.e. applicant or recipient needs two (2) or more individuals, or more than 50% of weightbearing assistance Total dependence on others 0 pts 3 pts 6 pts 9 pts ORIENTATION: MEMORY: LEVEL OF SUPERVISION: ABILITY TO MAKE A PATH TO SAFETY: HEARING IMPAIRMENT: SPEECH IMPAIRMENT: COGNITION: • Determine if the applicant or recipient has an issues in one or more of the following areas: • Cognitive skills for daily decision making • Memory or recall ability (short-term, procedural, situational memory) • Disorganized thinking/awareness - mental function varies over the course of the day • Ability to understand others or to be understood Person Place Time Situation No Yes No Yes COMMENT: No Yes Page 3 of 4 MO 580-3350 (12-2020) DHSS-DRL-109 (10-20) COMMENT: No assistance needed OR only set up or supervision needed Limited or moderate assistance needed, i.e. applicant or recipient performs more than 50% of tasks independently Maximum assistance, i.e. applicant or recipient requires two (2) or more individuals, more than 50% of weight-bearing assistance OR total dependence on others COMMENT: 0 pts 3 pts 6 pts BATHING: • Determine the amount of assistance the applicant or recipient needs with bathing. Bathing includes: taking a full body bath/shower and the transferring in and out of the bath/shower. COMMENT: No assistance needed OR only set up or supervision needed Limited or moderate assistance needed, i.e. applicant or recipient performs more than 50% of tasks independently Maximum assistance, i.e. applicant or recipient requires two (2) or more individuals, more than 50% of weight-bearing assistance OR total dependence on others None of the above therapies ordered Any of the above therapies ordered 1 time per week Any of the above therapies ordered 2-3 times per week Any of the above therapies ordered 4 or more times per week COMMENT: TYPE OF PHYSICIAN-ORDERED REHABILITATIVE SERVICES AND FREQUENCY: COMMENT: DRESSING AND GROOMING: • Determine the amount of assistance needed by the applicant or recipient to dress, undress and complete daily grooming tasks REHABILITATIVE SERVICES: • Determine if the applicant or recipient has the following medically ordered rehabilitative services: Physical therapy/Occupational therapy/Speech therapy/Cardiac rehabilitation/Audiology. 0 pts 3 pts 6 pts 0 pts 3 pts 6 pts 9 pts None of the above treatments were ordered by the physician One or more of the above treatments was ordered by the physician requiring daily attention by a license professional No assistance needed OR only set up or supervision needed Limited or moderate assistance needed, i.e. applicant or recipient performs more than 50% of tasks Maximum assistance, i.e. an individual performs more than 50% of tasks for the applicant or recipient OR total dependence on others TYPE OF PHYSICIAN-ORDERED TREATMENT/COMMENT: COMMENT: TREATMENTS: • Determine if the applicant or recipient requires any of the following treatments: • Catheter/Ostomy care • Alternate modes of nutrition (tube feeding, TPN) • Suctioning • Ventilator/respirator • Wound care (skin must be broken) MEAL PREPARATION: • Determine the amount of assistance the applicant or recipient needs to prepare a meal. This includes planning, assembling ingredients, cooking, and setting out the food and utensils. 0 pts 6 pts 0 pts 3 pts 6 pts COMMENT: No assistance needed Set up help needed OR supervision needed OR limited or moderate assistance needed, i.e. applicant or recipient performs more than 50% of tasks Maximum assistance needed, i.e. an individual performs more than 50% of tasks for the applicant or recipient OR total dependence on others COMMENT: 0 pts 3 pts 6 pts MEDICATION MANAGEMENT: • Determine the amount of assistance the applicant or recipient needs to safely manage their medications. Assistance may be needed due to a physical or mental disability. Page 4 of 4 6(&7,21( 5()(55,1*,1',9,'8$/&203/(7,1*$33/,&$7,21 FIRST AND LAST NAME: POSITION/TITLE: TYPE OF ENTITY: NAME OF ENTITY: TELEPHONE NUMBER: EXT: FAX NUMBER: EMAIL ADDRESS: DATE REFERRAL COMPLETED: CHECK IF SAME AS REFERRING INDIVIDUAL OR COMPLETE CONTACT PERSON IF LEVEL II SCREENING INDICATED: TELEPHONE NUMBER: EXT: EMAIL: FAX NUMBER: MO 580-3350 (12-2020) DHSS-DRL-109 (10-20) No difficulty or some difficulty with vision AND no falls in last 90 days AND no recent problems with balance Severe difficulty with vision (sees only lights and shapes) OR has fallen in the last 90 days OR has current problems with balance OR preliminary score of 0 AND Age OR Institutionalization No vision OR has fallen in last 90 days AND has current problems with balance OR Preliminary score of 0 AND Age AND Institutionalization OR Preliminary score of 3 AND Age OR Institutionalization Preliminary score of 6 AND Institutionalization TRIGGER: Preliminary score of 6 AND Age OR Preliminary Score of 3 AND Age AND Institutionalization DATE OF LAST FALL: TYPE OF INSTITUTIONALIZATION: TIMEFRAME OR DATE ADMITTED TO INSTITUTION: COMMENT: 6$)(7< • Determine if the individual exhibits any of the following risk factors: • Vision Impairment • Falling • Problems with balance. Balance is moving to standing position, turning to face the opposite direction, dizziness, or unsteady gait • After determination of preliminary score, history of institutionalization and age will be considered to determine final score. • Institutionalization in the last 5 years - long-term care facility, mental health residence, psychiatric hospital, inpatient substance abuse, or settings for persons with intellectual disabilities. • Aged - 75 years and over. 0 pts 3 pts 6 pts 9 pts 18 pts  &HQWUDO2IÀFH8VH2QO\'5/&2058 Level of Care Determination by DRL Central Office MEETS LEVEL OF CARE Yes No SIGNATURE DATE Next Section Next Section