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.

Editor's Note: The secretary of state has determined that the publication of this rule in its entirety would be unduly cumbersome or expensive. The entire text of the material referenced has been filed with the secretary of state. This material may be found at the Office of the Secretary of State or at the headquarters of the agency and is available to any interested person at a cost established by state law.

1. (1) For purposes of this rule only, the following definitions shall apply:

   1. (A) Applicant—any resident or prospective resident of a certified long-term care facility who is seeking to receive inpatient Title XIX assistance;
   2. (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;
   3. (C) Initial determination of level-of-care need—the original decision whether an individual qualifies for either intermediate nursing care or skilled nursing care;
   4. (D) Inpatient Title XIX assistance—Title XIX payments for intermediate or skilled nursing care in a certified long-term care facility;
   5. (E) Inspection of care (IoC)—a formal review conducted at least annually for each Title XIX recipient in a certified long-term care facility to assure services are adequate to meet health, rehabilitation and social needs of the recipient;
   6. (F) Intermediate care facility (ICF)—as defined in section 198.006, RSMo;
   7. (G) Intermediate nursing care—twentyfour (24)-hour care provided under the daily supervision of a licensed practical nurse or a registered nurse;
   8. (H) 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 distinct part or swing bed under Chapter 197, RSMo;
   9. (I) Plan I facility—an ICF facility which has made private utilization review arrangements through a committee of professionals not directly involved with the facility;
   10. (J) Plan II facility—an ICF facility which has no private utilization review arrangements and must be reviewed by the state;
   11. (K) Pro re nata (PRN)—medication or treatment ordered by a physician to be administered as needed, but not regularly scheduled;
   12. (L) Recipient—any resident in a certified long-term care facility who is receiving inpatient Title XIX assistance;
   13. (M) Redetermination of level-of-care—the periodic assessment of the recipients’ continued eligibility and need for continuation at the previously assigned level-of-care;
   14. (N) Resident—as defined in section 198.006, RSMo;
   15. (O) Skilled nursing care—is a twenty-four (24)-hour care requiring specialized judgment by licensed nursing personnel provided under the daily supervision of a registered nurse;
   16. (P) Skilled nursing facility (SNF)—as defined in section 198.006, RSMo; and
   17. (Q) Utilization review (UR)—a review of all inpatient Title XIX recipients who are residents in long-term care facilities to assure the recipients are receiving appropriate levels of care and continued stay is necessary.

2. (2) Initial Determination of Level-of-Care Needs.

   1. (A) The Division of Aging staff or its designated agents, or both, will conduct a review and assessment of the evaluations made by the attending physician pursuant to 42 CFR Section 456.270 for an applicant in or seeking admission to an SNF, or of the evaluation made by the interdisciplinary team pursuant to 42 CFR Section 456.370 for an applicant in or seeking admission to an ICF, for the purpose of making an initial determination of level-of-care need. The review and assessment shall be conducted in accordance with 42 CFR Sections 456.271 and 456.371 for applicants in or seeking admission to an SNF or ICF respectively and the assessment criteria in section (5) of this rule and it shall be completed within ten (10) working days from receipt by the Division of Aging central office of the completed evaluation required under 42 CFR Section 456.270 or 456.370. No Title XIX payment for intermediate or skilled nursing care services in a certified long-term care facility may be made prior to completion of the review and assessment process. 13 CSR 15-9

3. (3) IoC and UR.

   1. (A) The Division of Aging will be responsible for performing medical review functions required under 42 U.S.C. 1396.
   2. (B) The Division of Aging will conduct onsite annual inspections of care of all inpatient Title XIX recipients in long-term care facilities certified by the Division of Aging as specified in 42 CFR 456.600—456.657.
   3. (C) The Division of Aging will conduct semiannual utilization reviews of all inpatient Title XIX recipients in Plan II facilities. Plan I facilities shall conduct UR every six (6) months of all inpatient Title XIX ICF recipients. SNFs shall conduct UR on each skilled recipient at least every thirty (30) days for the first ninety (90) days and at least every ninety (90) days after that. The facilities shall notify the Division of Aging if there is any change in level-of-care of any recipient.
   4. (D) Redetermination of level-of-care of individual recipients in long-term care facilities will be established by the Division of Aging through a review of the ongoing records and notations made by the resident’s physician regarding care needed as well as by considering the individual’s functional ability as indicated in sections (4) and (5).

4. (4) Level-of-Care Criteria for Intermediate and Skilled Nursing Care—Qualified Title XIX Recipients and Applicants.

   1. (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.
   2. (B) 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. (C) To qualify for 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 skilled nursing care.
   4. (D) To qualify for intermediate level-ofcare, an applicant or recipient shall exhibit physical or mental impairment, or both, which requires intermediate nursing care.

5. (5) Assessed Needs Point Designations.

