DATA DICTIONARY For TRAUMA REHABILITATION DATA COLLECTION From Inpatient Rehabilitation Facilities

Transcription

1 OHIO TRAUMA REGISTRY DATA DICTIONARY For TRAUMA REHABILITATION DATA COLLECTION From Inpatient Rehabilitation Facilities OHIO DEPARTMENT OF PUBLIC SAFETY EMS DIVISION 1970 W. Broad Street, P.O. Box Columbus, OH (614) (800) EMS Data Center (614) Effective January 1, 2005

2 Table of Contents Patient Inclusion Criteria...3 Field Definitions...5 Field #1 Rehabilitation Facility Code...6 Field #2 Unique Patient Encounter/Admission Number...7 Field #3 Date Exported...8 Field #4 Zip Code of Residence...9 Field #5 Patient s Date of Birth...10 Field #6 Gender...11 Field #7 Race/Ethnicity...12 Field #8 Date of Onset (date injury occurred)...13 Field #9 Rehabilitation Admission From...14 Field #10 Pediatric Pre-hospital Setting...16 Field #11 Pediatric Living With...17 Field #12 Pediatric Education Category...18 Field #13 Pediatric Educational Setting...19 Field #14 Adult Pre-hospital Living With...20 Field #15 Adult Pre-hospital Vocational Category...21 Field #16 Adult Pre-hospital Vocational Effort...22 Field #17 Transferring Facility ID...23 Field #18 Rehabilitation Facility Arrival Date...24 Field #19 Etiological Diagnosis (ICD-9-CM Code)...25 Field #20 Co-Morbid Conditions (ICD-9-CM Codes)...26 Field #21 Complications During Rehabilitation Stay (ICD-9-CM Codes)...27 Field #22 Disability Assessment Tool Adult/Pediatric (FIM WeeFIM instrument)...28 Field #23 Disability Assessment Score Upon Admission (FIM WeeFIM rating)...29 Field #24 Disability Assessment Score Upon Discharge (FIM WeeFIM rating)...30 Field #25 Date of Discharge or Death...31 Field #26 Discharge Status...32 Field #27 Adult Discharge Disposition...33 Field #28 Adult Discharge Living With...34 Field #29 Pediatric Discharge Disposition...35 Field #30 Pediatric Discharge Living With...36 Field #31 Discharge Referrals...37 Field #32 Transfer to Other Hospital / Facility...38 Field #33 Billed Rehabilitation Facility Charges...39 Field #34 Payment Source...40 Field #35 Adult Rehabilitation Length of Stay...41 Field #36 Pediatric Rehabilitation Length of Stay...42 APPENDICES 1 - Ohio Rehabilitation Facility Codes Ohio Hospital Codes Out of State Rehabilitation, Hospital and Nursing Facility Codes Ohio Nursing Facility Codes... 5 Authority/Mandate... 6 Trauma Registry Advisory Subcommittee... 7 File Key Layout... 2

3 Ohio Trauma Registry Inpatient Rehabilitation Facility Patient Inclusion Criteria Patient s first or initial admission to an inpatient rehabilitation facility who meet one of the following inclusion criteria; 1. Patients whose acute care hospitalization included any of the inclusion criteria; OR 2. Patients who have an Impairment Group Code on admission listed in the table on page 4 Inclusion Criteria ICD-9-CM Diagnosis Codes on discharge from acute care hospital ICD-9-CM Diagnosis Codes ICD-9-CM Diagnoses Descriptions Fractures Fractures, dislocations/sprains, intracranial injury, internal injury of thorax, abdomen and pelvis, open wounds, injury to blood vessels 911.0, 911.1, 912.0, Abrasions/friction burns to trunk, shoulder and upper arm 916.0, 916.1, 919.0, Abrasions / friction burns hip, thigh, leg, ankle, other or multiple sites Contusions and crush injury Burns, injury to nerves and spinal cord, traumatic complications and unspecified injury Smoke inhalation Frostbite, hypothermia and external effects of cold 994.0, 994.1, 994.7, Asphyxiation, strangulation, drowning, and electrocution Child maltreatment and abuse ***OR*** ICD-9-CM Diagnoses E-CODE Anoxic Brain Injury E800 E Uncal herniation E878 E905.0 E906.0 E , Cerebral Edema E950.0 E Pneumocephalus Subconjunctival hemorrhage Traumatic ARDS Epistaxis AND WITH ANY OF THE FOLLOWING External Cause Codes (E-Codes) Acute Care Hospitalization ICD-9-CM Diagnoses Codes EXCLUDED Isolated hip fracture Late effects of injury , , , , Blisters, insect bites , , , , Foreign bodies Acute Care Hospitalization External Cause Codes EXCLUDED E849.0 E849.9 Place of occurrence E850.0 E869.9 Poisonings E870.0 E879.9 Misadventures during surgical and medical care E905.1 E905.9 Venomous animals and plants (except snakes) E929.0 E929.9 Late effects of Accidental Injury E930.0 E949.9 Drugs, medicinal and biological substances causing adverse effects in therapeutic use 3

4 Adult Impairment Group Code on Admission to Rehabilitation Facility Brain Dysfunction Orthopedic Disorders 02.1 Non-traumatic injury * Status Post Bilateral Hip Fractures * must be associated with an acceptable E-code Status Post Femure (shaft) Fracture 08.3 Status Post Pelvic Fracture Traumatic, open injury 08.4 Status Post Major Multiple Fractures Traumatic, closed injury Spinal Cord Dysfunction, Traumatic Paraplegia, unspecified Amputation of Limb (trauma related) Paraplegia, incomplete 05.1 Unilateral Upper Limb above the elbow (AE) Paraplegia, complete 05.2 Unilateral Upper Limb below the elbow (BE) Quadriplegia, Unspecified 05.3 Unilateral Lower Limb above the knee (AK) Quadriplegia, Incomplete C Unilateral Lower Limb below the knee (BK) Quadriplegia, Incomplete C Bilateral Lower Limb above the knee (AK/AK) Quadriplegia, Complete C Bilateral Lower Limb above/below the knee (AK/AK) Quadriplegia, Complete C Bilateral Lower Limb below the knee (BK/BK) Other Traumatic Spinal Cord 05.9 Other amputation Dysfunction Major Multiple Trauma Burns 14.1 Brain + Spinal Cord Injury 11 Burns 14.2 Brain + Multiple Fracture/Amputation 14.3 Spinal Cord + Multiple Fracture/amputation 14.9 Other multiple trauma Pediatric Impairment Group Code on Admission to Rehabilitation Facility Traumatic Brain Dysfunction Burns 2.21 Traumatic, open injury 7.1 Burns 2.22 Traumatic, closed injury 2.9 Unspecified traumatic brain injury Orthopedic Disorders 2.11 Anoxic/Hypoxemic Encephalopathy Orthopedic Conditions Traumatic Spinal Cord Dysfunction 5.11 Status Post Unilateral Hip Fracture 4.21 Incomplete Traumatic Paraplegia 5.12 Status Post Femure (shaft) Fracture 4.22 CompleteTraumatic Paraplegia 5.13 Status Post Pelvic Fracture 4.23 Unspecified Traumatic Paraplegia 5.14 Status Post Major Multiple Fractures 4.24 Incomplete Traumatic Tetraplegia Quadriplegia, C1-4 Amputation of Limb (trauma related) 4.25 Incomplete Traumatic Tetraplegia Quadriplegia, 5.21 Unilateral Upper Extremity above the elbow C Complete Traumatic Tetraplegia Quadriplegia, 5.22 Unilateral Upper Extremity below the elbow C Complete Traumatic Tetraplegia Quadriplegia, 5.23 Unilateral Lower Extremity above the knee C Unspecified Traumatic Tetraplegia Quadriplegia 5.24 Unilateral Lower Extremity below the elbow 5.25 Bilateral Lower Extremity above the knee Major Multiple Trauma 5.26 Bilateral Lower Ext. above/below the knee 6.1 Brain + Spinal Cord Injury 5.27 Bilateral Lower Extremity below the knee 5.29 Other amputation 6.2 Brain + Multiple Fracture/Amputation 6.3 Spinal Cord + Multiple Fracture/amputation 6.9 Other multiple trauma 4

5 Ohio Trauma Rehabilitation Registry Field Definitions Unless specifically indicated, these definitions apply to all fields in the database: ND = Not Documented If the information is probably known but is not documented, or the information is not documented but should have been and would have been knowable. Example: sex NA = Not Applicable If the information requested is not applicable, or the information does not make sense for this field Example: seat belt use for motorcycle crash 0 = Zero Use only for numeric fields when that is what the correct number is. Example: in Length of Stay fields if the patient did not have a LOS in that area NT = Not Tested Use for fields in which the desired data is a laboratory test result when the test was not ordered. Example: for alcohol level, when that test was never ordered UNK = Unknown If the information is unknowable and cannot ever be obtained. That is, there is no way to know the answer, or the information is specifically documented as unknown in the medical record. Example: The time of injury if the patient is found unconscious the next morning 5

6 Field # 1: Values: Rehabilitation Facility Code The facility code assigned by the Ohio Department of Public Safety. 1. Length 4 2. Start Position 1 3. End Position 4 4. Allow blank or not NO 5. Data Type (Numeric, Character). NUMERIC See Appendix 1 ODPS Rehabilitation Facility Codes. Field Instructions: Must be present on all records submitted to the Ohio Department of Safety. A four-digit code assigned by the Ohio Department of Public Safety. This code needs to be entered initially. After initial entry it will automatically be entered for each record. Click Here to return to the Table of Contents 6

7 Field #2: Values: Version 1.0 Effective January 1, 2005 Unique Patient Encounter/Admission Number A number assigned by each facility to the patient at the time of admission. This number should be unique for each patient AND each visit. This number may be referred to as a patient account number. Medical record numbers are typically specific to each patient BUT are frequently the same for all rehabilitation facility visits by the same patient. 1. Length Start Position 5 3. End Position Allow blank or not NO 5. Data Type (Numeric, Character). NUMERIC Field Instructions: Enter the rehabilitation facility s unique patient number for this patient. This record is for audit purposes only and will not be made public. Click Here to return to the Table of Contents 7

8 Field #3: Date Exported Version 1.0 Effective January 1, 2005 Value: Date (mmddyyyy) that this record was submitted to the Ohio Trauma Registry. 1. Length 8 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). DATE Field Instructions: This is a generated field and will be completed when the record is exported to Ohio Trauma Registry. Click Here to return to the Table of Contents 8

9 Field # 4: Values: Zip Code of Residence The patient s five-digit zip code for place of residence, at the time of their injury. Enter for patients that reside outside of the USA. 1. Length 5 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). NUMERIC Field Instructions: Enter in the patients zip code number of their residence at the time of their injury. If patient is homeless, enter the zip code of the location of injury. Enter for patients that reside outside of the USA. Do not enter the 4-digit extension. Click Here to return to the Table of Contents 9

10 Field #5: Values: Patient s Date of Birth mmddyyyy Not documented 1. Length 8 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). DATE Field Instructions: The patient s date of birth. Enter the month, day and year of the patient s Date of Birth. If the patients age is known, but the date of birth is not, enter 01/01/YYYY (YYYY appropriate to patients known age) Entire year must be used Example: 1998 Enter in the patient s date of birth. Must use this format 01/01/1998. It is necessary to enter the year using the entire year. Click Here to return to the Table of Contents 10

11 Field #6: Values: Gender 1- Male 2- Female 3- ND (Not Documented) 1. Length 1 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). NUMERIC Field Instructions: The patient s gender at the injury date. Enter the patient s gender using the options available from code table above. Use the pulldown menu to select this field. Select the most appropriate option. Click Here to return to the Table of Contents 11

12 Field #7: Values: Race/Ethnicity 1- American Indian or Alaskan Native 2- Asian 3- Black, not of Hispanic origin 4- Hispanic or Latino 5- Native Hawaiian or Other Pacific Islander 6- White 7 Other 8 Multi-racial 9- ND (Not Documented) 1. Length 1 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). NUMERIC Field Instructions: The patient s race/ethnic group. Enter the patient s race from the available options. Use the pulldown menu to select this field. Select the most appropriate option. If more than one race value #1 to #6 is selected then value number 8 Multiracial must be selected. Note that pediatric facilities are limited to selection of only one value. Adult facilities can select multiple values, which will reported as 8 multi-racial. Values: 1- White 2- Black 3- Hispanic 4- Native American 5- Asian 6- Other 7- Multi-racial Click Here to return to the Table of Contents 12

13 Field #8: Values: Date of Onset (Date Injury Occurred) mmddyyyy ND (Not Documented) Unknown, if specifically documented as Unknown in the medical record. 1. Length 8 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). DATE Field Instructions: The date the injury occurred. Enter the month, day and year of the injury. The year must be 4-digits. Example: The date on which injury occurred must be the earliest date associated with the trauma event. All treatment dates must be equal to or after the date on which the injury occurred. Enter the patient s actual date of injury Click Here to return to the Table of Contents 13

14 Field #9: Values: Version 1.0 Effective January 1, 2005 Rehabilitation Admission From 1 Home 2 Board and Care 3 Transitional Living 4 Intermediate care 5 Skilled Nursing Facility 6 Acute Unit of own facility 7 Acute Unit another facility 8 - Chronic Hospital (LTAC) 9 Rehabilitation facility 10 Other 12 Alternate Level of care 13 Subacute setting 14 Assisted Living Residence 1. Length 2 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). NUMERIC Field Instructions: If # 4, 5, 7, or 9 is selected, field # 10 Transferring Facility ID must be competed. Value number 11 is purposefully not utilized for this field. Definitions Home: A private, community based dwelling (a house, apartment, mobile home, etc) that houses the patient, family, or friends. Board and Care: A community based setting where individuals have private space (either a room or apartment), or a structured retirement facility. The facility may provide transportation, laundry, and meals, but no nursing care. Transitional Living: A community based, supervised setting where individuals are taught skills so they can live independently in the community. Intermediate care (nursing home): A long term care setting that provides health related services but a registered nurse is not present 24 hours a day. Patients live by institutional rules; care is ordered by a physician, and a medical record is maintained. Patients in intermediate care are generally less disabled than those in skilled care facilities Skilled Nursing Facility (nursing home): A long term care setting that provides skilled nursing services. A registered nurse is present 24 hours a day. Patients live by institutional rules; care is ordered by a physician, and a medical record is maintained. Acute Unit of own Facility: An acute medical/surgical care unit in the same facility as the rehabilitation unit. Acute Unit another Facility: An acute medical/surgical care facility separate from the rehabilitation unit. Chronic Hospital (LTAC): A long-term care setting classified as a hospital, long term acute care. Rehabilitation facility: An inpatient setting that admits patients with specific disabilities and provides a team approach to comprehensive rehabilitation services, with a physiatrist (or physician of equivalent training/experience) as the physician of record. 14

