Section 360. Criteria for care in facilities for mentally retarded persons

§ 4.0 Definitions. The following words and terms, when used in these criteria, shall have the following meaning, unless the context clearly indicated otherwise:

"no assistance" shall mean no help is needed.

"prompting/structuring" shall mean prior to the functioning, some verbal direction and/or some rearrangement of the environment is needed.

"supervision" shall mean that a helper must be present during the function and provide only verbal direction, general prompts, and/or guidance.

"some direct assistance" shall mean that helper must be present and provide some physical guidance/support (with or without verbal direction).

"total care" shall mean that a helper must perform all or nearly all of the functions.

"rarely" shall mean that a behavior occurs quarterly or less.

"sometimes" shall mean that a behavior occurs once a month or less.

"often" shall mean that a behavior occurs 2-3 times a month.

"regularly" shall mean that a behavior occurs weekly or more.

§ 4.1 Utilization Control regulations require that criteria be formulated for guidance for appropriate levels of services. Traditionally, care for the mentally retarded has been institutionally based; however, this level of care need not be confined to a specific setting. The habilitative and health needs of the client are the determining issues.

§ 4.2 The purpose of these regulations is to establish standard criteria to measure eligibility for Medicaid payment. Medicaid can pay for care only when the client is receiving appropriate services and when "active treatment" is being provided. An individual's need for care must meet these criteria before any authorization for payment by Medicaid will be made for either institutional or waivered rehabilitative services for the mentally retarded.

§ 4.3 Care in facilities for the mentally retarded requires planned programs for habilitative needs and/or health related services which exceed the level of room, board, and supervision of daily activities.

Such cases shall be combination of habilitative, rehabilitative, and health services directed toward increasing the functional capacity of the retarded person. Examples of services shall include training in the activities of daily living, task-learning skills, socially acceptable behaviors, basic community living programming, or health care and health maintenance. The overall objective of programming shall be the attainment of the optimal physical, intellectual, social, or task learning level which the person can presently or potentially achieve.

§ 4.4 The evaluation and re-evaluation for care in a facility for the mentally retarded shall be based on the needs of the person, the reasonable expectations of the resident's capabilities, the appropriateness of programming, whether progress is demonstrated from the training and, in an institution, whether the services could reasonably be provided in a less restrictive environment.

§ 4.5 Patient assessment criteria. The patient assessment criteria are divided into broad categories of needs, or services provided. These must be evaluated in detail to determine the abilities/skills which will be the basis for the development of a plan for care. The evaluation process will demonstrate a need for programming an array of skills and abilities or health care services. These have been organized in seven major categories. Level of functioning in each category is graded from the most dependent to the least dependent. In some categories, the dependency status is rated by the degree of assistance required. In other categories, the dependency is established by the frequency of a behavior or ability to perform a given task.

§ 4.6 The resident must meet the indicated dependency level in TWO OR MORE of categories 1 through 7.

1. Two or more questions must be answered with a 4, OR

2. Question "j" must be answered "yes."

B. Communication Skills - To meet this category three or more questions must be answered with a 3 or a 4.

C. Task Learning Skills - To meet this category three or more questions must be answered with a 3 or a 4.

D. Personal Care - To meet this category

1. Question "a" must be answered with a 4 or a 5, OR

2. Question "b" must be answered with a 4 or a 5, OR

3. Questions "c" and "d" must be answered with a 4 or a 5.

E. Mobility - To meet this category any one question must be answered with a 4 or a 5.

F. Behavior - To meet this category any one question must be answered with a 3 or a 4.

G. Community Living - To meet this category

1. Any two of the questions "b", "e", or "g" must be answered with a 4 or a 5, OR

2. Three or more questions must be answered with a 4 or a 5.

§ 4.7. Level of functioning survey.

