R414-502-3. Approval of Level of Care

(1) The department shall document that at least two of the factors listed in Subsections (1)(a) through (1)(c) exist when determining whether an applicant has a cognitive or physical condition that requires the level of care provided in a nursing facility or equivalent care provided through a Medicaid home and community-based services (HCBS) waiver program. (a)(i) Due to a diagnosed medical condition, the applicant requires substantial ongoing physical assistance with multiple categories of activities of daily living above the level of verbal prompting, supervising, or setting up. (ii) Each program using level of care criteria shall determine a list of activities of daily living that would qualify an applicant for that program based on the type of setting. (b) The attending provider has diagnosed and documented that the applicant's ongoing cognitive dysfunction is not related to an acute condition and requires long-term nursing facility care or equivalent care provided through a Medicaid home and community-based waiver program. (i) The attending provider shall evidence any cognitive dysfunction by conducting current cognitive testing and documentation. (ii) Cognitive dysfunction may include disorientation. (c) The applicant's medical condition and intensity of services indicate that the long-term care needs of the applicant cannot be safely met in a less structured setting or without the services and supports of a Medicaid home and community-based waiver program. (2)(a) The department shall determine whether at least two of the factors described in Subsection (1) exist by reviewing clinical documentation. (b) Required clinical documentation varies between specific programs based on the type of setting. (c) Required documentation for an HCBS waiver program is described in waiver implementation plans approved by the Centers for Medicare and Medicaid Services (CMS). (d) A nursing facility provider shall include in the required clinical documentation: (i) an applicant's current history and physical examination completed by an attending provider; (ii) a comprehensive resident assessment for an applicant, completed, coordinated, and certified by a registered nurse; (iii) a social services evaluation of an applicant that meets the criteria in 42 CFR 456.370, completed by a person licensed as a social worker, or with a higher degree of training and licensure; (iv) a written plan of care for an applicant established by an attending provider; (v) an attending provider's written certification that an applicant requires nursing facility placement; (vi) weekly narrative nursing summaries that outline the care required and include the three factors of level of care criteria; (vii) daily documentation of physical assistance given to an applicant for activities of daily living; (viii) applicable and current cognitive testing with associated narrative charting related to an applicant's cognitive need with examples of impact; (ix) any applicable pre-admission screening and resident review evaluation, in accordance with Rule R414-503; (x) documentation indicating that less restrictive alternatives or services to prevent or defer nursing facility care for an applicant have been explored; (xi) the cognitive dysfunction attestation form published by the department; and (xii) any other pertinent documentation related to the factors described in Subsection (1). (3) If the department finds that at least two of the factors described in Subsection (1) exist, the department shall determine whether the applicant meets criteria for nursing facility level of care and is medically approved for Medicaid reimbursement of nursing facility services or equivalent care provided through a Medicaid home and community-based waiver program. (a) Meeting medical eligibility for nursing facility services does not guarantee Medicaid payment. (b) Financial eligibility and other home and community-based waiver targeting criteria apply.