15 Other: Used only if no other code is appropriate Alternate Level of care: Physically and fiscally distinct units that provides care to individuals who no longer meet acute care criteria Subacute setting: Subacute care is goal-oriented, comprehensive, inpatient care designed for an individual who has an acute illness, injury or exacerbation of a disease process. It is rendered immediately after, or instead of, acute hospitalization to treat one or more specific active, complex medical conditions an overall situation. Generally the condition of an individual receiving subacute care is such that the care does not depend heavily on high technology monitoring or complex diagnostic procedures. Subacute care requires the coordinated services of an interdisciplinary team, including physicians, nurses, and other relevant professional disciplines whoa re knowledgeable and trained to assess and manage specific conditions and perform the necessary procedures. Subacute care is given as part of a specially designed program, regardless of the site. Subacute care is generally more intensive than traditional nursing home care, but less than acute inpatient care. It requires frequent (daily to weekly) patient assessment and review of the clinical course and treatment plan for a limited time period (several days to several months), until a condition is stabilized or a predetermined course is completed. Assisted Living Residence: A community based setting that combines housing, private quarters, freedom of entry and exit, supportive services, personalized assistance, and healthcare designed to respond to individual needs of those who need help with activities of daily living and instrumental activities of daily living. Supportive services are available 24 hours a day to meet scheduled and unscheduled needs in a way that promotes maximum dignity and independence for each resident. These services involve the resident s family, neighbors, and friends. Click Here to return to the Table of Contents 15

16 Field #10: Pediatric Prehospital Setting Values: Version 1.0 Effective January 1, Home 02 Acute Care unit of own facility 03 Acute care unit of another facility 04 Rehabilitation facility 05 Residential facility 06 Transitional living center 07 - Skilled nursing facility 08 Shelter 09 Other 10 - Died 1. Length 2 2. Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Field Instructions: Select the value that most accurately describes the patients living arrangements prior to their hospitalization. Note the value 04 is not used in this field. Values: Click Here to return to the Table of Contents 16

17 Field #11: Pediatric Living With Values: 01 Two parents 02 One parent 03 - Relatives 04 Foster care 05 - Other 07 ND 1. Length 2 2. Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Version 1.0 Effective January 1, 2005 Field Instructions: Select a value in this field ONLY if the value selected in field # 10 Pediatric Prehospital Setting is equal to "01- Home" Click Here to return to the Table of Contents 17

18 Field #12: Pediatric Education Category Values: 01 Not a student 02 Early Intervention program 03 Preschool 04 Kindergarten through 12th 05 Other Version 1.0 Effective January 1, Length 2 2. Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character) NUMERIC Field Instructions: Select the value that best describes the patients educational category Click Here to return to the Table of Contents 18

19 Field #13: Pediatric Educational Setting Version 1.0 Effective January 1, 2005 Values: 01 Regular Class 02 Regular class with accommodation 03 Special Class 04 Home-based or Home Schooled 05 Day Care/nursery school/center-based/community 1. Length 2 2. Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Field Instructions: If value 2, 3 or 4 is selected for the Pediatric Education Category, then an appropriate value for this field must be reported. If 01 or 05 is selected for Pediatric Education Category, then 06- NA must be selected. Click Here to return to the Table of Contents 19

20 Field #14: Adult Prehospital Living With Values: 01 Alone 02 Family/Relatives 03 - Friends 04 Attendant 05 - Other 06 - ND 1. Length 2 2. Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Version 1.0 Effective January 1, 2005 Field Instructions: Select the value that most accurately describes the patients living arrangements prior to their hospitalization Click Here to return to the Table of Contents 20

21 Field #15: Adult Prehospital Vocational Category Values: 01 Employed 02 Sheltered 03 - Student 04 Homemaker 05 Not Working 06 Retired for Age 07 Retired for Disability 08 - ND 1. Length 2 2. Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character) NUMERIC. Field Instructions: Select the value that most accurately describes the patients vocation prior to their hospitalization DEFINITIONS Employed The patient works for pay in a competitive environment or is self employed Sheltered The patient works for pay in a non-competitive environment Student the patient is enrolled in an accredited school (including trade school), college or university. Homemaker The patient works at home, does not work outside the home, is not paid by an employer, and is not self employed Not Working The patient is unemployed, but is not retired or receiving disability benefits Retired for Age The patient is retired (usually 60 years of age or older) and is receiving retirement benefits Retired for Disability The patient is receiving disability benefits and is less than 60 years of age. Click Here to return to the Table of Contents 21

22 Field #16: Adult Prehospital Vocational Effort Values: 01 Full-time 02 Part-time 03 Adjusted Work load 04 NA 05 - ND 1. Length 2 2. Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Field Instructions: Select the value that most accurately describes the patients vocation prior to their hospitalization, if values 1 4 are selected in field # Prehospital Vocation Category, then are valid selections for this field. If are selected in field #, then 04 must be selected DEFINITIONS Full-time The patient worked a full schedule (i.e or 40 hours per week) which ever is normal where he/she works Part-time - The patient worked less than full time (i.e. less than 37.5 or 40 hours per week) depending on the norm where he/she works. Adjusted Workload The patients workload was adjusted due to disability. The patient was not able to perform all the work duties of the position Click Here to return to the Table of Contents 22

23 Field #17: Transferring Facility ID Values: ODH or ODPS assigned number. 1. Length 4 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). NUMERIC Version 1.0 Effective January 1, 2005 Field Instructions: If the patient is transferred from an Ohio hospital, enter the ODH assigned Ohio hospital code. See Appendix 2 for the list of ODH assigned Ohio hospital codes If the patient is transferred from an out of state hospital, enter the ODPS assigned out of state hospital code. See Appendix 3 for the list of ODPS assigned out of state hospital codes. If the patient is transferred from an Ohio Rehabilitation Facility, enter the ODPS assigned Ohio Rehabilitation Facility code. See Appendix 1 for the list of ODPS assigned Ohio Rehabilitation Facility codes If the patient is transferred from an Ohio Nursing Facility, enter the ODH assigned Ohio Nursing Facility code. See Appendix 4 for the list of ODH assigned Ohio Nursing Facility codes Click Here to return to the Table of Contents 23

24 Field #18: Rehabilitation Facility Arrival Date Values: mmddyyyy 1. Length 8 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character) DATE Field Instructions: The arrival date that the patient actually arrived at the rehabilitation facility. Enter the month, day and year. The actual date that the patient arrived at the rehabilitation facility. Date format: 01/29/1998. The year must be complete year (1998). Click Here to return to the Table of Contents 24

25 Field #19: Etiologic Diagnosis (ICD-9-CM Code) Values: Report the ICD-9-CM diagnosis codes 1. Length 5 2. Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Field Instructions: Use an ICD-9-CM code to indicate the etiologic problem that led to the condition for which the patient is receiving rehabilitation. These should be diagnosis codes, not external cause of injury codes. When creating a data file the decimal point MUST be used. Example: = or 810 = Give the complete code not category codes. Click Here to return to the Table of Contents 25

26 Field #20: Co-Morbid Conditions (ICD-9-CM Codes) Values: Report 10 additional ICD-9-CM codes of diagnoses 1. Length Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Field Instructions: The ICD-9-CM code for each injury diagnosis. List up to 10 codes. When creating a data file the decimal point MUST be used. Example: = or 810 = Click Here to return to the Table of Contents 26

27 Field #21: Complications during Rehabilitation Stay (ICD-9-CM Codes) Values: Report up to 6 ICD-9-CM codes 1. Length Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Field Instructions: Enter an ICD-9-CM code for each complication that began with this rehabilitation stay. List up to 6 codes. When creating a data file the decimal point MUST be used. Example: = or 810 = Click Here to return to the Table of Contents 27

28 Field # 22: Disability Assessment Tool Adult/Pediatric (FIM /WeeFIM instrument) Values: 1- Adult 2- Pediatric 1. Length 1 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character) NUMERIC. Field Instructions: Facilities using an adult assessment-scoring model (i.e. FIM TM instrument) should select 1 - Adult. Facilities that use a pediatric scoring model, (i.e. WeeFIM instrument) regardless of the patient's age should select 2 - Pediatric. The FIM instrument and the WeeFIM instrument incorporated or referenced herein are the property of UB Foundation Activities, Inc. 1993, 2001 (FIM Instrument) 1998, 2000 (WeeFIM instrument) UB Foundation Activities, Inc. The FIM and WeeFIM marks are owned by UB Foundation Activities, Inc. Click Here to return to the Table of Contents 28

29 Field #23: Disability Assessment Score upon Admission (FIM /WeeFIM instrument) Values: 0- Activity Does Not Occur (applies only to the FIM instrument) 1- Total Assistance 2- Maximum Assistance 3- Moderate Assistance 4- Minimal Assistance 5- Supervision / Set-up 6- Modified Independence 7- Complete independence 25 Self-Care: Eating 26 Self-Care: Grooming 27 Self-Care: Bathing 28 Self-Care: Dressing-Upper Body 29 Self Care: Dressing-Lower Body 30 Self-Care: Toileting 31 Sphincter Control: Bladder Management 32 Sphincter Control: Bowel Management 33 Transfers: Bed, Chair, Wheelchair 34 Transfers: Toilet 35 Transfers: Tub, Shower 36 Locomotion: Walk. Wheelchair, crawl 37 Locomotion: Stairs 38 Communication: Comprehension 39 Communication: Expression 40 Social Cognition: Social Interaction 41 Social Cognition: Problem Solving 42 Social Cognition: Memory Motor Subscore Cognitive subscore Total Motor and Cognitive score 1. Length Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character) NUMERIC. Field Instructions: Motor Subscore is a calculated field, the sum of fields #25 through #37 Cognitive Subscore is a calculated field; the sum of fields #38 through #42 Total Motor and Cognitive score is a calculated field, the sum of Motor subscore and Cognitive subscore Disability Assessment upon admission should be determined during the first three calendar days of the patients admission The FIM instrument and the WeeFIM instrument incorporated or referenced herein are the property of UB Foundation Activities, Inc. 1993, 2001 (FIM Instrument) 1998, 2000 (WeeFIM instrument) UB Foundation Activities, Inc. The FIM and WeeFIM marks are owned by UB Foundation Activities, Inc. Click Here to return to the Table of Contents 29

30 Field #24: Disability Assessment Score upon Discharge (FIM /WeeFIM instrument) Values: 1-Complete Dependence 2-Maximum assistance 3-Moderate Assistance 4-Minimal Assistance 5-Supervision / Set-up 6-Modified Independence 7-Complete independence 25 Self-Care: Eating 26 Self-Care: Grooming 27 Self-Care: Bathing 28 Self-Care: Dressing-Upper Body 29 Self Care: Dressing-Lower Body 30 Self-Care: Toileting 31 Sphincter Control: Bladder Management 32 Sphincter Control: Bowel Management 33 Transfers: Bed, Chair, Wheelchair 34 Transfers: Toilet 35 Transfers: Tub, Shower 36 Locomotion: Walk. Wheelchair, crawl 37 Locomotion: Stairs 38 Communication: Comprehension 39 Communication: Expression 40 Social Cognition: Social Interaction 41 Social Cognition: Problem Solving 42 Social Cognition: Memory Motor Subscore Cognitive subscore Total Motor and Cognitive score 1. Length Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). NUMERIC Field Instructions: Motor Subscore is a calculated field, the sum of fields #25 through #37 Cognitive Subscore is a calculated field; the sum of fields #38 through #42 Total Motor and cognitive score is a calculated field, the sum of Motor subscore and cognitive subscore The FIM instrument and the WeeFIM instrument incorporated or referenced herein are the property of UB Foundation Activities, Inc. 1993, 2001 (FIM Instrument) 1998, 2000 (WeeFIM instrument) UB Foundation Activities, Inc. The FIM and WeeFIM marks are owned by UB Foundation Activities, Inc. Click Here to return to the Table of Contents 30

31 Field # 25: Date of Discharge or Death Values: mmddyyyy 1. Length 8 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). DATE Field Instructions: Enter the date of the patient s discharge, transfer or death from the rehabilitation facility. The actual date that the patient was discharged from the rehabilitation facility or date that the patient was pronounced dead. Date format: 01/29/1998. The year must be complete year (1998). Click Here to return to the Table of Contents 31

32 Field # 26: Discharge Status Values: 1- Alive 2- Dead 1. Length 1 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). NUMERIC Version 1.0 Effective January 1, 2005 Field Instructions: Enter the status of the patient upon discharge from the rehabilitation facility. The patient was alive or dead when they left the rehabilitation facility. Click Here to return to the Table of Contents 32

33 Field #27: Adult Discharge Disposition Values: 1 Home 2 Board and Care 3 Transitional Living 4 Intermediate care 5 Skilled Nursing Facility 6 Acute Unit of own facility 7 Acute Unit another facility 8 - Chronic Hospital (LTAC) 9 Rehabilitation facility 10 Other 11 - Died 12 Alternate Level of care 13 Subacute setting 14 Assisted Living Residence 1. Length 2 2. Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Version 1.0 Effective January 1, 2005 Field Instructions: The patient s disposition upon discharge from the rehabilitation facility. If #01 is selected you must make an entry in Field # XX Discharge Living With. If #04, 05, 07, or 09 is selected you must enter an ODPS or ODH Assigned facility code in field # XX-Transfer to Other Rehabilitation Facility. Click Here to return to the Table of Contents 33

34 Field # 28: Adult Discharge Living With Values: 01 Alone 02 Family/Relatives 03 - Friends 04 Attendant 05 - Other 06 - NA 1. Length 2 2. Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Version 1.0 Effective January 1, 2005 Field Instructions: If values1, 2, 3 or 14 are selected in field #27 Adult Discharge Disposition, then values 01 through 05 are valid for this field, otherwise 06- NA must be selected. Click Here to return to the Table of Contents 34

35 Field # 29: Pediatric Discharge Disposition Values: 01 Home 02 Acute Care unit of own facility 03 Acute care unit of another facility 04 Rehabilitation facility 05 Residential facility 06 Transitional living center 07 - Skilled nursing facility 08 Shelter 09 Other 10 - Died 1. Length 2 2. Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Field Instructions: Select the value that most accurately describes the patients living arrangements prior to their hospitalization. Note that the value "04" is not used in this field. Click Here to return to the Table of Contents 35

36 Field # 30 Pediatric Discharge Living With Values: 01 Two parents 02 One parent 03 - Relatives 04 Foster care 05 - Other 07 ND 1. Length 2 2. Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Field Instructions: Select a value in this field ONLY if the value selected in field # 29 Pediatric Prehospital Setting is equal to "01- Home" Click Here to return to the Table of Contents 36

37 Field # 31: Discharge Referrals Version 1.0 Effective January 1, 2005 Values: 01 - None 02 Outpatient 03 Home-based paid professional therapy 04 Both 2 and 3 05 Inpatient hospital 06 - Day treatment 07 School-based 08 Other (examples homeless or women s shelters, protective services, etc.) 1. Length Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). NUMERIC Field Instructions: More than one value may be selected. Click Here to return to the Table of Contents 37

38 Field # 32: Transfer to Other Hospital/Facility Value: ODH assigned # for in-state hospitals ODPS assigned # for out of state hospitals ODPS assigned # for rehabilitation facilities ODH assigned # for licensed nursing home 1. Length 4 2. Start Position End Position Allow blank or not YES/NO 5. Data Type (Numeric, Character). NUMERIC Field Instructions: Enter the location of the patient disposition from the hospital. If the patient is transferred to another Ohio hospital, enter the ODH assigned Ohio hospital code. See Appendix 1-A for the list of ODH assigned Ohio hospital codes. If the patient is transferred to an out of state hospital, enter the ODPS assigned out of state hospital code. See Appendix 1-B for the list of ODPS assigned out of state hospital codes. If the patient is transferred to a rehabilitation facility, enter the ODPS assigned rehabilitation facility code. See Appendix 1-C for the list of ODPS assigned rehabilitation facilities codes. If the patient is transferred to a licensed nursing home, enter the ODH assigned nursing home facility code. See Appendix 1-D for the list of ODH assigned nursing home facilities codes. Click Here to return to the Table of Contents 38

