19 CSR 30-81.030 Evaluation and Assessment Measures for Title XIX Recipients and Applicants in Long-Term Care Facilities

PURPOSE: This rule sets the requirements for the periodic
evaluation and assessments of residents in long-term care
facilities in relation to evaluation and assessment
processes, level-of-care needed by individuals, and
appropriate placement of individuals in order to receive
this care.

(1) For purposes of this rule only, the following definition n s shall apply:
(A) Applicant—any resident or prospective resident o f 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 the 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 determination of lev elof-care need pursuant to 19 CSR 30-81.030 and designat ed
Forms DA-124 A/B (dated 6-05) and DA-124 C (dated 4- 05) and Notice To Applicant Form, DA-124C ATT.
(attachment) (dated 12-01), incorporated by reference in this rule and available through the Department of Health
and Senior Services website: www.dhss.mo.gov or by mail at: Department of Health and Senior Services Warehouse,
Attention General Services Warehouse, PO Box 570, Jefferson City, Missouri 65102-0570; telephone: (573) 526-
3861; fax: (573) 751-1574, shall be considered the approved Initial Assessment Forms. This rule does not
incorporate any subsequent amendments or additions.
(D) Inpatient Title XIX assistance—Title XIX payment s for intermediate or skilled nursing care in a certified longterm 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 need—the decision whether an individual qualifies for long-term 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 n eed
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, an d t h e 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
Department of Social Services, Family Support Division;
(K) 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
(L) The department—Department of Health and Senior Services.
(2) Initial Determination of Level-of-Care Needs Requirements.
(A) For the purpose of making a determination of lev elof-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 section (5) of this rule.
(B) 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.
(3) Redetermination of Level-of-Care Requirements.
(A) 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-124 A/B and C forms and
any documentation provided by the resident’s attending physician.
(B) Required documentation on the DA-124 C form shall include the resident’s physician’s signature and his or her
Physician Identification Number.
(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 enables 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—mobility, diet are , restorative services, monitoring, medication, behavioral,
treatments, personal care, and rehabilitative services.
(C) To qualify for intermediate or skilled nursing care, an applicant or recipient shall exhibit physical impairmen t ,
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-ofcare 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. 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.
(C) For individuals seeking admission to a long-term care facility on or after July 15, 2017, 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 twenty-four (24) 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, 2017, an applicant with
twenty-one (21) points or lower will be assessed as ineligible for Title XIX-funded long-term care in a longterm care facility, unless the applicant qualifies as
otherwise provided in subsections, (5)(E) and/or (F) of the rule.
(E) 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:
1. Administration of levine tube or gastrostomy tube feedings;
2. Nasopharyngeal and tracheotomy aspiration;
3. Insertion of medicated or sterile irrigation and replacement catheters;
4. Administration of parenteral fluids;
5. Inhalation therapy treatments;
6. Administration of injectable medications other than insulin, if required other than on the day shift; and
7. Requirement of intensive rehabilitation services by a professional therapist at least five (5) days per week.
(F) 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 a residential care facility
(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. Responding to the verbal direction or the sound of an alarm;
2. Moving at a reasonable speed; and
3. If using a wheelchair or other assistive device, such as a walker or cane, being able to transfer into the
wheelchair or reach the assistive device without staff assistance.
(G) 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. Mobility is defined as the individual’s ability to
move from place to place. 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. The applicant or the recipient may use assistive devices (cane, walker,
wheelchair) but is consistently capable of negotiating without the assistance of another individual;
B. 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;
C. Six (6) points if assessed as requiring moderate assistance, in that the applicant or recipient is mobile o n ly
with direct staff assistance. The applicant or recipient must be assisted even when using canes, walker or other assistive
devices; and
D. Nine (9) points if assessed as requiring maximum assistance, in that the applicant or recipient is
totally dependent upon staff for mobility. The applican t o r the recipient is unable to ambulate or participate in the
ambulation process, requires positioning, supportive device, application, prevention of contractures or p ressure
sores and active or passive range of motion exercises;
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—

A. Zero (0) points if assessed as independent in dietary needs, in that the applicant or recipient requires n o
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);
B. 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;
C. 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
D. 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;
3. 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—
A. Zero (0) points if restorative services are not required;
B. Three (3) points if assessed as requiring minimum services in order to maintain level of functioning;
C. Six (6) points if assessed as requiring moderate services in order to restore the individual to a higher level
of functioning; and
D. 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;
4. Monitoring is defined as observation and assessment of the applicant’s or recipient’s physical and/o r
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—
A. 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;
B. 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;
C. 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
D. 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;
5. 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 the recipient will receive—
A. Zero (0) points if assessed as requiring no medication, or has not required PRN medication within t h e
thirty (30) days prior to review and evaluation by the department;
B. Three (3) points if assessed as requiring any regularly scheduled medication and the applicant or
the recipient exhibits a stable condition;
C. Six (6) points if assessed as requiring moderate supervision of regularly scheduled medications, requiring
daily monitoring by licensed personnel; and
D. 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;
6. Behavioral is defined as an individual’s social or
mental activities. The applicant or recipient will receive—
A. Zero (0) points if assessed as requiring little or no behavioral assistance. Applicant or recipient is orien t ed
and memory intact;
B. 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;
C. 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

D. 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;
7. Treatments are defined as a systematized course of nursing procedures ordered by the attending physician. The
applicant or recipient will receive—
A. Zero (0) points if no treatments are ordered by the physician;
B. Three (3) points if assessed as requiring minimal type-ordered treatments, including nonroutine and
preventative treatments, such as whirlpool baths and o t h er services;
C. 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
D. 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;
8. Personal care is defined as activities of daily livin g, 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 applican t
or recipient will receive—
A. 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;
B. 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);
C. 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
D. 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
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 the
applicant’s or recipient’s potential for rehabilitation as determined by the rehabilitation evaluation. The applican t
or recipient will receive—
A. Zero (0) points if assessed as requiring no ordered rehabilitation services;
B. Three (3) points, if assessed as requiring minimal-ordered rehabilitation services of one (1) time p er week;
C. Six (6) points if assessed as requiring moderateordered rehabilitative services of two (2) or three (3) t im es per week; and
D. Nine (9) points if assessed as requiring maximum-ordered rehabilitative services of four (4) times
per week or more.

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