Okla. Admin. Code § 317:35-19-7.1 - Level of care medical eligibility determination

The OKDHS area nurse, or nurse designee (OHCA, LOCEU makes some determinations when PASRR is involved), determines medical eligibility for the ADvantage program or nursing facility services based on the LTC nurse's UCAT III assessment, outcome of the Level II PASRR, if completed, and professional judgment.

(1) Definitions. The following words and terms when used in this subchapter, shall have the following meaning, unless the context clearly indicates otherwise:

(A) "ADL" means the activities of daily living. Activities of daily living are activities that reflect the client's ability to perform self-care tasks essential for sustaining health and safety such as:

(i) bathing,

(ii) eating,

(iii) dressing,

(iv) grooming,

(v) transferring (includes getting in and out of a tub, bed to chair, etc.),

(vi) mobility,

(vii) toileting, and

(viii) bowel/bladder control.

(B) "ADLs score in high risk range" means the client's total weighted UCAT ADL score is 10 or more which indicates the client needs some help with 5 ADLs or that the client cannot do 3 ADLs at all plus the client needs some help with 1 other ADL.

(C) "ADLs score at the high end of the moderate risk range" means the client's total weighted UCAT ADL score is 8 or 9 which indicates the client needs help with 4 ADLs or that the client cannot do 3 ADLs at all.

(D) "Client Support high risk" means the client's UCAT Client Support score is 25 which indicates in the UCAT assessor's clinical judgment that, excluding from consideration existing Ryan White CARE Act, Indian Health Service, Medicaid NF, ADvantage and/or State Plan Personal Care services, very little or no support is available from informal and formal sources and the client requires additional care that is not available through Medicare, Veterans Administration, or other federal entitlement programs.

(E) "Client Support moderate risk" means the client's UCAT Client Support score is 15 which indicates in the UCAT assessor's clinical judgment, excluding from consideration existing Ryan White CARE Act, Indian Health Service, Medicaid NF, ADvantage and/or State Plan Personal Care services, support from informal and formal sources is available, but overall, it is inadequate, changing, fragile or otherwise problematic and the client requires additional care that is not available through Medicare, Veterans Administration, or other federal entitlement programs.

(F) "Environment high risk" means the client's UCAT Environment score is 25 which indicates in the UCAT assessor's clinical judgment, the physical environment is strongly negative or hazardous.

(G) "Environment moderate risk" means the client's UCAT Environment score is 15 which indicates in the UCAT assessor's clinical judgment, many aspects of the physical environment are substandard or hazardous.

(H) "IADL" means the instrumental activities of daily living.

(I) "IADLs score in high risk range" means the client's total weighted UCAT IADL score is 12 or more which indicates the client needs some help with 6 IADLs or cannot do 4 IADLs at all.

(J) "ICN" means the client's individual care needs.

(K) "ICN Score" means the sum of the MSQ, Health Assessment, Nutrition, ADL and IADL scores.

(L) "Instrumental activities of daily living" means those activities that reflect the client's ability to perform household chores and tasks within the community essential for sustaining health and safety such as:

(i) shopping,

(ii) cooking,

(iii) cleaning,

(iv) managing money,

(v) using a telephone,

(vi) doing laundry,

(vii) taking medication, and

(viii) accessing transportation.

(M) "MSQ" means the mental status questionnaire.

(N) "MSQ score in high risk range" means the client's total weighted UCAT MSQ score is 12 or more which indicates a severe orientation-memory-concentration impairment, or a severe memory impairment.

(O) "MSQ score at the high end of the moderate risk range" means the client's total weighted UCAT MSQ score is 10 or 11 which indicates an orientation-memory-concentration impairment, or a significant memory impairment.

(P) "Nutrition high risk" means a total weighted UCAT Nutrition score is 12 or more which indicates the client has significant eating difficulties combined with poor appetite, weight loss, and/or special diet requirements.

(Q) "Social Resources high risk" means a total weighted UCAT Social Resources score is 15 or more which indicates the client lives alone combined with none or very few social contacts and no supports in times of need.

(2) Minimum UCAT criteria. The minimum UCAT criteria for NF level of care are:

(A) The UCAT documents need for assistance to sustain health and safety as demonstrated by:

(i) either the ADLs or MSQ score is in the high risk range; or,

(ii) any combination of two or more of the following:

(I) ADLs score is at the high end of moderate risk range; or,

(II) MSQ score is at the high end of moderate risk range; or,

(III) IADLs score is in the high risk range; or,

(IV) Nutrition score is in the high risk range; or,

(V) Health Assessment is in the moderate risk range, and, in addition,

(B) The UCAT documents absence of support or adequate environment to meet the needs to sustain health and safety as demonstrated by:

(i) Client Support is moderate risk; or,

(ii) Environment is high risk; or,

(iii) Environment is moderate risk and Social Resources is in the high risk range.

(3) NF Level of Care Services. To be eligible for NF level of care services, meeting the minimum UCAT criteria demonstrates the individual must:

(A) require a treatment plan involving the planning and administration of services that require skills of licensed technical or professional personnel, are provided directly or under the supervision of such personnel;

(B) have a physical impairment or combination of physical and mental impairments;

(C) require professional nursing supervision (medication, hygiene and/or dietary assistance);

(D) lack the ability to care for self or communicate needs to others;

(E) require medical care and treatment to minimize physical health regression and deterioration;

(F) require care that is not available through family and friends, Medicare, Veterans Administration, or other federal entitlement program with the exception of Indian Health Service; and,

(G) require care that cannot be met through Medicaid state plan services, including Personal Care, if financially eligible.

Notes

Okla. Admin. Code § 317:35-19-7.1

Added at 14 Ok Reg 56, eff 4-30-96 (emergency); Added at 14 Ok Reg 1802, eff 5-27-97; Amended at 15 Ok Reg 3715, eff 5-18-98 (emergency); Amended at 16 Ok Reg 1438, eff 5-27-99; Amended at 17 Ok Reg 2410, eff 6-26-00; Amended at 21 Ok Reg 2252, eff 6-25-04