39 Field #33: Billed Rehabilitation Facility Charges Values: Whole Dollar amount of total rehabilitation facility charges rounded off to the nearest dollar Blank* Not Documented 1. Length Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). NUMERIC Field Instructions: The final billed amount charged for this admission, excluding professional fees, at the rehabilitation facility, expressed in a whole dollar figure. Total amount charged to the patient for treatment received at the rehabilitation facility expressed in a whole dollar amount. *If the information is not documented leave this field blank. NOTE that it isacceptable to leave this field blank. Calculations that will be performed on this field (addition, averages, means, etc.) require either a whole dollar amount or a blank field. DO NOT use ND or 9999 in this field. Click Here to return to the Table of Contents 39

40 Field #34: Payment Source 1 Primary Source 2 Secondary Source Version 1.0 Effective January 1, 2005 Code each source with one of the following values 01 Blue Cross (Adult/IRFPAI) 02 Medicare non-mco (Adult/IRFPAI) 03 Medicaid non-mco (Adult/IRFPAI) 04 Commercial Insurance (Adult/IRFPAI) 05 MCO HMO (Adult/IRFPAI) 06 Workers Compensation (Adult/IRFPAI) 07 Crippled Children's Services / Bureau of Children with Medical Handicaps (Adult/IRFPAI) 08 Developmental Disabilities Services (Adult/IRFPAI) 09 State Vocational Rehabilitation (Adult/IRFPAI) 10 Private Pay (Adult/IRFPAI) 11 Employee Courtesy (Adult/IRFPAI) 12 Unreimbursed (Adult/IRFPAI) 13 CHAMPUS (Adult/IRFPAI) 14 Other (Adult/IRFPAI) 15 None (Adult/IRFPAI) 16 No-Fault Auto Insurance (Adult/IRFPAI) 21 Medicaid non MCO (Pediatric/WeeFIM II) 22 Medicaid Waiver Program (non-mco) (Pediatric/WeeFIM II) 23 Medicaid MCO (Pediatric/WeeFIM II) 24 Medicaid Waiver Program (MCO) (Pediatric/WeeFIM II) 25 MCO HMO (Pediatric/WeeFIM II) 26 Commercial Insurance/PPO (Pediatric/WeeFIM II) 27 Medicare (Pediatric/WeeFIM II) 28 SSI (Pediatric/WeeFIM II) 29 State Education Department (Pediatric/WeeFIM II) 30 State Vocational Rehabilitation (Pediatric/WeeFIM II) 31 Developmental Disabilities Services (Pediatric/WeeFIM II) 32 Crippled Children's Services / Bureau of Children with Medical Handicaps (Pediatric/WeeFIM II) 33 State health Department/Department of Human Resources (Pediatric/WeeFIM II) 34 Children s Health Insurance Program (Pediatric/WeeFIM II) 35 Worker s Compensation (Pediatric/WeeFIM II) 36 TRICARE (Pediatric/WeeFIM II) 37 - Private Pay (Pediatric/WeeFIM II) 38 Unreimbursed Care (Pediatric/WeeFIM II) 39 - No-Fault Auto Insurance (Pediatric/WeeFIM II) 40 Government program (non U.S.) (Pediatric/WeeFIM II) 41 Other (Pediatric/WeeFIM II) 51 Medicare MCO (Adult/IRFPAI) 52 Medicaid MCO (Adult/IRFPAI) 1. Length 4 2. Start Position End Position Allow blank or not NO 5. Data Type (Numeric, Character). NUMERIC Field Instructions: The entity that is expected to be responsible for the largest percentage of the patient s bill for the current encounter, both as a primary payor source as well as a secondary payor source. Values and are not 40

41 utilized. Version 1.0 Effective January 1, 2005 Select from the pulldown menu the appropriate final payment source responsible for the outstanding charges incurred. Click Here to return to the Table of Contents 41

42 Field #35: Adult Length of Stay in Rehabilitation Facility Values: mm/dd/yyyy Interruptions in care #1 1 st Interruption date mm/dd/yyyy 1 st Return date mm/dd/yyyy Interruptions in care #2 2nd Interruption date 2nd Return date Interruptions in care #3 3rd Interruption date 3rd Return date mm/dd/yyyy mm/dd/yyyy mm/dd/yyyy mm/dd/yyyy 1. Length Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). DATE Field Instructions: Enter the dates of up to three interruptions in care. The length of stay in the rehabilitation facility will be calculated by subtracting the total number of days of interrupted care from the total number of days from admission to discharge. Using this process will allow the LOS to be calculated An interruption in care is defined as a discharge from the rehabilitation center and returns to the same facility within three consecutive days. Click Here to return to the Table of Contents 42

43 Field #36: Pediatric Length of Stay in Rehabilitation Facility Values: mm/dd/yyyy Interruptions in care #1 1 st Interruption date mm/dd/yyyy 1 st Return date mm/dd/yyyy Interruptions in care #2 2nd Interruption date 2nd Return date Interruptions in care #3 3rd Interruption date 3rd Return date mm/dd/yyyy mm/dd/yyyy mm/dd/yyyy mm/dd/yyyy 1. Length Start Position End Position Allow blank or not YES 5. Data Type (Numeric, Character). DATE Field Instructions: Enter the dates of up to three interruptions in care. The length of stay in the rehabilitation facility will be calculated by subtracting the total number of days of interrupted care from the total number of days from admission to discharge. Using this process will allow the LOS to be calculated. Click Here to return to the Table of Contents 43

44 APPENDIX 1 Ohio Rehabilitation Facility Codes Code County Facility Name 1007 Cuyahoga Parma Community General Hospital 1011 Madison Madison County Hospital 1015 Franklin Doctor's Hospital West - Columbus 1016 Stark Doctor's Hospital - Stark County 1021 Gallia Holzer Medical Center 1024 Hamilton Bethesda North - Cincinnati 1026 Hamilton Franciscan Hospital - Mt. Airy 1036 Miami Upper Valley Medical Center 1102 Allen Lima Memorial Hospital 1103 Allen St. Rita's Medical Center 1113 Belmont Belmont Community Hospital 1116 Butler Middletown Regional Hospital 1123 Clark Mercy Medical Center - Springfield 1131 Crawford MedCentral - Crestline 1133 Cuyahoga Euclid Hospital 1134 Cuyahoga Lakewood Hospital 1136 Cuyahoga Marymount Hospital 1145 Cuyahoga Fairview Hospital 1149 Cuyahoga Lutheran Hospital 1150 Cuyahoga MetroHealth Medical Center 1151 Cuyahoga Cleveland Clinic Foundation 1156 Cuyahoga University Hospitals of Cleveland 1164 Erie Firelands Community Hospital - Decatur St. Facility 1167 Fairfield Fairfield Medical Center 1169 Franklin Columbus Children's Hospital 1171 Franklin Ohio State University Medical Center 1173 Franklin Grant Medical Center 1175 Franklin Mount Carmel West Hospital 1180 Greene Greene Memorial Hospital 1183 Hamilton Mercy Franciscan Hospital - Western Hills 1186 Hamilton Cincinnati Children's Hospital Medical Center 1187 Hamilton The Christ Hospital 1190 Hamilton Deaconess Hospital - Cincinnati 1191 Hamilton Tri-Health Good Samaritan Hospital - Cincinnati 1200 Highland Greenfield Area Medical Center 1208 Jefferson Trinity Medical Center - East 1218 Lorain Community Health Partners 1225 Lucas St. Vincent Mercy Medical Center 1227 Lucas Flower Hospital 1228 Lucas Medical College of Ohio Hospital 1230 Mahoning St. Elizabeth's Health Center 1233 Marion Marion General Hospital 1235 Medina Wadsworth-Rittman Hospital 1245 Montgomery Good Samaritan Hospital - Dayton 1246 Montgomery Grandview Hospital 1247 Montgomery Miami Valley Hospital 1251 Muskingum Genesis Good Samaritan Hospital - Zanesville 1254 Pickaway Berger Hospital 44

45 1257 Richland MedCentral - Mansfield 1264 Scioto Southern Ohio Medical Center 1269 Stark Alliance Community Hospital 1270 Stark Aultman Hospital 1271 Stark Mercy Medical Center - Canton 1272 Stark Massillon Community Hospital 1275 Summit Akron City Hospital 1278 Summit St. Thomas Hospital 1279 Summit Barberton Citizen's Hospital 1289 Washington Marietta Memorial Hospital 1294 Williams Community Hospital of Williams Co. - Montpelier 1297 Cuyahoga South Pointe Hospital 1318 Sandusky St. Francis Health Center 1320 Summit Edwin Shaw Rehab Center 1321 Trumbull Hillside Rehabilitation Hospital 1409 Hamilton Drake Center Inc Cuyahoga Cleveland Clinic Children's Hospital for Rehabilitation 1420 Geauga Rehab Hospital at Heather Hill 9000 Other Ohio Rehabilitation Facility 45

46 APPENDIX 2 Version 1.0 Effective January 1, 2005 Ohio Hospital Facility Codes 1100 Adams Adams County Hospital 1029 Ross Adena Regional Medical Center 1277 Summit Akron Children's Hospital Medical Center 1275 Summit Akron City Hospital 1276 Summit Akron General Medical Center 1219 Lorain Allen Memorial Hospital 1269 Stark Alliance Community Hospital 1215 Lorain Amherst Hospital 1106 Ashtabula Ashtabula County Medical Center 1270 Stark Aultman Hospital 1443 Stark Aultman Hospital West 1279 Summit Barberton Citizen's Hospital 1112 Belmont Barnesville Hospital Association 1178 Lucas Bay Park Community Hospital 1113 Belmont Belmont Community Hospital 1254 Pickaway Berger Hospital 1250 Muskingum Bethesda Hospital - Zanesville 1024 Hamilton Bethesda North - Cincinnati 1194 Hancock Blanchard Valley Regional Health Center 1101 Allen Blanchard Valley Regional Health Center - Bluffton 1115 Brown Brown County General Hospital 1107 Ashtabula Brown Memorial Hospital 1130 Crawford Bucyrus Community Hospital 1186 Hamilton Cincinnati Children's Hospital Medical Center 1028 Clermont Clermont Mercy Hospital 1151 Cuyahoga Cleveland Clinic Foundation 1124 Clinton Clinton Memorial Hospital 1169 Franklin Columbus Children's Hospital 1018 Lorain Community Health Partners - West 1447 Fulton Community Hospital - Williams County - Archbold Hospital 1293 Williams Community Hospital - Williams County - Bryan 1122 Clark Community Hospital of Springfield 1294 Williams Community Hospital of Williams Co. - Montpelier 1161 Defiance Community Memorial Hospital 1129 Coshocton Coshocton County Memorial Hospital 1280 Summit Cuyahoga Falls General Hospital 1411 Montgomery Dayton Children's Medical Center 1431 Montgomery Dayton Heart Hospital 1190 Hamilton Deaconess Hospital - Cincinnati 1152 Cuyahoga Deaconess Hospital - Cleveland 1160 Defiance Defiance Hospital 1016 Stark Doctors Hospital -- Massillon 1110 Athens Doctors Hospital - Nelsonville 1015 Franklin Doctor's Hospital West - Columbus 1291 Wayne Dunlap Memorial Hospital 1127 Columbiana East Liverpool City Hospital 1114 Belmont East Ohio Regional Hospital 1217 Lorain EMH Regional Medical Center 1133 Cuyahoga Euclid Hospital 1167 Fairfield Fairfield Medical Center 46

47 1145 Cuyahoga Fairview Hospital 1168 Fayette Fayette County Memorial Hospital 1164 Erie Firelands Community Hospital 1204 Huron Fisher-Titus Medical Center 1227 Lucas Flower Hospital 1117 Butler Fort Hamilton-Hughes Memorial Hospital 1195 Seneca Fostoria Community Hospital 1026 Hamilton Franciscan Hospital Mt. Airy 1177 Fulton Fulton County Health Center 1132 Crawford Galion Community Hospital 1251 Muskingum Genesis Good Samaritan Hospital - Zanesville 1245 Montgomery Good Samaritan Hospital - Dayton 1163 Delaware Grady Memorial Hospital 1246 Montgomery Grandview Hospital 1173 Franklin Grant Medical Center 1817 Greene Greene Memorial Hospital 1200 Highland Greenfield Area Medical Center 1252 Ottawa H.B. Magruder Memorial Hospital 1196 Hardin Hardin Memorial Hospital 1022 Harrison Harrison Community Hospital 1198 Henry Henry County Hospital 1199 Highland Highland District Hospital 1019 Cuyahoga Hillcrest Hospital 1201 Hocking Hocking Valley Community Hospital 1438 Jackson Holzer Jackson Medical Center 1021 Gallia Holzer Medical Center 1148 Cuyahoga Huron Hospital 1445 Allen Institute for Orthopedic Surgery 1003 Hamilton Jewish Hospital 1111 Auglaize Joint Township District Memorial Hospital 1017 Montgomery Kettering Memorial Medical Center 1030 Knox Knox Community Hospital 1211 Lake Lake East Hospital 1006 Lake Lake West Hospital 1134 Cuyahoga Lakewood Hospital 1213 Licking Licking Memorial Hospital 1102 Allen Lima Memorial Hospital 1234 Medina Lodi Community Hospital 1218 Lorain Lorain Community - St. Joseph's 1149 Cuyahoga Lutheran Hospital 1011 Madison Madison County Hospital 1289 Washington Marietta Memorial Hospital 1233 Marion Marion General Hospital 1214 Logan Mary Rutan Hospital 1136 Cuyahoga Marymount Hospital 1272 Stark Massillon Community Hospital 1119 Butler Mc Cullough-Hyde Memorial Hospital 1131 Crawford MedCentral - Crestline 1257 Richland MedCentral - Mansfield 1259 Richland MedCentral - Shelby 1228 Lucas Medical College of Ohio Hospital 1236 Medina Medina General Hospital 1263 Sandusky Memorial Hospital - Fremont 1108 Ashtabula Memorial Hospital - Geneva 47