   1. (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.
   2. (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 cited in subsections (4)(C) and (D) of this rule.
   3. (C) The higher point value will be assessed, unless the lower point value can be justified.
   4. (D) An applicant or recipient will be determined to be qualified for skilled nursing care if s/he is determined to need care with an assessed point level of fifty-four (54) points or above, using the assessment procedure as stated in this section.
   5. (E) An applicant or recipient will be determined to be qualified for intermediate nursing care if s/he is determined to need care with an assessed point level of eighteen to forty-eight (18—48) points using the assessment procedure as stated in this section.
   6. (F) Applicants or recipients with twelve

6. (12) points or lower will normally be assessed as ineligible for Title XIX-funded intermediate or skilled nursing services in an long-term care facility, unless they qualify as otherwise provided in subsection (5)(H) or (J), or both, of this rule.

   1. (G) A special central office review will be conducted by Division of Aging administrative staff and medical staff for applicants or recipients assessed at fifty-one (51) points (between skilled care and intermediate care) and applicants or recipients assessed at fifteen (15) points (between intermediate care and lower levels of care).

   2. (H) Applicants or recipients may occasionally require care or services, or both, which could qualify as skilled nursing services. In these instances, it may be that a single nursing service requirement will be used as the qualifying factor, making the person eligible for skilled nursing care regardless of the total point count. The determining factor will be the availability of professional personnel to perform or supervise the services. These special qualifying care services may include, but are not limited to:

      1. 1. Administration of levine tube or gas-

trostomy tube feedings;

1. 2. Nasopharyngeal and tracheotomy

aspiration;

1. 3. Insertion of medicated or sterile irri-

gation and replacement catheters;

1. 4. Administration of parenteral fluids;
2. 5. Inhalation therapy treatments;
3. 6. Administration of injectable medica-

tions other than insulin, if required other than on the day shift; and

1. 7. Requirement of intensive rehabilita-

tion services by a professional therapist at least five (5) days per week.

1. (I) If the provider’s records show that the resident’s attending physician has ordered certain care, medication or treatments for an applicant or recipient, the Division of Aging staff will—a) assess points for a PRN order only if the applicant or recipient has actually received or required that care, medication or treatment at some time during the prior thirty (30) days or b) assess points for other ordered care, medications or treatments, unless a state physician consultant determines with reasonable medical certainty, after consultation with the attending physician, that the ordered care, medication or treatment is no longer needed by the recipient.

2. (J) 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 adult boarding facility/residential care facility (ABF/RCF) residency as specified by section 198.073, RSMo. In order to meet this requirement, an applicant or recipient must be able to reach and go through a required exit door on the floor where the resident is located by—

   1. 1. Responding to verbal direction or the

sound of an alarm;

1. 2. Moving at a reasonable speed; and
2. 3. If using a wheelchair or other assis-

tive device, such as a walker or cane, being able to transfer into the wheelchair or reach the assistive device without staff assistance.

1. (K) Points will be assigned to each category, as stated in subsection (4)(B) of this rule, in multiples of three (3) according to the following guide:

   1. 1. Mobility is defined as the individual’s

ability to move from place-to-place. The applicant or recipient will receive—

1. A. Zero (0) points if considered to be

independently mobile, in that the applicant or recipient requires no assistance. The applicant or recipient may use assistive devices (cane, walker, wheelchair) but is consistently capable of negotiating without assistance;

1. B. Three (3) points if considered to

require minimum assistance, in that the applicant or recipient is independently mobile once the applicant or recipient receives assistance with transfers, braces, prothesis or other assistive devices, or a combination of these (example, independent use of wheelchair after assistance with transfer). This category includes persons who are not consistently independent and need assistance periodically;

1. C. Six (6) points if considered to

require moderate assistance, in that the applicant or recipient is mobile only with direct assistance. The applicant or recipient must be assisted even when using canes, walker or other devices; and

1. D. Nine (9) points if considered to

require maximum assistance, in that the applicant or recipient is totally dependent. The applicant or recipient is unable to ambulate or participate in the process, requires positioning, supportive devices, prevention of contractures or decubiti and active or passive exercises;

1. 2. 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—

1. A. Zero (0) points if considered to be

independent in dietary needs, in that the applicant or recipient requires no assistance to eat. The applicant or recipient has regular diet, mechanically altered or only minor modifications (example, limited desserts, no salt or sugar on tray);

1. B. Three (3) points if considered to

require 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 are included;

1. C. Six (6) points if considered to

require 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

1. D. Nine (9) points if considered to

require maximum assistance, in that the applicant or recipient requires extensive assistance for special dietary needs, which could include tube feedings, parenteral fluids and the like;

1. 3. Restorative services are defined as

specialized services provided to help applicants or recipients obtain or maintain, or both, their optimal 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 (selftransfer, self-administration of medications, self-care), range of motion, bowel and bladder program, remotivational therapy, reality orientation, patient/family program and individualized activity program. The applicant or recipient will receive—

1. A. Zero (0) points if restorative ser-

vices are not required;

1. B. Three (3) points if considered to

require minimum services in order to maintain level of functioning;

1. C. Six (6) points if considered to

require moderate services in order to restore to a higher level of functioning; and