	A. HEALTH STATUS
	How often is nursing care or nursing supervision by a licensed nurse required for the following? (Key:1=rarely, 2=sometimes, 3=often, and 4=regularly)
	1. Medication administration and/or evaluation for effectiveness of a medication regimen?		1	2	3	4
	2. Direct services: i.e., care for lesions, dressings, treatments, (other than shampoos, foot power, etc.)		1	2	3	4
	3. Seizures control		1	2	3	4
	4. Teaching diagnosed disease control and care, including diabetes		1	2	3	4
	5. Management of care of diagnosed circulatory or respiratory problems		1	2	3	4
	6. Motor disabilities which interfere with all activities of Daily Living - Bathing, Dressing, Mobility, Toileting, etc.		1	2	3	4
	7. Observation for choking/aspiration while eating, drinking?		1	2	3	4
	8. Supervision of use of adaptive equipment, i.e., special spoon, braces, etc.		1	2	3	4
	9. Observation for nutritional problems (i.e., undernourishment, swallowing difficulties, obesity)		1	2	3	4
	10. Is age 55 or older, has a diagnosis of a chronic disease and has been in an institution 20 years or more		1	2	3	4
	B. COMMUNICATION
	Using the Key 1=regularly, 2=often, 3=sometimes, 4=rarely, how often does this person
	1. Indicate wants by pointing, vocal noises, or signs?		1	2	3	4
	2. Use simple words, phrases, short sentences?		1	2	3	4
	3. Ask for at least ten things using appropriate names?		1	2	3	4
	4. Understand simple words, phrases or instructions containing prepositions: i.e., on in behind?		1	2	3	4
	5. Speak in an easily understood manner?		1	2	3	4
	6. Identify self, place of residence, and significant others?		1	2	3	4
	C. TASK LEARNING SKILLS
	How often does this person perform the following activities (Key: 1=regularly, 2=often, 3=sometimes, 4=rarely)
	1. Pay attention to purposeful activities for 5 minutes?		1	2	3	4
	2. Stay with a 3 step task for more than 15 minutes?		1	2	3	4
	3. Tell time to the hour and understand time intervals?		1	2	3	4
	4. Count more than 10 objects?		1	2	3	4
	5. Do simple addition, subtraction?		1	2	3	4
	6. Write or print ten words?		1	2	3	4
	7. Discriminate shapes, sizes, or colors?		1	2	3	4
	8. Name people or objects when describing pictures?		1	2	3	4
	9. Discriminate between one, many, lot?		1	2	3	4
	D. PERSONAL and SELF CARE
	With what type of assistance can this person currently (Key: 1=No Assistance, 2=Prompting/Structures, 3=Supervision, 4=Some Direct Assistance, 5=Total Care)
	1. Perform toileting functions: i.e., maintain bladder and bowel continence, clean self, etc.?	1	2	3	4	5
	2. Perform eating/feeding functions: i.e., drinks liquids and eats with spoon or fork, etc.?	1	2	3	4	5
	3. Perform bathing function: i.e., bathes, runs bath, dry self, etc.?	1	2	3	4	5
	4. Dress self completely, i.e., including fastening, putting on clothes, etc.?	1	2	3	4	5
	E. MOBILITY
	With what type of assistance can this person currently (Key: 1=No Assistance, 2=Prompting/Structures, 3=Supervision, 4=Some Direct Assistance, 5=Total Care)
	1. Move, (walking, wheeling) around environment?	1	2	3	4	5
	2. Rise from lying down to sitting positons, sits without support?	1	2	3	4	5
	3. Turn and position in bed, roll over?	1	2	3	4	5
	F. BEHAVIOR
	How often does this person (Key:1=Rarely, 2=Sometimes, 3=Often, and 4=Regularly)
	1. Engage in self destructive behavior?		1	2	3	4
	2. Threaten or do physical violence to others?		1	2	3	4
	3. Throw things, damage property, have temper outbursts?		1	2	3	4
	4. Respond to others in a socially unacceptable manner - (without undue anger, frustration, or hostility)		1	2	3	4
	G. COMMUNITY LIVING SKILLS
	With what type of assistance can this person currently (Key:1=No Assistance, 2=Prompting/Structures, 3=Supervision, 4=Some Direct Assistance, 5=Total Care)
	1. Prepare simple foods requiring no mixing or cooking?	1	2	3	4	5
	2. Take care of personal belongings, room (excluding vacuuming, ironing, clothes washing/drying, wet mopping)?	1	2	3	4	5
	3. Add coins of various denominations up to one dollar?	1	2	3	4	5
	4. Use the telephone to call home, doctor, fire, police?	1	2	3	4	5
	5. Recognize survival signs/words: i.e., stop, go, traffic lights, police, men, women, restrooms, danger, etc.?	1	2	3	4	5
	6. Refrain from exhibiting unacceptable sexual behavior in public?	1	2	3	4	5
	7. Go around cottage, ward, building, without running away, wandering off, or becoming lost?	1	2	3	4	5
	8. Make minor purchases, i.e., candy, soft drink, etc?	1	2	3	4	5

Historical Notes

Derived from VR460-03-3.1301 § 4, eff. June 29, 1994.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.