48 1286 Union Memorial Hospital - Union County 1240 Mercer Mercer County Joint Twp. Community Hospital 1183 Hamilton Mercy Franciscan Hospital - Western Hills 1193 Hamilton Mercy Hospital - Anderson 1033 Butler Mercy Hospital - Fairfield 1267 Seneca Mercy Hospital - Tiffin 1205 Huron Mercy Hospital - Willard 1271 Stark Mercy Medical Center - Canton 1123 Clark Mercy Medical Center - Springfield 1121 Champaign Mercy Memorial Hospital 1150 Cuyahoga MetroHealth Medical Center 1247 Montgomery Miami Valley Hospital 1116 Butler Middletown Regional Hospital 1249 Morrow Morrow County Hospital 1027 Franklin Mount Carmel East Hospital 1175 Franklin Mount Carmel West Hospital 1231 Mahoning Northside Medical Center 1109 Athens O'Bleness Memorial Hospital 1171 Franklin Ohio State University Medical Center 1170 Franklin OSU East 1007 Cuyahoga Parma Community General Hospital 1253 Paulding Paulding County Hospital 1299 Pike Pike Community Hospital 1202 Holmes Pomerene Hospital 1165 Erie Providence Hospital 1008 Cuyahoga Richmond Heights Hospital 1212 Lawrence River Valley Health System 1222 Lucas Riverside Mercy Hospital 1005 Franklin Riverside Methodist Hospital 1255 Portage Robinson Memorial Hospital 1125 Columbiana Salem Community Hospital 1104 Ashland Samaritan Regional Health System 1288 Washington Selby General Hospital 1808 Hamilton Shriners Burn Hospital 1297 Cuyahoga South Pointe Hospital 1181 Guernsey Southeastern Ohio Regional Medical Center 1264 Scioto Southern Ohio Medical Center 1035 Montgomery Southview Hospital & Family Health Center 1140 Cuyahoga Southwest General Health Center 1444 Lucas St. Anne Mercy Hospital 1606 Franklin St. Ann's Hospital 1223 Lucas St. Charles Hospital 1230 Mahoning St. Elizabeth's Health Center 1034 Cuyahoga St. John West Shore Hospital 1000 Trumbull St. Joseph Health Center 1224 Lucas St. Luke's Hospital - Toledo 1154 Cuyahoga St. Luke's Medical Center - Cleveland 1158 Cuyahoga St. Michael Hospital 1103 Allen St. Rita's Medical Center 1155 Cuyahoga St. Vincent Charity 1225 Lucas St. Vincent Mercy Medical Center 1031 Montgomery Sycamore Hospital 1261 Sandusky The Bellevue Hospital 1187 Hamilton The Christ Hospital 48

49 1226 Lucas The Toledo Hospital 1189 Hamilton The University Hospital - Cincinnati 1441 Lawrence Three Gables Surgery Center 1191 Hamilton Tri-Health Good Samaritan Hospital - Cincinnati 1208 Jefferson Trinity Medical Center - East 1004 Jefferson Trinity Medical Center - West 1283 Trumbull Trumbull Memorial Hospital 1284 Tuscarawas Twin City Hospital 1141 Cuyahoga UHHS - Bedford Medical Center 1001 Geauga UHHS - Geauga Regional Hospital 1142 Cuyahoga UHHS - Rainbow Babies and Children s Hospital 1285 Tuscarawas Union Hospital 1242 Miami Upper Valley Medical Center 1700 Cuyahoga VA Medical Center - Brecksville 1706 Ross VA Medical Center - Chillicothe 1704 Hamilton VA Medical Center - Cincinnati 1701 Cuyahoga VA Medical Center - Cleveland 1705 Montgomery VA Medical Center - Dayton 1287 Van Wert Van Wert County Hospital 1235 Medina Wadsworth-Rittman Hospital 1159 Darke Wayne Hospital 1268 Shelby Wilson Hospital 1295 Wood Wood County Hospital 1292 Wayne Wooster Community Hospital 1180 Montgomery Wright Patterson Medical Center - 74th Medical Division 1296 Wyandot Wyandot Memorial Hospital 1998 Specialty Hospital/LTC 1999 Free Standing Emergency Center 49

50 APPENDIX 3 Version 1.0 Effective January 1, 2005 Out of State Hospital, Rehabilitation and Nursing Facility Codes INDIANA Code State County Facility Name 6000 IN Other Indiana Hospital 6001 IN Steuben Cameron Memorial Community Hospital 6002 IN DeKalb Dekalb Memorial Hospital 6003 IN Allen Dupont Hospital 6004 IN Allen Lutheran Hospital of Indiana 6005 IN Allen Parkview Hospital 6006 IN Allen St. Joseph Hospital 6007 IN Adams Adams County Memorial Hospital 6008 IN Jay Jay County Hospital 6009 IN Randolph St. Vincent Randolph Hospital 6010 IN Wayne Reid Hospital and Health Care Services 6011 IN Dearborn Dearborn County Hospital 6012 IN LaGrange Lagrange Community Hospital 6013 IN Noble Parkview Noble Hospital 6014 IN Whitley Whitley Memorial Hospital 6015 IN Wells Bluffton Regional Medical Center 6016 IN Blackford Blackford County Hospital 6017 IN Delaware Ball Memorial Hospital 6018 IN Henry Henry County Memorial Hospital 6019 IN Fayette Fayette Memorial Hospital Association 6020 IN Ripley Margaret Mary Community Hospital 6888 IN Other Indiana Nursing Facility 6999 IN Other Indiana Rehabilitation Facility KENTUCKY Code State County Facility Name 7000 KY Other Kentucky Hospital 7001 KY Kenton St. Elizabeth Medical Center - North 7002 KY Kenton St. Elizabeth Medical Center - South 7003 KY Campbell St. Luke Hospital - East 7004 KY Fleming Fleming County Hospital 7005 KY Mason Meadowview Regional Medical Center 7006 KY Rowan St. Claire Medical Center 7007 KY Boyd King's Daughters' Medical Center 7008 KY Greenup Our Lady of Bellefonte Hospital 7009 KY Harrison Harrison Memorial Hospital 7010 KY Grant St. Elizabeth Medical Center - Grant 7011 KY Boone St. Luke Hospital - West 7888 KY Other Kentucky Nursing Facility 7999 KY Other Kentucky Rehabilitation Facility MICHIGAN Code State County Facility Name 5000 MI Other Michigan Hospital 5001 MI Berrien Community Hospital 5002 MI Berrien Lakeland Hospital 5003 MI Branch Community Health Center of Branch 5004 MI Calhoun Battle Creek Health System 5005 MI Calhoun Fieldstone Center of Battle Creek 5006 MI Cass Lee Memorial 50

51 5007 MI Hillsdale Hillsdale Community Health Center 5008 MI Jackson Doctors Hospital of Jackson 5009 MI Jackson W.A. Foote Memorial Hospital 5010 MI Kalamazoo Borgess Medical Center 5011 MI Kalamazoo Bronson Methodist Hospital 5012 MI Kalamazoo Bronson Vicksburg Hospital 5013 MI Lenawee Emma L. Bixby Medical Center 5014 MI Lenawee Herrick Memorial Hospital 5015 MI Monroe Mercy Memorial Hospital 5016 MI St. Joseph Sturgis Memorial 5017 MI St. Joseph Three Rivers Area Hospital 5018 MI Van Buren Lakeview Community Hospital 5019 MI Van Buren South Haven Community Hospital 5020 MI Washtenaw Chelsea Community Hospital 5021 MI Wayne Forest Health Medical Center 5022 MI Wayne Saline Community Hospital 5023 MI Wayne St. Joseph Mercy Hospital 5024 MI Wayne University of Michigan Health Center 5888 MI Other Michigan Nursing Facility 5999 MI Other Michigan Rehabilitation Facility PENNSYLVANIA Code State County Facility Name 8000 PA Other Pennsylvania Hospital 8001 PA Allegheny Allegheny General Hospital 8002 PA Allegheny Allegheny Valley Hospital 8003 PA Washington AUMC Canonsburg 8004 PA Allegheny Children's Hospital of Pittsburgh 8005 PA Erie Corry Memorial Hospital 8006 PA Allegheny Forbes Regional Hospital 8007 PA Greene Greene County Memorial Hospital 8008 PA Erie Hamot Medical Center 8009 PA Allegheny Lifecare Hospitals of Pittsburgh 8010 PA Crawford Meadville Medical Center 8011 PA Beaver Medical Center Beaver PA 8012 PA Allegheny Mercy Hospital of Pittsburgh 8013 PA Allegheny Mercy Providence Hospital 8014 PA Erie Metro Health Center 8015 PA Erie Millcreek Community Hospital 8016 PA Washington Monongahela Valley Hospital 8017 PA Allegheny Ohio Valley General Hospital 8018 PA Erie St. Vincent Health Center 8019 PA Allegheny Sewickley Valley Hospital 8020 PA Mercer Sharon Regional Health System 8021 PA Erie Shriners Hospital for Children - Erie 8022 PA Allegheny South Hills Health System 8023 PA Allegheny St. Clair Memorial Hospital 8024 PA Allegheny Suburban General Hospital - Pittsburgh 8025 PA Crawford Titusville Area Hospital 8026 PA Erie Union City Memorial Hospital 8027 PA Mercer United Community Hospital 8028 PA Beaver UPMC Beaver Valley 8029 PA Allegheny UPMC Braddock 8030 PA Mercer UPMC Horizon 8031 PA Allegheny UPMC Mckeesport 51

52 8032 PA Allegheny UPMC Passavant 8033 PA Allegheny UPMC Presbyterian 8034 PA Allegheny IPMC Shadyside 8035 PA Allegheny UPMC South side 8036 PA Allegheny UPMC St. Margaret 8037 PA Erie VA Medical Center - Erie 8038 PA Washington Washington Hospital 8039 PA Allegheny Western Pennsylvania Hospital 8888 PA Other Pennsylvania Nursing Facility 8999 PA Other Pennsylvania Rehabilitation Facility WEST VIRGINIA Code State County Facility Name 4000 WV Other West Virginia Hospital 4001 WV Brooke Weirton Medical Center 4002 WV Ohio Ohio Valley Medical Center 4003 WV Ohio Peterson Hospital 4004 WV Ohio Wheeling Hospital 4005 WV Marshall Reynolds Memorial Hospital 4006 WV Wetzel Wetzel County Hospital 4007 WV Tyler Sistersville General Hospital 4008 WV Mason Pleasant Valley Hospital 4009 WV Wayne Huntington VA Medical Center 4010 WV Marion Fairmont General Hospital 4011 WV Roane Roane General Hospital 4012 WV Putnam Putnam General Hospital 4013 WV Kanawha CAMA General Hospital 4014 WV Cabell Cabell Huntington Hospital 4015 WV Cabell Mildred Mitchell-Bateman Hospital 4016 WV Cabell River Park Hospital 4017 WV Cabell St. Mary's Hospital 4018 WV Wood Camden-Clark Memorial 4019 WV Wood St. Joseph's Hospital/Parkersburg 4888 WV Other West Virginia Nursing Facility 4999 WV Other West Virginia Rehabilitation Facility STATES OTHER THAN MI. WV. IN. PA. KY. Code State County Facility Name Rehabilitation Facility in a state other than MI, WV, IN, PA, 9227 KY 9300 Nursing Facility in another country 9333 Hospital in a state other than MI, WV, IN, PA, KY 9444 Hospital in another country 9888 Nursing Facility in a state other than MI, WV, IN, PA, KY 52

53 APPENDIX 4 Version 1.0 Effective January 1, 2005 Ohio Nursing Facility Codes 2020 Cuyahoga A. M. McGregor Home 2021 Cuyahoga A. M. McGregor Home 2170 ADAMS Adams County Manor 2770 Muskingum Adams Lane Care Center 2115 Hamilton Alaska Acres Care Center 2039 Cuyahoga Algart Health Care, Inc Hamilton Alois Alzheimer Center The 2907 Cuyahoga Altenheim 2765 Stark Altercare of Alliance Center for Rehab. & Nursing Care, Inc Crawford Altercare of Bucyrus Center for Rehab. & Nursing Care, Inc Stark Altercare of Canton 2271 Stark Altercare of Hartville Center for Rehabilitation & Nursing Care, Inc Cuyahoga Altercare of Mayfield Village, Inc Lake Altercare of Mentor Center for Rehab. & Nursing Care, Inc Stark Altercare of Navarre Center for Rehab. & Nursing Care, Inc Portage Altercare of Ravenna Center for Rehab. & Nursing Care, Inc Fairfield Altercare of Valley View Nursing Home, Inc Medina Altercare of Wadsworth Center for Rehab. & Nursing Care, Inc Cuyahoga Amasa Stone House Div, A M McGregor Hm 2094 Tuscarawas Amberwood Manor 2357 Lorain Amherst Manor 2321 Lorain Anchor Lodge Nursing Home, Inc Hamilton Anderson, The 2758 Ashtabula Andover Village Retirement Community 2919 Portage Anna Maria of Aurora, Inc Wayne Apostolic Christian Home, Inc Stark Arbors at Canton Subacute Rehabilitation Center 2509 Sandusky Arbors at Clyde - Nursing Center 2158 Montgomery Arbors at Dayton Nursing & Subacute Center 2760 Delaware Arbors at Delaware 2550 Summit Arbors at Fairlawn 2801 Gallia Arbors at Gallipolis 2522 Franklin Arbors at Hilliard 2868 Madison Arbors at London 2551 Washington Arbors at Marietta 2559 Clermont Arbors at Milford 2673 Lucas Arbors at Oregon 2241 Lucas Arbors at Sylvania 2902 Lucas Arbors at Toledo Subacute & Rehab Center 2502 Lucas Arbors at Waterville 2414 Franklin Arbors East Subacute and Rehabilitation Center 2747 Madison Arbors West 2281 Hocking Arcadia Acres, Inc Athens Arcadia Nursing Center 2041 Hamilton Archbishop Leibold Home 2608 Cuyahoga Aristocrat Berea Nursing Home 2858 Cuyahoga Aristocrat Lakewood Nursing Home Corp Franklin Arlington Court Nursing Home 2385 Hancock Arlington Good Samaritan Center 2735 Licking Arlington Nursing Home 53

54 2251 Ashtabula Ashtabula County Medical Center SNU 2508 Ashtabula Ashtabula County Nursing Home 2469 Mahoning Assumption Village, The 2217 Crawford Atwood Manor, Inc Montgomery Auburn Hills Healthcare Center 2557 Fayette Auburn Manor 2231 Stark Aultman Transitional Care Center 2418 Portage Aurora Manor Special Care Centre 2218 Ashtabula Austinburg Nursing & Rehabilitation Ctr 2575 Mahoning AustinWoods Nursing Center 2341 Lorain Autumn Aegis Nursing Center 2108 Putnam Autumn Court 2383 Coshocton Autumn Health Care of Coshocton, Inc Licking Autumn Healthcare 2562 Trumbull Autumn Hills Care Center, Inc Clinton Autumn Years Nursing Center 2779 Seneca Autumnwood Care Center 2646 Wayne Autumnwood Nursing and Rehabilitation Center 2490 Lorain Avon Oaks Nursing Home 2658 Cuyahoga Baldwin Manor Nursing Home, Inc Holmes Baltic Country Manor 2089 Belmont Barnesville Health Care Center 2712 Clermont Batavia Nursing and Convalescent Inn 2416 Summit Bath Manor 2440 Hamilton Bayley Place 2920 Cuyahoga Beachwood Nursing & Health Care Center 2090 Tuscarawas Beacon Pointe Rehab Center 2142 Muskingum Beckett House at New Concord 2731 Hamilton Beechwood Home 2122 Mahoning Beeghly Oaks 2034 Stark Bel-Air Convalescent Center 2181 Guernsey Bell Nursing Home 2861 Belmont Bell Nursing Home, Inc Greene Bellbrook Health Care Center 2676 Clark Belle Manor Nursing Home 2178 Sandusky Bellevue Care Center 2126 Belmont Belmont Manor 2123 Morrow Bennington Glen Nursing and Rehabilitation Center 2380 Cuyahoga Berea Center 2246 Butler Berkeley Square Retirement Center 2768 Scioto Best Care Nursing & Rehab 2693 Montgomery Bethany Lutheran Village 2973 Stark Bethany Nursing Home 2680 Sandusky Bethesda Care Center 2885 Franklin Beverly Health & Rehab. Center 2883 Allen Beverly Healthcare Lima 2945 Hancock Birchaven Health Care 2156 Butler Birchwood 2776 Wood Blakely Care Center 2918 Wood Blakely Care Center of Bowling Green 2655 Clinton Blanchester Care Center 2184 Geauga Blossom Hill Care Center 2146 Columbiana Blossom Nursing and Rehabilitation Center 2878 Hamilton Blue Ash Nursing & Rehabilitation Center, L.L.C. 54