1. D. Nine (9) points if considered to

require maximum services in order to restore to a higher level of functioning. These are intensive services, usually requiring professional supervision or direct services;

1. 4. Monitoring is defined as observation

and assessment of the applicant’s or recipient’s physical or mental condition, or both. This monitoring could include assessment of—routine lab work (digoxin levels), clinitest and acetest, intake and output, weights and other routine procedures. The applicant or recipient will receive —

1. A. Zero (0) points if considered to

require only routine monitoring, such as monthly weights, temperatures, blood pressures and routine supervision;

1. B. Three (3) points if considered to

require 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;

1. C. Six (6) points if considered to

require moderate monitoring, in that the applicant or recipient requires regular assessment of routine procedures due to applicant’s or recipient’s unstable physical or mental condition; and

1. D. Nine (9) points if considered to

require maximum monitoring which is intensive monitoring usually by professional personnel due to applicant’s or recipient’s unstable physical or mental condition;

1. 5. Medication is defined as the drug regimen of all physician-ordered legend drugs, and any physician-ordered nonlegend drug for which the physician has ordered monitoring due to the complexity of the drug or the condition of the applicant or recipient. The applicant or recipient will receive—

   1. A. Zero (0) points if considered to

require no medication, or little medication in the form of irregular use of PRN medication;

1. B. Three (3) points if considered to

require any regularly scheduled medication and exhibits a stable condition;

1. C. Six (6) points if considered to

require moderate supervision of regularly scheduled medications, requiring daily monitoring by licensed personnel; and

1. D. Nine (9) points if considered to

require maximum supervision of regularly scheduled medications, complex drug regime, unstable condition or use of drugs requiring professional observation and assessment, or a combination of these;

1. 6. Behavioral is defined as an individu-

al’s social or mental activities. The applicant or recipient will receive—

1. A. Zero (0) points if considered to

require little or no behavioral assistance. Applicant or recipient is oriented and memory intact;

1. B. Three (3) points if considered to

require 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;

1. C. Six (6) points if considered to

require moderate behavioral assistance in the form of supervision due to disorientation, mental or developmental disabilities or uncooperative behavior; and

1. D. Nine (9) points if considered to

require 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;

1. 7. Treatments are defined as a system-

atized course of nursing procedures ordered by the attending physician. The applicant or recipient will receive—

1. A. Zero (0) points if no treatments are

ordered by the physician;

1. B. Three (3) points if considered to

require minimal type-ordered treatments, including nonroutine and preventative treatments, such as whirlpool baths and other services;

1. C. Six (6) points if considered to

require 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 decubitus ulcers, wet/moist packs, maximist and other such services; and

1. D. Nine (9) points if considered to

require 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, 13 CSR 15-9

such as advanced decubiti or necrotic lesions; infrared heat and other services;

1. 8. Personal care is defined as activities

of daily living, including hygiene; personal grooming, such as dressing, bathing, oral 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—

1. A. Zero (0) points if considered to

require 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;

1. B. Three (3) points if considered to

require minimal assistance with personal care, in that the applicant or recipient requires assistance with personal grooming, exhibits infrequent incontinency, or both;

1. C. Six (6) points if considered to

require moderate assistance with personal care, in that the applicant or recipient requires assistance with personal grooming, requiring close supervision or exhibits frequent incontinency, or a combination of these; and

1. D. Nine (9) points if considered to

require maximum assistance with personal care, in that the applicant or recipient requires total personal care to be performed by another person, exhibits continuous incontinency, or both; and

1. 9. 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 applicant’s or recipient’s potential for rehabilitation as indicated by the rehabilitation evaluation. The applicant or recipient will receive—

1. A. Zero (0) points if considered to

require no ordered rehabilitation services;

1. B. Three (3) points, if considered to

require minimal-ordered rehabilitation services of one (1) time per week;

1. C. Six (6) points if considered to

require moderate-ordered rehabilitative services of two (2) or three (3) times per week; and

1. D. Nine (9) points if considered to

require maximum-ordered rehabilitative services of four (4) times per week or more.

AUTHORITY: sections 207.020 and 208.159, RSMo 1986 and 208.153, RSMo Supp. 1991.* This rule was previously filed as 13 CSR 40-81.084. Original rule filed Aug. 9, 1982, effective Nov. 11, 1982. Emergency rescission filed Nov. 24, 1982, effective Dec. 4, 1982, expired March 10, 1983. Rescinded: Filed Nov. 24, 1982, effective March 11, 1983. Readopted: Filed Dec. 15, 1982, effective March 11, 1983. Emergency amendment filed Dec. 21, 1983, effective Jan. 1, 1984, expired April 11, 1984. Emergency amendment filed March 14, 1984, effective April 12, 1984, expired June 10, 1984. Amended: Filed March 14, 1984, effective June 11, 1984. *Original authority: 207.020, RSMo 1945, amended 1961, 1965, 1977, 1981, 1982, 1986; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991; and 208.159, RSMo 1979.