55 2890 Mahoning Boardman Community Care Center 2812 Wood Bowling Green Manor 2860 Cuyahoga Bradley Bay Health Center 2520 Cuyahoga BraeView Care & Rehabilitation Center 2185 Wayne Brenn-Field Nursing Center 2503 Summit Brentwood Healthcare Center 2149 Ashland Brethren Care, Inc Darke Brethren Retirement Community 2056 Stark Brewster Parke 2343 Geauga Briar Hill Health Care Residence 2659 Mahoning Briarfield at Ashley Circle 2934 Lucas Briarfield at Glanzman Road 2437 Mahoning Briarfield Manor 2333 Trumbull Briarfield of Cortland 2236 Erie Briarfield of Milan 2387 Erie Briarfield of Sandusky 2806 Mercer Briarwood Manor 2409 Summit Briarwood The 2862 Summit Bridgepark Center for Rehab & Nsg Srvcs 2507 Pike Bristol Pavilion 2323 Lake Broadfield Manor Nursing Home, Inc Franklin Broadview Health Care Center of Columbus 2494 Cuyahoga Broadview Multi-Care Center 2751 Montgomery Brookhaven Nursing & Care Center 2729 Defiance Brookview Healthcare Center 2533 Hamilton Brookwood Retirement Community 2194 Pickaway Brown Memorial Home, Inc Lawrence Bryant Health Center 2400 Franklin Bryden Place 2381 Hamilton Burlington House 2215 Geauga Burton Health Care Center 2307 Columbiana Calcutta Health Care Center 2279 Putnam Calvary Manor Nursing Home 2413 Hamilton Camargo Manor Nursing Home 2483 Guernsey Cambridge Health & Rehabilitation Center 2319 Mahoning Camelot Arms Care Center 2798 Cuyahoga Candlewood Park Healthcare Center 2614 Stark Canterbury Villa of Alliance 2042 Stark Canton Christian Home 2228 Stark Canton Health Care Center 2535 Stark Canton Regency Retirement Community 2240 Mahoning Caprice Health Care Center 2846 Ashtabula Carington Park 2255 Warren Carlisle Manor Health Care, Inc Fayette Carlton Manor 2013 Harrison Carriage Inn of Bowerston, Inc Harrison Carriage Inn of Cadiz, Inc Montgomery Carriage Inn of Dayton 2855 Jefferson Carriage Inn of Steubenville, Inc Mahoning Carrington South Health Care Center, Inc 2632 Carroll Carroll Healthcare Center, Inc Clark Castle Knoll, The K.W. Hess Ohio Pythian Home 2022 Muskingum Cedar Hill Care Center 2006 Preble Cedar Springs Care Center 55

56 2188 Warren Cedar Village 2032 Warren Cedars of Lebanon 2933 Cuyahoga Cedarwood Plaza 2781 Mercer Celina Manor 2320 Darke Center of Hope 2553 Lorain Center Ridge Nursing Home Inc Cuyahoga Century Oak Care Center 2692 Stark Chapel Hill Home 2534 Geauga Chardon Center 2946 Delaware Cherith Care Center at Willow Brook 2225 Butler Chesterwood Village Realty LTD 2546 Ross Chillicothe Nursing & Rehab. Center 2310 Montgomery Christel Manor of Miamisburg 2392 Cuyahoga Cityview Manor, Inc Cuyahoga Clare Hall 2733 Clermont Clermont Nursing Care Center 2309 Cuyahoga Cleveland Clinic Subacute Services 2334 Cuyahoga Cleveland Rehabilitation and Special Care Center 2656 Hamilton Clovernook Health Care Pavilion 2661 Mahoning Colonial Manor 2496 Ashland Colonial Manor Health Care Center, Inc Stark Colonial Nursing Center 2948 Mercer Colonial Nursing Home 2422 Franklin Columbus Alzheimer Care Center 2752 Franklin Columbus Colony for Elderly Care, Inc Franklin Columbus Healthcare Center 2497 Franklin Columbus Rehabilitation & Subacute Institute 2455 Franklin Columbus West Park Nursing & Rehab Ctr 2833 Hamilton Communicare of Clifton 2472 Stark Community Care Center 2815 Marion Community Healthcare Center 2367 Williams Community Hospitals of Williams Co.-LTC 2791 Butler Community Multicare Center 2757 Trumbull Community Skilled Health Care Centre 2621 Clinton Continental Manor Nursing and Rehabilitation Center 2528 Franklin Convalarium at Indian Run 2060 Columbiana Convalescent Center # Van Wert Convoy Care Center 2482 Summit Copley Health Center, Inc Hardin Corinthian The 2443 Trumbull Cortland Center 2391 Coshocton Coshocton Health & Rehabilitation Center 2576 Hamilton Cottingham Retirement Community 2754 Tuscarawas Country Club Center I 2584 Ashtabula Country Club Center III 2442 Knox Country Club Retirement Center II 2543 Belmont Country Club Retirement Center IV 2856 Knox Country Court 2300 Stark Country Lawn Nursing Home 2286 Richland Country Meadow Care Center 2822 Fayette Court House Manor 2456 Hamilton Courtyard at Seasons 2458 Cuyahoga Covenant Care Center 2702 Miami Covington Care Center 56

57 2637 Mahoning Crandall Nursing Home 2294 Crawford Crestline Nursing Home 2396 Cuyahoga Crestmont Nursing Home North Corp Belmont Crestview Health Care Center 2689 Greene Crestview Manor 2829 Fairfield Crestview Manor Nursing Home # Fairfield Crestview Manor Nursing Home # Richland Crestwood Care Center 2346 Highland Crestwood Nursing Center 2144 Auglaize Cridersville Nursing Home 2461 Summit Crown Center at Laurel Lake 2352 Franklin Crown Pointe Care Center 2402 Scioto Crystal Care Center 2099 Ashland Crystal Care Center of Ashland 2337 Richland Crystal Care Center of Mansfield 2261 Carroll Cumberland Health Care Center 2465 Cuyahoga Cuyahoga County Nursing Home 2845 Summit Cuyahoga Falls Country Place 2372 Paulding Dallas Lamb Foundation Home 2430 Mahoning Danridge's Burgundi Manor 2808 Lucas Darlington Nursing & Rehabilitation Center 2716 Washington DaySpring Healthcare Center 2164 Clark Dayspring of Miami Valley Health Care Center & Rehabilitation 2198 Clark DayView Care Center, Inc Delaware Delaware Court 2931 Hamilton Deupree Retirement Community 2592 Jefferson Dixon Health Care Center, Inc Clermont Dobbins Nursing Home, Inc Shelby Dorothy Love Retirement Community 2545 Wayne Doylestown Healthcare Center 2949 Hamilton Drake Center 2339 Hamilton Dual Manor Health Care Center 2626 ADAMS Eagle Creek Nursing Center 2242 Wyandot Eaglewood Care Center 2554 Clark Eaglewood Care Center 2007 Carroll East Carroll Nursing Home 2514 Hamilton East Galbraith Health Care Center, Inc 2046 Columbiana East Liverpool Conv. Center, Home # Belmont East Ohio Regional Hospital Long Term Care 2518 Cuyahoga East Park Care Center 2135 Cuyahoga Eastern Star Home of Cuyahoga County 2481 Clermont Eastgate Health Care Center 2638 Franklin Eastland Care Center 2390 Fairfield Echo Manor Extended Care Center 2024 Coshocton Echoing Hills Residential Center 2347 Franklin Edge Wood Manor of Westerville 2697 Ottawa Edgewood Manor Nursing Center 2877 Highland Edgewood Manor of Greenfield 2627 Scioto Edgewood Manor of Lucasville I 2348 Scioto Edgewood Manor of Lucasville II 2349 Scioto Edgewood Manor of Lucasville II 2342 Jackson Edgewood Manor of Wellston 2924 Summit Edwin Shaw Hospital for Rehabilitation 2205 Cuyahoga Eliza Bryant Center 57

58 2226 Cuyahoga Eliza Jennings Home 2132 Lucas Elizabeth Scott Memorial Care Center 2031 Summit Ellet Manor 2189 Lorain Elms Retirement Village, Inc Sandusky Elmwood 2895 Lorain Elyria United Methodist Village 2136 Cuyahoga Emerald Ridge of Solon Senior and Health Care Community 2912 Montgomery Englewood Manor 2088 Cuyahoga Enniscourt 2950 Erie Erie County Care Facility 2210 Columbiana Essex of Salem I 2202 Columbiana Essex of Salem II 2264 Columbiana Essex of Salem III 2753 Clark Essex of Springfield 2590 Summit Essex of Tallmadge 2691 Williams Evergreen Manor Nursing Home 2567 Medina Evergreen Rehab & Specialty Care Center 2100 Shelby Fair Haven Shelby County Home 2200 Cuyahoga Fairfax Health Care Center 2706 Wyandot Fairhaven Retirement and Hlth Care Comm Fulton Fairlawn Haven 2630 Lake Fairmount Health Ctr. of Breckenridge Vlg 2324 Cuyahoga Fairview Hospital Skilled Nursing Unit 2698 Lucas Fairview Skilled Nursing & Rehabilitation 2195 Cuyahoga Falling Water Health Care Center 2951 Summit Falls Village Retirement Community LTD 2928 Franklin First Community Village Healthcare Ctr Licking Flint Ridge Nursing and Rehabilitation Center 2544 Belmont Forest Hill Retirement Community 2313 Franklin Forest Hills Center 2695 Cuyahoga Forest Hills Center for Rehabilitation & Nursing Care, Inc Jefferson Forester Nursing Home, Inc Lucas Foundation Park Care Center 2293 Scioto Fountainhead Nursing Home 2363 Montgomery Fountainview The 2565 Jackson Four Winds Nursing Facility 2809 Hancock Fox Run Manor 2531 Montgomery Franciscan at St. Leonard, The 2368 Lucas Franciscan Care Center-Sylvania 2775 Cuyahoga Franklin Plaza Extended Care 2619 Warren Franklin Ridge 2561 Franklin Franklin Woods Nursing and Rehabilitation 2063 Montgomery Friendly Nursing Home, Inc Greene Friends Care Center of Yellow Springs 2828 Montgomery Friendship Village 2767 Franklin Friendship Village Health Center 2648 Franklin Friendship Village of Dublin 2209 Fulton Fulton Manor Nursing and Rehabilitation 2405 Union Gables at Green Pastures 2247 Harrison Gables Care Center 2009 Lake Gables Nursing Home 2075 Darke Gade Nursing Home, Inc Darke Gade Nursing Home, Inc Crawford Galion Community Hospital SNF 58

59 2881 Butler Garden Manor Extended Care Ctr., Inc Hamilton Garden Park 2952 Mercer Gardens at Celina 2121 Mercer Gardens at St. Henry The 2058 Stark Gaslite Villa Convalescent Center, Inc Cuyahoga Gateway Health Care Center 2743 Huron Gaymont Nursing Center 2290 Geauga Geauga Hospital Sub-Acute Care Center 2570 Ottawa Genoa Care Center 2180 Trumbull Gillette Nursing Home 2654 Butler Glen Meadows 2165 Hamilton Glencare Center 2262 Wayne Glendora Health Care Center 2942 Franklin Glenmont 2436 Trumbull Glenn View Manor 2975 Lucas Goerlich Center 2916 Hamilton Golden Age Care Center 2953 Medina Golden Leaf of Sterling Oaks 2826 Scioto Golden Years Convalescent Center 2120 Butler Golden Years Nursing Center 2896 Lorain Good Samaritan Nursing Home, LLC 2326 Seneca Good Shepherd Home 2911 Ashland Good Shepherd The 2016 Clark Good Shepherd Village, LLC 2002 Montgomery Grace Brethren Village 2529 Montgomery Grafton Oaks Nursing Center 2134 Wood Grand Rapids Care Center 2245 Ashtabula Grand Valley Country Manor 2289 Cuyahoga Grande Pointe Healthcare Community 2560 Carroll Great Trail Care Center 2792 Logan Green Hills Center 2612 Stark Green Meadows Health and Wellness Center 2412 Mahoning Greenbriar Center 2727 Scioto Greenbriar Convalescent Center 2411 Preble Greenbriar Nursing Center 2887 Cuyahoga Greenbrier Health Care Center 2615 Greene Greene Oaks Health Center 2721 Greene Greenewood Manor 2192 Cuyahoga Greens Postacute & Rehab. Center 2061 Richland Griffeth Nursing Home, Inc Scioto Hallmark Care Center, Inc Cuyahoga Hanna House Skilled Nursing Center 2841 Stark Hanover House, Inc Cuyahoga Harborside HC-Beachwood Rehab & NC 2571 Cuyahoga Harborside HC-Broadview Hgts. Rehab & NC 2724 Cuyahoga Harborside HC-Westlake I Rehab & NC 2725 Cuyahoga Harborside HC-Westlake II Rehab & NC 2431 Williams Harborside Healthcare - Northwestern OH 2597 Wood Harborside Healthcare - Perrysburg 2504 Fulton Harborside Healthcare - Swanton 2849 Miami Harborside Healthcare - Troy 2682 Defiance Harborside Healthcare, Defiance 2312 Montgomery Harborside Healthcare-Dayton 2376 Montgomery Harborside Healthcare-New Lebanon 59

60 Harborside Healthcare-Point Place Rehabilitation and Nursing 2259 Lucas Center 2375 Lucas Harborside Sylvania 2295 Washington Harmar Place Rehab. & Extended Care 2107 Hamilton Harmony Court 2923 Hamilton Harrison House 2254 Paulding Hawthorn Court 2444 Butler Hawthorn Glen Nursing Center 2492 Cuyahoga Health Center at The Renaissance 2055 Summit Healthaven Nursing Home 2478 Franklin Healthcare Center at The Forum 2260 Highland Hearth & Care at Greenfield 2795 Fairfield Heartland - Fairfield 2605 Logan Heartland of Bellefontaine 2603 Lucas Heartland of Browning 2601 Crawford Heartland of Bucyrus 2672 Knox Heartland of Centerburg 2206 Montgomery Heartland of Centerville 2635 Ross Heartland of Chillicothe 2651 Preble Heartland of Eaton 2667 Darke Heartland of Greenville 2599 Highland Heartland of Hillsboro 2030 Logan Heartland of Indian Lake Nursing Center 2568 Logan Heartland of Indian Lake Rehab Center 2771 Jackson Heartland of Jackson 2604 Montgomery Heartland of Kettering 2473 Washington Heartland of Marietta 2634 Union Heartland of Marysville 2548 Lake Heartland of Mentor 2585 Montgomery Heartland of Oak Ridge 2722 Lucas Heartland of Oregon 2665 Wood Heartland of Perrysburg 2609 Miami Heartland of Piqua 2628 Scioto Heartland of Portsmouth 2600 Lawrence Heartland of Riverview 2679 Clark Heartland of Springfield 2789 Champaign Heartland of Urbana 2814 Fulton Heartland of Wauseon 2784 Greene Heartland-Beavercreek 2415 Lucas Heartland-Holly Glen 2649 Belmont Heartland-Lansing Nursing Center 2825 Franklin Heartland-Victorian Village 2713 Licking Heath Nursing Care Center 2925 Geauga Heather Hill, Inc Summit Heather Knoll of Summit County 2512 Lucas Heatherdowns Rehabilitation and Residential Care Center 2976 Muskingum Helen Purcell Home 2583 Scioto Hempstead Manor 2119 Tuscarawas Hennis Care Centre of Bolivar 2423 Tuscarawas Hennis Care Centre of Dover 2435 Cuyahoga Heritage Care 2813 Shelby Heritage Care Center 2662 Hancock Heritage Manor 2643 Auglaize Heritage Manor Nursing Center 60

61 2906 Mahoning Heritage Manor, Jewish Home for Aged 2102 Wayne Heritage Park Nursing and Rehabilitation 2556 Defiance Hickory Creek at Hicksville 2623 Athens Hickory Creek of Athens 2732 Scioto Hill View Retirement Center 2258 Butler Hillandale 2068 Lake Hillandale Manor 2091 Fayette Hillcrest Manor 2369 ADAMS Hillcrest Nursing Home 2930 Hamilton Hillebrand Nursing and Rehabilitation Center 2064 Marion Hillside Care Center 2940 Cuyahoga Hillside Plaza 2131 Warren Hillspring Health Care & Rehabilitation Center 2266 Putnam Hilty Memorial Home 2315 Columbiana Holander House, Ltd Geauga Holly Hill Nursing Home 2977 Cuyahoga Holy Family Home 2297 Gallia Holzer Senior Care Center 2954 Hamilton Home at Hearthstone The 2694 Lake Homestead I 2870 Lake Homestead II 2012 Ashtabula Homestead Nursing Home 2663 Warren Horizon Village Nursing & Rehabilitation Center 2222 Wayne Horn Nursing Home 2936 Greene Hospitality Home East 2830 Greene Hospitality Home West 2057 Stark Hospitality House 2978 Stark House of Loreto 2397 Summit Hudson Elms Nursing Home 2130 Mahoning Humility House 2322 Erie Huron Health Care Center 2773 Vinton Huston Nursing Home, Inc Lucas IHS at Waterford Commons 2594 Montgomery IHS of Huber Heights at Spring Creek 2573 Huron IHS of New London at Firelands 2617 Montgomery IHS of West Carrollton at Elm Creek 2932 Warren Imperial Skilled Care Center 2407 Hancock Independence House 2564 Cuyahoga Indian Hills Health and Rehabilitation Center 2734 Ashtabula Inn-Conneaut Health Center 2572 Lake Inn-Madison Health Center 2114 Franklin Isabelle Ridgway Nursing Center 2720 Hamilton Ivy Woods Care Center 2536 Mahoning Ivy Woods Manor 2054 Coshocton Jacob's Dwelling Nursing Home 2027 Hamilton Jean Byars Care Center, Inc Ashtabula Jefferson Geriatric & Rehab Center 2742 Jackson Jenkins Memorial Health Facility 2253 Cuyahoga Jennings Hall 2790 Montgomery Jewish Home for Aged 2450 Auglaize Joint Twp. Dist. Mem. Transitional Unit 2645 Lawrence Jo-Lin Health Center, Inc Hamilton Judson Care Center 2399 Cuyahoga Judson Park 61

62 2329 Lorain Kendal at Oberlin 2292 Portage Kensington Care Center 2427 Portage Kent Center 2419 Hardin Kenton Nursing and Rehabilitation Center 2892 Hamilton Kenwood Terrace Care Center 2941 Cuyahoga Kethley House at Benjamin Rose Place 2015 Athens Kimes Convalescent Center, Ltd Ross Kingston Health Care Center 2580 Ashland Kingston of Ashland 2586 Lorain Kingston of Vermilion 2513 Miami Koester Pavilion 2280 Jefferson LaBelle View Nursing Home 2922 Lucas Lake Park Nursing Care Center 2010 Lake Lakeland 2532 Lake LakeMed Nursing and Rehabilitation Center, The 2168 Hamilton Lakeridge Villa Healthcare Center 2668 Jefferson Lancia Villa Royale Nursing Home 2110 Fairfield Lanfair Nursing & Rehabilitation Center 2774 Defiance Laurels of Defiance The 2301 Highland Laurels of Hillsboro The 2227 Stark Laurels of Massillon 2764 Knox Laurels of Mt. Vernon The 2876 Franklin Laurels of Norworth The 2183 Mercer Laurels of Shane Hill The 2864 Franklin Laurels of Worthington 2410 Trumbull Laurie Ann Nursing Home 2359 Warren Lebanon Country Manor 2549 Warren Lebanon Nursing & Rehabilitation Residence 2220 Stark Legends Care Center 2285 Richland Lexington Court Care Center 2193 Trumbull Liberty Health Care Center, Inc Sandusky Liberty Nursing Center of Fremont, Inc Greene Liberty Nursing Center of Jamestown, Inc Huron Liberty Nursing Center of Willard, Inc Greene Liberty Nursing Center of Xenia, Inc Montgomery Liberty Retirement Community of Washington Township 2139 Lorain Life Care Center of Elyria 2913 Medina Life Care Center of Medina 2201 Hamilton Lighthouse Pointe Health Care Center 2979 Allen Lima Convalescent Home 2834 Allen Lima Manor 2159 Hamilton Lincoln Crawford 2480 Montgomery Lincoln Park Manor 2065 Lucas Little Sisters of the Poor 2078 Cuyahoga Little Sisters of the Poor-Home for the Aged 2577 Montgomery Livingston Care Center 2711 Hamilton Llanfair Retirement Community 2810 Brown Locust Ridge Nursing Home 2384 Hamilton Lodge Care Center The 2485 Logan Logan Acres 2839 Pickaway Logan Elm Health Care 2739 Hocking Logan Health Care Center 2797 Portage Longmeadow Care Center 2404 Lorain Lorain Manor Nursing Home 62

63 2821 Summit Lorantffy Care Center, Inc Allen Lost Creek Care Center 2302 Stark Louisville Center For Rehabilitation & Nursing Care, Inc Warren Loveland Health Care Center 2704 Licking LPN Health Care Facility, Inc Ottawa Luther Home of Mercy 2153 Henry Lutheran Home 2937 Cuyahoga Lutheran Home 2128 Lucas Lutheran Home at Toledo 2019 Erie Lutheran Memorial Home 2124 Lucas Lutheran Village at Wolf Creek 2687 Franklin Lutheran Village of Columbus - The Care Center 2647 Hamilton Madeira Health Care Center 2831 Lake Madison Health Care 2004 Lake Madison Village Nursing Home 2077 Cuyahoga Madonna Hall 2745 Medina Magnolia Care & Rehabilitation Center 2282 Fairfield Main Street Terrace Care Center 2526 Summit Maison Aine' 2591 Holmes Majora Lane Center for Rehab & Nursing Care, Inc Cuyahoga Manor at Hamlet Village in Chagrin Falls The 2276 Wood Manor at Perrysburg 2001 Franklin Manor at Whitehall 2882 Franklin Manor Care - Westerville 2824 Summit Manor Care Health Services - Akron 2807 Summit Manor Care Health Services - Barberton 2817 Stark Manor Care Health Services - Belden Village 2832 Lake Manor Care Health Services - Willoughby 2840 Hamilton Manor Care of Cincinnati 2511 Butler Manor Care of Woodridge 2889 Hamilton Manor Care-Woodside Nursing Center 2620 Cuyahoga ManorCare Health Services - Lake Shore 2796 Cuyahoga ManorCare Health Services-Mayfield Heights 2827 Cuyahoga ManorCare Health Services-North Olmsted 2772 Cuyahoga ManorCare Health Services-Rocky River 2903 Richland Mansfield Memorial Homes 2542 Cuyahoga Maple Care Center 2800 Hamilton Maple Knoll Village 2104 Ross Maple View Manor 2527 Portage Maple Wood Care Centre 2125 Mahoning Maplecrest Nursing & Home for the Aged 2818 Marion Maplewood Nursing Center, Inc Montgomery Maria-Joseph Center The 2462 Washington Marietta Nursing and Rehabilitation Center 2921 Lucas Mariner Health Care of Toledo 2891 Marion Marion Manor Nursing Home, Inc Morgan Mark Rest Center 2186 Montgomery Mary Scott Nursing Center 2305 Cuyahoga Marymount Skilled Nursing Unit 2109 Warren Mason Health Care Center 2175 Hamilton Masonic Eastern Star Community, Inc Clark Masonic Health Care, Inc Stark Massillon Community Skilled Nursing Unit 2759 Franklin Mayfair Village Nursing Care Center 63

64 2589 Stark McCrea Manor Nursing & Rehab Ctr Belmont McGraw Nursing Home 2574 Stark McKinley Health Care Center The 2379 Warren MCV - Health Care Facilities, Inc Stark Meadow Wind Health Care Center, Inc Hamilton Meadowbrook Care Center 2371 Trumbull Meadowbrook Manor 2140 Hamilton Meadows of Forest Park The 2644 Medina Meadowview Healthcare Center 2873 Brown MeadowWood Assisted Living, Inc Allen Mennonite Memorial Home 2910 Cuyahoga Menorah Park Center for Senior Living 2283 Lake Mentor Way Nursing & Rehabilitation Center, Inc Butler Mercy Franciscan at Schroder 2613 Hamilton Mercy Franciscan at West Park 2362 Hamilton Mercy Franciscan Skilled Nursing Unit Western Hills 2366 Hamilton Mercy Franciscan Terrace 2956 Seneca Mercy Hospital of Tiffin TCU 2578 Champaign Mercy McAuley Center 2439 Montgomery Mercy Siena Retirement Community 2336 Hamilton Mercy St. Theresa Center 2338 Cuyahoga Meridia Euclid Subacute Care Center 2517 Mahoning Meridian Arms Living Center 2036 Hamilton Miami Haven 2678 Montgomery Miami Shores of Moraine Nursing Center 2939 Summit Middlebury Manor Health Care Center 2489 Richland Mifflin Care Center 2611 Union Milcrest Nursing Center 2267 Erie Mill Manor 2171 Franklin Mill Run Care Center 2129 Stark Minerva Eldercare Center 2451 Franklin Minerva Park Nursing and Rehabilitation 2176 Franklin Mohun Health Care Center 2238 Monroe Monroe County Care Center 2929 Cuyahoga Montefiore Home 2917 Franklin Monterey Care Center 2816 Hamilton Montgomery Care Center 2179 Morgan Morgan Care Center 2897 Tuscarawas Morning View Care Center 2052 Knox Morning View Care Center # Knox Morning View Care Center of Danville 2345 Marion Morning View Care Center of Marion 2477 Delaware Morning View Care Center Sunbury 2101 Clermont Morris Nursing Home 2851 Morrow Morrow County Hosp. Long Term Care Fac Morrow Morrow Manor 2981 Hamilton Mother Margaret Hall Nursing Home 2982 Cuyahoga Mount Alverna Annex, Inc Cuyahoga Mount Alverna Home, Inc Hamilton Mount Healthy Christian Home 2105 Hamilton Mount Notre Dame Health Center 2794 Butler Mount Pleasant Retirement Village 2157 Cuyahoga Mount Royal Villa 2699 Cuyahoga Mount Saint Joseph 64

65 2750 Hamilton Mount Washington Care Center 2785 Hamilton Mountain Crest Nursing & Rehabilitation Center 2786 Hamilton Mountain Crest Nursing & Rehabilitation Center 2161 Franklin Nelson Park Care Center 2081 Columbiana Nentwick Convalescent Home, Inc Franklin New Albany Care Center 2304 Tuscarawas New Dawn Health Care Center 2748 Licking Newark Healthcare Center 2355 Cuyahoga Normandy Manor of Rocky River 2530 Mahoning North Eastern OH Alzheimer Research Ctr 2894 Henry Northcrest Nursing & Rehab Center 2957 Summit Northfield Village Retirement Community 2581 Lorain Northridge Health Center The 2111 Licking Northview Senior Living Center 2446 Cuyahoga Northwestern Center 2351 Montgomery Northwood Nursing and Rehabilitation Center 2566 Huron Norwalk Memorial Home 2374 Montgomery Oak Creek Terrace 2486 Henry Oak Grove Center 2424 Richland Oak Grove Manor 2657 Lorain Oak Hills Nursing Center 2766 Cuyahoga Oak Park Health Care Center 2898 Hamilton Oak Pavilion Nursing Center 2092 Hamilton Oak Terrace at East Galbraith 2172 Stark Oakhill Manor Care Center, Inc Cuyahoga Oakridge Home The 2361 Clark Oakwood Village 2653 Trumbull O'Brien Memorial Nursing Home 2207 Clark Odd Fellows Home of Ohio 2714 Muskingum Ohio District Council Nursing Home 2229 Knox Ohio Eastern Star Health Care Center 2983 Knox Ohio Eastern Star Home 2598 Lorain Ohio Extended Care Center 2479 Medina Ohio Pythian Home of Medina 2782 Brown Ohio Valley Manor Nursing & Rehabilitation Center 2035 Erie Ohio Veterans Home - Sandusky 2666 Cuyahoga Olmsted Manor Skilled Nursing Center 2740 Mahoning Omni Manor 2303 Trumbull Orange Village Care Center, Inc Lucas Orchard Villa 2000 Other Ohio Nursing Home 2688 Ottawa Ottawa County Riverview Nursing Home 2018 Putnam Otterbein Leipsic Retirement Community 2249 Auglaize Otterbein-Cridersville Retirement Community 2802 Warren Otterbein-Lebanon Retirement Community 2639 Wood Otterbein-Portage Valley 2330 Auglaize Otterbein-St. Marys Retirement Community 2525 Meigs Overbrook Center 2943 Cuyahoga Overlook House 2863 Butler Oxford View Nursing Center 2154 Lorain Palm Crest East, Inc Cuyahoga Palm Crest, Bellaire, Inc Lorain Palm Crest, West, Inc Putnam Paradise Oaks Center 65

66 2958 Ashtabula Park Haven Home 2317 Belmont Park Health Center 2640 Williams Park View Nursing Center 2214 Tuscarawas Park Village Health Care Center 2852 Mahoning Park Vista Retirement Community 2487 Columbiana Parkside Health Care Center 2959 Cuyahoga Parkside Villa 2224 Sandusky Parkview Care Center 2298 Erie Parkvue Health Care Center 2493 Cuyahoga Parma Care Center 2325 Cuyahoga Parma Community Skilled Nursing Facility 2460 Licking Pataskala Oaks Care Center 2741 Cuyahoga Patrician Skilled Nursing Center 2314 Greene Patriot Ridge 2837 Shelby Pavilion The 2521 Summit Pebble Creek Senior Care Residence 2652 Pickaway Pickaway Manor Care Center 2588 Fairfield Pickerington Nursing & Rehabilitation Center 2328 Pike Piketon Nursing Center 2378 Clark Pillars Nursing Home, Ltd Warren Pine Crest Nursing Center 2066 Licking Pine Kirk Nursing Home 2787 Summit Pine Valley Care Center 2406 Stark Pines The 2062 Pike Pineview Manor, Inc Miami Piqua Manor 2457 Lucas Plaza Care Center 2730 Pike Pleasant Hill Manor 2538 Cuyahoga Pleasant Lake Villa 2762 Summit Pleasant View Health Care Center 2079 Columbiana Pleasant View North Retirement Center 2080 Columbiana Pleasant View Nursing Home 2914 Cuyahoga Pleasantview Care Center 2344 Allen Plus Health Care Center 2037 Franklin Plus of Gahanna Health Care Center 2715 Hamilton Price Hill Nursing Home 2316 Erie Providence Care Center 2048 Lawrence Pulley Nursing Home 2350 Putnam Putnam Acres Care Center 2318 Warren Quaker Heights Nursing Home 2069 Hamilton Queen City Nursing Home 2243 Cuyahoga Rae Ann Nursing Center 2417 Cuyahoga Rae Ann Suburban 2252 Ashtabula Rae-Ann Geneva 2905 Cuyahoga Rae-Ann Westlake 2223 Hardin Ravenwood Care Center 2043 Guernsey Red Carpet Health Care Center 2701 Franklin Regency Manor Rehabilitation and Subacute Care 2117 Wayne Regency Park Nursing and Rehabilitation Center 2880 Hamilton Regency Village Ltd Summit Regina Health Center 2454 Geauga Rehabilitation Hosp. Skilled Nrsg Unit 2707 Hamilton Residence at Garden Gate 2736 Hamilton Residence at Greystone The 66

67 2113 Butler Residence at Huntington Court 2718 Butler Residence at Kensington Place 2710 Hamilton Residence at Park View The 2705 Hamilton Residence at Salem Woods The 2199 Scioto Rest Haven Nursing Home 2728 Darke Rest Haven Nursing Home, Inc Allen Richland Manor Nursing Home 2501 Trumbull Ridge Crest Care Center 2686 Hamilton Ridge Pavilion 2884 Hamilton Ridge Terrace 2838 Summit Ridgewood Healthcare Center 2331 Lucas Ridgewood Manor 2671 Clark Ridgewood Nrsg & Rehabilitation Center 2756 Lawrence River's Bend Health Care, LLC 2085 Pike Riverside Manor 2744 Tuscarawas Riverside Manor 2875 Franklin Riverside Methodist Hosp Skilled Nursing Unit 2394 Montgomery Riverside Nursing and Rehabilitation Center 2669 Hamilton Riverview Community 2053 Jefferson Riverview Nursing Home 2005 Stark Rockhill Place 2709 Fairfield Rockmill Rehabilitation Centre 2726 Meigs Rocksprings Rehabilitation Center 2926 Summit Rockynol Retirement Community 2723 Medina Rolling Hills Healthcare Center 2491 Mahoning Ron Joy Nursing Home 2960 Lucas Rosary Care Center 2152 Knox Rose Garden Nursing Home 2844 Stark Rose Lane Health Center 2505 Allen Roselawn Manor Nursing Home 2014 Stark Roselawn Terrace 2116 Jefferson Rosewood Manor 2799 Crawford Rosewood Manor 2498 Cuyahoga Royal Oak Nursing & Rehabilitation Center 2901 Cuyahoga Rudwick Manor Special Care Centre 2190 Seneca Ruffing Family Care Center 2311 Seneca Ruffing Family Care Center of Bloomville 2086 Athens Russell Nursing Home 2593 Clermont S.E.M. Haven Health Care Center 2327 Ashtabula Sacred Heart Nursing Center 2388 Cuyahoga Saint Augustine Manor 2177 Mahoning Saint Elizabeth Health Center-Subacute Unit 2909 Sandusky Saint Francis Health Care Centre 2204 Seneca Saint Francis Home, Inc Clark Saint John's Center 2370 Stark Saint Joseph Care Center 2674 Stark Saint Luke Lutheran Home for the Aging 2515 Hamilton Saint Margaret Hall 2516 Hamilton Saint Margaret Hall 2448 Auglaize Saint Mary's Living Center 2984 Hamilton Saint Mary's Memorial Home 2738 Franklin Saint Raphael Home for the Aged 2893 Franklin Saint Rita's Home for the Aged, Inc Medina Samaritan Care Center, Inc. 67

68 2145 Franklin Sanctuary At Tuttle Crossing 2464 Montgomery Sanctuary At Whispering Meadows 2017 Van Wert Sarah Jane Living Center The 2073 Delaware Sarah Moore Health Care Center 2961 Hamilton Scarlet Oaks Retirement Community 2625 Gallia Scenic Hills Nursing Center 2045 Holmes Scenic View Nursing Home 2962 Franklin Scioto Community 2471 Ashtabula Serenity Manor 2622 Wayne Shady Lawn Home 2038 Belmont Shadyside Care Center 2084 Clark Sharonview Nursing Home 2793 Allen Shawnee Manor 2963 Trumbull Shepherd of the Valley - Howland 2631 Mahoning Shepherd of the Valley Lutheran Retirement 2836 Trumbull Shepherd of the Valley Lutheran Retirement Services, Inc Montgomery Shiloh Springs Care Center, Inc Shelby Sidney Care Center 2049 Cuyahoga Singleton Health Care Center 2365 Lake Skilled Nursing & Rehabilitation Unit 2642 Cuyahoga Slovene Home for the Aged 2141 Stark Smith Nursing Home, Inc Wayne Smithville-Western Care Center 2500 Perry Somerset Center 2277 Cuyahoga Somerset Point 2749 Clark Southbrook Health Care Center, Inc Cuyahoga Southern Hills Health and Rehabilitation Center 2360 Cuyahoga Southwest General HC, Shalkhauser TCU 2610 Champaign Spring Meadows Care Center 2256 Lucas Spring Meadows Extended Care Facility 2389 Miami SpringMeade Health Center 2106 Allen Springview Manor Nursing Home 2377 Hancock St. Catherine's Care Center of Findlay 2636 Seneca St. Catherine's Care Center of Fostoria 2353 Fayette St. Catherine's Care Center of WCH 2234 Cuyahoga St. John West Shore Hospital Skilled Nursing Unit 2308 Hamilton St. John's Transitional Care Unit 2239 Cuyahoga St. Vincent Charity Hospital Skilled Nursing Unit 2208 Jefferson Steubenville Convalescent Center 2964 Jefferson Steubenville Country Club Manor 2033 Summit Stow Glen Health Care Center 2965 Cuyahoga Stratford Commons 2879 Cuyahoga Suburban Pavilion, Inc Summit Summa Health System: TCU 2606 Noble Summit Acres Nursing Home 2288 Summit Summit Villa Care Center 2408 Summit Sumner Home for the Aged 2719 Pickaway SunBridge Care & Rehabilitation for Circleville 2602 Marion SunBridge Care & Rehabilitation for Marion 2633 Perry SunBridge Care & Rehabilitation for New Lexington 2866 Fairfield SunBridge Care & Rehabilitation-Homestead 2386 Lucas SunBridge Care and Rehabilitation for West Toledo 2074 Delaware Sunbury Nursing Home 2660 Delaware Sunny Vee Nursing Home, Inc. 68

69 2248 Muskingum Sunnyview Nursing Home 2082 Clermont Sunrise Manor & Convalescent Center, Inc 2675 Cuyahoga Sunrise Pointe 2966 Jefferson Sunset Health Care, Inc Lucas Sunset House 2871 Ashtabula Sunset Manor 2118 Lawrence Sunset Nursing Center 2196 Cuyahoga Sunset Nursing Home 2274 Holmes Sunset View Castle Nursing Home 2968 Lucas Sunset Village 2299 Lucas Swan Creek Retirement Village 2257 Lucas Swan Pointe Care Center 2232 Fulton Swanton Health Care & Retirement Center 2296 Montgomery Sycamore Glen Health Center 2040 Holmes Terrace View Castle Nursing Home 2162 Hamilton Terrace View Gardens 2470 Mahoning The Assumption Village 2737 Champaign The Wellington Nursing and Rehabilitation Center 2915 Hamilton Three Rivers Nursing & Rehabilitation Center 2143 Lucas Toledo Hospital The 2434 Summit Traditions at Bath Road 2213 Franklin Traditions at Stygler Road 2904 Cuyahoga Traditions Care Center 2769 Butler Tri-County Extended Care Center 2476 Greene Trinity Home 2523 Jefferson Trinity Skilled Care Center 2677 Huron Twilight Gardens Home, Inc Vinton Twin Maples Nursing Home 2403 Richland Twin Oaks Care Center 2133 Summit Twin Pines Retreat Care Center 2969 Hamilton Twin Towers 2211 Cuyahoga UHHS - Richmond Heights Hospital TCU 2008 Darke Union City Christel Manor 2429 Cuyahoga University Manor Health Care Center 2908 Summit University Park Nursing and Rehabilitation Center 2970 Lucas Ursuline Center 2155 Licking Utica Nursing Home 2872 Auglaize Valley Nursing & Rehabilitation Center 2230 Ross Valley View Alzheimer's Care Center 2421 Sandusky Valley View Healthcare Center 2900 Summit Valley View Nursing & Rehab Center 2867 Van Wert Van Wert Manor 2865 Van Wert Vancrest Health Care Center 2127 Allen Vancrest Health Care Center of Delphos 2221 Preble Vancrest Health Care Center of Eaton 2398 Henry Vancrest Health Care Center of Holgate 2263 Montgomery Vandalia Park 2373 Darke Versailles Health Care Center 2003 Hamilton Victoria Retirement Center 2696 Hamilton Victory Park Nursing Home 2780 Franklin Villa Angela Care Center 2629 Lorain Villa Camillus 2466 Brown Villa Georgetown 2269 Cuyahoga Villa Sancta Anna Home for the Aged, Inc 69

70 2432 Clark Villa Springfield 2425 Summit Village at St. Edward Nursing Care The 2607 Franklin Village at Westerville Nursing Center 2777 Crawford Village Care Center 2219 Columbiana Vista Centre 2438 Montgomery Walnut Creek Nursing Center 2087 Holmes Walnut Hills Nursing Home 2051 Ross Walnut Manor 2539 Cuyahoga Walton Manor Health Care Center 2869 Auglaize Wapakoneta Manor 2468 Trumbull Washington Square Healthcare Center 2025 Summit Wayside Farm Nursing & Rehab Center 2070 Franklin Wecare Health Facility 2681 Lorain Welcome Nursing Home 2650 Butler Wellington Manor 2047 Lorain Wellington Manor Nursing Home, Inc Hamilton Wellspring Health Center 2203 Cuyahoga Welsh Home for the Aged 2685 Franklin Wesley Glen, The Health Center at 2356 Hamilton Wesley Hall 2420 Butler West Chester Nursing & Rehabilitation Residence 2029 Hamilton West Hills Nursing Home, Inc Coshocton West Lafayette Rehabilitation and Nursing Center 2848 Lucas West Toledo Healthcare and Rehabilitation Center 2163 Wayne West View Manor, Inc Hamilton Western Hills Retirement Village 2843 Lake Western Reserve Healthcare Center 2150 Medina Western Reserve Masonic Community, Inc Franklin Westerville Center for Rehab. & Nursing Care, Inc Cuyahoga Westlake Healthcare Center 2755 Franklin Westminster-Thurber Community 2618 Ross Westmoreland Place 2971 Butler Westover Retirement Community 2026 Hamilton Westside Health Center 2935 Franklin Wexner Heritage Village 2854 Franklin Whetstone Gardens & Care Ctr 2284 Knox Whispering Hills Care Center 2275 Stark White Oak Convalescent Home 2495 Lucas Whitehouse Country Manor 2778 Lake Wickliffe Country Place 2137 Montgomery Widows Home of Dayton 2484 Huron Willard Center 2166 Williams Williams County Hillside Country Living 2306 Franklin Willow Brook Christian Home 2097 Muskingum Willow Haven Care Center 2579 Butler Willow Knoll Nursing Center 2433 Cuyahoga Willow Park Convalescent Home, Inc Medina Willowood Care Center of Brunswick, Inc Clinton Wilmington Nursing & Rehabilitation Residence 2582 Franklin Winchester Place Nursing and 2364 Richland Winchester Terrace 2537 Summit Windsong Care Center 2717 Mahoning Windsor House 2555 Sandusky Windsor Lane Healthcare Center 70

71 2985 Stark Windsor Medical Center, Inc Hamilton Windsor Park Nursing Home, Inc Delaware Wintersong Village of Delaware 2291 Ashland Wintersong Village of Hayesville 2071 Fayette Wintersong Village of Washington Court House 2524 Montgomery Wood Glen Nursing Center 2103 Scioto Woodland Care Center 2197 Butler Woodland Country Manor, Inc Portage Woodlands at Robinson, The 2708 Richland Woodlawn Health Care & Rehabilitation 2112 Hamilton Woods Edge Pointe 2690 Monroe Woodsfield Nursing & Rehab. Center 2270 Morrow Woodside Village Care Center 2563 Franklin Worthington Christian Village 2506 Greene Wright Nursing and Rehabilitation Center 2147 Wyandot Wyandot County Nursing Home 2853 Wyandot Wyandot Manor 2474 Summit Wyant Woods Care Center 2187 Hamilton Zion Care Center, Inc. 71

72 APPENDIX 5 Authority/Mandate Ohio Revised Code Incidence reporting system for collecting information on delivery and frequency of services; trauma registries; confidentiality of information. Text of Statute (A) The state board of emergency medical services shall establish an emergency medical services incidence reporting system for the collection of information regarding the delivery of emergency medical services in this state and the frequency at which the services are provided. All emergency medical service organizations shall submit to the board any information that the board determines is necessary for maintaining the incidence reporting system. (B) The board shall establish a state trauma registry to be used for the collection of information regardingthe care of adult and pediatric trauma victims in this state. The registry shall provide for the reporting of adult and pediatric trauma-related deaths, identification of adult and pediatric trauma patients, monitoring of adult and pediatric trauma patient care data, determination of the total amount of uncompensated adult and pediatric trauma care provided annually by each facility that provides care to trauma victims, and collection of any other information specified by the board. All persons designated by the board shall submit to the board any information it determines is necessary for maintaining the state trauma registry. At the request of the board any state agency possessing information regarding adult or pediatric trauma care shall provide the information to the board. The board shall maintain the state trauma registry in accordance with rules adopted under section of the Revised Code. Rules relating to the state trauma registry adopted under this section and section of the Revised Code shall not prohibit the operation of other trauma registries and may provide for the reporting of information to the state trauma registry by or through other trauma registries in a manner consistent with information otherwise reported to the state trauma registry. Other trauma registries may report aggregate information to the state trauma registry, provided the information can be matched to the person that reported it. Information maintained by another trauma registry and reported to the state trauma registry in lieu of being reported directly to the state trauma registry is a public record and shall be maintained, made available to the public, held in confidence, risk adjusted, and not subject to discovery or introduction into evidence in a civil action as provided in section of the Revised Code and this section. Any person who provides, maintains, or risk adjusts such information shall comply with this section and rules adopted under it in performing that function and has the same immunities with respect to that function as a person who performs that function with respect to the state trauma registry. (C) The board and any employee or contractor of the board or the department of public safety shall not make public information it receives under Chapter of the Revised Code that identifies or would tend to identify a specific recipient of emergency medical services or adult or pediatric trauma care. (D) Not later than two years after the effective date of this amendment, the board shall adopt and implement rules under section of the Revised Code that provide written standards and procedures for risk adjustment of information received by the board under Chapter of the Revised Code. The rules shall be developed in consultation with appropriate medical, hospital, and emergency medical service organizations and may provide for risk adjustment by a contractor of the board. Before risk adjustment standards and procedures are implemented, no member of the board and no employee or contractor of the board or the department of public safety shall make public information received by the board under Chapter of the Revised Code that identifies or would tend to identify a specific provider of emergency medical services or adult or pediatric trauma care. After risk adjustment standards and procedures are implemented, the board shall make public such information only on a risk adjusted basis. (E) The board shall adopt rules under section of the Revised Code that specify procedures for ensuring the confidentiality of information that is not to be made public under this section. The rules shall specify the circumstances in which deliberations of the persons performing risk adjustment functions under this section are 72

73 not open to the public and records of those deliberations are maintained in confidence. Nothing in this section prohibits the board from making public statistical information that does not identify or tend to identify a specific recipient or provider of emergency medical services or adult or pediatric trauma care. (F) No provider that furnishes information to the board with respect to any patient the provider examined or treated shall, because of this furnishing, be deemed liable in damages to any person or be held to answer for betrayal of a professional confidence in the absence of willful or wanton misconduct. No such information shall be subject to introduction in evidence in any civil action against the provider. No provider that furnishes information to the board shall be liable for the misuse or improper release of the information by the board or any other person. No person who performs risk adjustment functions under this section shall, because of performing such functions, be held liable in a civil action for betrayal of professional confidence or otherwise in the absence of willful or wanton misconduct. Ohio Administrative Code State trauma registry. (A) In carrying out its responsiblities for the collection of trauma data pursuant to section ORC" of the Revised Code and this chapter, the board may reference commonly accepted medical diagnostic codes in identifying those conditions that are included within the definition of trauma. (B) The board shall use the state trauma registry to collect and analyze data that is necessary to evaluate the delivery of adult and pediatric trauma care within the state. The data collected by the state trauma registry shall be of such a nature as to allow the board to identify and evaluate the following: (1) Incidence, type, severity, and outcome of trauma injuries; (2) Criteria used to establish triage protocols; (3) Geographic patterns of injury, including but not limited to areas or regions of the state where improvements are needed in the delivery of trauma care; (4) Other factors to consider in recommending, designing, or implementing an integrated statewide trauma care delivery system, including but not limited to public education on trauma and injury prvention, access to trauma care, prehospital availability, and cost of trauma care. (C) Data and information submitted to, and maintained by, the state trauma registry shall be in such a format that: (1) Protects the identity of specific patients to whom medical care has been rendered; (2) Identifies specific health care facilities by a code or similar designation other than name; (3) Avoids or minimizes duplication of entry. HISTORY: Eff ; Rule promulgated under: RC <JL:JUMP,"119.03","1_PORC" Rule authorized by: RC <JL:JUMP," ","1_PORC" Rule amplifies: RC <JL:JUMP," ","1_PORC" R.C. <JL:JUMP," ","1_PORC" review dates: 2/11/2002 and 04/28/2007 <JD:" " Operation of state trauma registry. (A) As used in this rule, "subcommittee" means the trauma registry advisory subcommittee authorized in paragraph (B) of this rule. (B) The state trauma registry established pursuant to section <JL:JUMP," ","1_PORC" of the Revised Code and this chapter shall be overseen by a subcommittee of the state trauma committee, which shall be known as the trauma registry advisory subcommittee. (C) The board shall make appointments to the subcommittee. Membership of the subcommittee shall include the following: (1) Two surgeons selected from a list of nine names, three each submitted by the Ohio chapter of the American college of surgeons, the Ohio state medical association, and the Ohio osteopathic association, respectively. One of the two surgeons chosen shall be affiliated with a facility that has applied for designation as, or has been verified as, a level I or level II trauma center by the 73

74 American college of surgeons; (2) Two emergency physicians, one each selected from list of three names submitted by the Ohio chapter of the American college of emergency physicians and a list of three names submitted by the Ohio chapter of the American academy of pediatrics; (3) Two trauma registrars selected from a list of three names submitted by the alliance of Ohio trauma registrars; (4) Two nurses, one each selected from a list of three names submitted by the Ohio society of trauma nurse coordinators and a list of three names submitted by the Ohio emergency nurses association; (5) Two hospital representatives selected from a list of twelve names, three each submitted by the Ohio hospital association, the Ohio osteopathic association, the association of Ohio children's hospitals, and the health forum of Ohio, respectively; (6) One prehospital emergency medical services provider selected from a list of three names submitted by each organization representing prehospital emergency medical services providers that is authorized by section <JL:JUMP," ","1_PORC" of the Revised Code to submit nominations to the governor for appointments to the board; (7) One representative of rehabilitation providers selected from a list of three names submitted by the Ohio rehabilitation association; (8) One consumer who is not affiliated with an emergency medical services provider, selected from a list of three names submitted by the chairman of the board. (9) One physical medicine and rehabilitation physician selected from a list of nine names, three each submitted by the Ohio society of physical and rehabilitative medicine, the Ohio state medical association, and the Ohio osteopathic association, respectively. (10) One county coroner selected from a list of nine names, three each submitted by the Ohio state coroner's association, the Ohio state medical association, and the Ohio osteopathic association, respectively. (11) Two health information management technicians or medical record coders from non-trauma center hospitals, selected from a list of three names submitted by the Ohio health information management association. (12) One representative from a regional trauma registry selected from a list of three names submitted by the chairman of the state trauma committee. (D) In making appointments to the subcommittee, the board shall make a good faith effort to ensure representation from health care facilities of differing size and trauma care capabilities, and from various geographic regions of the state. (E) The initial subcommittee members shall serve staggered terms. Of the initial appointments to the subcommittee, the board shall designate four members whose terms shall end one year after the initial date of appointment and four members whose terms shall end two years after the initial date of appointment. The remaining initial subcommittee members shall each serve a term of three years. Any member appointed to the subcommittee after the initial appointments shall serve a term of three years. No member shall serve more than two consecutive terms. (F) The board may fill any vacancies that occur prior to the expiration of a term in the same manner as the original appointment. Any member appointed to fill a vacancy occurring prior to the expiration of the term for which his predecessor was appointed shall serve for the remainder of the unexpired term. Any member appointed to fill an unexpired term shall remain eligible to serve two additional three-year terms. (G) The subcommittee shall annually select a chairman from among its members. (H) The subcommittee may establish such task forces or work groups as it deems necessary to assist in its functions. HISTORY: Eff ; Rule promulgated under: RC <JL:JUMP,"119.03","1_PORC" Rule authorized by: RC <JL:JUMP," ","1_PORC" Rule amplifies: RC <JL:JUMP," ","1_PORC" R.C. <JL:JUMP," ","1_PORC" review dates: 2/11/2002 and 04/28/2007 <JD:" " 74

75 Required reporting to state trauma registry. (A) The following entities shall submit data and information to the state trauma registry: (1) Health care facilities including: (a) Hospitals registered under Chapter <JL:JUMP,"3701","1_PORC"3701. of the Revised Code; (b) Nursing facilities licensed or certified under Chapter <JL:JUMP,"3721","1_PORC"3721. of the Revised Code; (c) County homes or county nursing homes as defined in section <JL:JUMP," ","1_PORC" of the Revised Code; (d) Inpatient rehabilitation facilities as defined in Chapter of the Administrative Code; (e) Ambulatory surgical facilities as defined in section <JL:JUMP," ","1_PORC" of the Revised Code; (2) State and other public agencies designated by the board that possess information regarding trauma care; (3) County coroners. (B) Those entities required to submit data and information to the state trauma registry under this chapter shall provide information regarding injured patients in the following categories that are applicable to its operations: (1) Trauma patients who meet the minimum requirements set forth by the board for inclusion into the Ohio trauma registry; (2) Type of trauma injury as identified by medical diagnostic codes designated by the board; (3) Severity of injury; (4) Patient outcomes; (5) Type of prehospital emergency care received by each trauma patient; (6) Financial data pertinent to trauma care; (7) Remuneration received from all sources for treatment of trauma patients. (C) All trauma related deaths shall be reported by the coroner of the county in which the death occurred to the state trauma registry in a manner specified by the board within one hundred-eighty days after the death occurs, (D) The information required to be provided to the state trauma registry under section <JL:JUMP," ","1_PORC" of the Revised Code and this chapter shall be provided and maintained in such a way as to protect against revealing the identity of the patient. Any person handling information received for the state trauma registry has a fiduciary duty to maintain the confidentiality of such information and shall sign and adhere to a contract with the department of public safety, division of EMS, regarding the confidentiality of such information. If such person violates this fiduciary duty or violates any terms of the contract, the department of public safety, division of EMS, may terminate such person and employ any other remedies, legal or equitable, available to it. Health care facilities and other providers shall be identified in the registry by a code or similar designation other than name. (E) Except as provided in paragraph (C) of this rule or as otherwise specified by the board, the information required under section <JL:JUMP," ","1_PORC" of the Revised Code and this chapter shall be reported on a quarterly basis and shall be submitted to the state trauma registry not later than ninety calendar days after March thirty-first, June thirtieth, September thirtieth, and December thirty-first of each year. The board may develop policies for granting extensions to the submission deadlines. (F) The information required to be provided to the state trauma registry under section <JL:JUMP," ","1_PORC" of the Revised Code and this chapter shall be submitted in a format authorized by the board for such purpose, (G) In identifying the information to be provided to the state trauma registry under section <JL:JUMP," ","1_PORC" of the Revised Code and this chapter, the board shall take into consideration the financial and other burdens that these requirements will place on the entities that are required to report. (H) Any entity, otherwise required to report to the state trauma registry under section <JL:JUMP," ","1_PORC" of the Revised Code or this chapter, that reports required information to a regional trauma registry need not report individually to the state trauma registry, provided the regional registry reports such information to the state trauma registry in compliance with section <JL:JUMP," ","1_PORC" of the Revised Code and this chapter. Those entities intending to report through a regional registry shall so notify the board in a manner 75

76 indicated by the board. (I) Any entity that fails to submit data and information to the state trauma registry, as required under section <JL:JUMP," ","1_PORC" of the Revised Code or this chapter, may be ineligible to participate in the emergency medical services grants program established under section <JL:JUMP," ","1_PORC" of the Revised Code and as provided in Chapter of the Administrative Code. HISTORY: Eff ; Rule promulgated under: RC <JL:JUMP,"119.03","1_PORC" Rule authorized by: RC <JL:JUMP," ","1_PORC" Rule amplifies: RC <JL:JUMP," ","1_PORC" R.C. <JL:JUMP," ","1_PORC" review dates: 2/11/2002 and 04/28/2007 <JD:" " Definitions. (A) "Glasgow coma scale" or "GCS" is a numeric rating used to assess the severity of neurologic injury. (B) "Information that identifies or would tend to identify a specific recipient of emergency medical services or adult or pediatric care" shall have the same meaning as "individually identifiable health information" as defined in the health insurance portability and accountability act (HIPAA) of 1996, attached hereto as an appendix. (C) As used in HIPAA and this chapter, "Individually identifiable health information" is information that is a subset of health information, including demographic information collected from an individual, and (1) Is created or received by a health care provider, health plan, employer, or health care clearinghouse; and (2) Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and (a) That identifies the individual; or (b) With respect to which there is a reasonable basis to believe the information can be used to identify the individual. (D) "Injury severity score" or "ISS" is a mathematical measure assessing the cumulative effect of injury severity. (E) "Major Trauma Outcome Study" or "MTOS" is a nationally based research project conducted between 1982 and 1987, which created and validated the TRISS Methodology. (F) "Risk Adjustment" means methodologies applied to a data set in order to identify and control patient variables that are present which may influence patient outcome. (G) "TRISS" is a methodology which combines the following variables in order to determine a probability of survival: (1) Physiologic (Systolic Blood Pressure, Respiratory Rate, Glasgow Coma Scale Score); (2) Anatomic injury severity score; (3) Age (55 years or older, or younger than 55 years); (4) Trauma Type (Blunt or Penetrating Injury). HISTORY: Eff Rule promulgated under: RC <JL:JUMP,"119.03","1_PORC" Rule authorized by: RC <JL:JUMP," ","1_PORC" Rule amplifies: RC R.C. <JL:JUMP," ","1_PORC" review dates: 04/28/2007 <JD:" " Purpose of risk adjustment. The purpose of risk adjustment is to identify and control patient variables that are present which may influence patient outcome. HISTORY: Eff Rule promulgated under: RC <JL:JUMP,"119.03","1_PORC" Rule authorized by: RC <JL:JUMP," ","1_PORC" Rule amplifies: RC <JL:JUMP," ","1_PORC" R.C. 76

77 <JL:JUMP," ","1_PORC" review dates: 04/28/2007 <JD:" " Risk adjustment of state trauma registry data. (A) Methodologies (1) TRISS shall be the primary methodology used to risk adjust data in the state trauma registry. (2) The subcommittee may evaluate other methodologies and make recommendations to the trauma committee and board on the use of such methodologies. (3) The coefficients used to calculate TRISS shall be those derived from the MTOS. (4) The subcommittee may evaluate the possibility of creating Ohio specific coefficients, based upon the Ohio trauma registry data set, to utilize with the TRISS methodology, and when appropriate, these equations may be utilized. Additionally, the subcommittee may evaluate other appropriate data sets for use in developing specific coefficients. (B) Analysis (1) The subcommittee shall utilize a variety of acceptable techniques for providing statistical analysis of risk-adjusted data. (2) The subcommittee shall utilize a variety of methodologies to risk adjust by sex, age, or other factors, in order to analyze state trauma registry data for specific age groupings, including pediatric and geriatric age groupings. (C) Risk Adjusted Outcomes (1) Mortality shall be an outcome that is risk adjusted. In addition, the subcommittee may evaluate the feasibility of risk adjusting other outcomes and make recommendations to the trauma committee and board on the selection and evaluation of such outcomes. HISTORY: Eff Rule promulgated under: RC <JL:JUMP,"119.03","1_PORC" Rule authorized by: RC <JL:JUMP," ","1_PORC" Rule amplifies: RC <JL:JUMP," ","1_PORC" R.C. <JL:JUMP," ","1_PORC" review dates: 04/28/2007 <JD:" " Protected information within the state trauma registry. (A) Information that identifies or would tend to identify a specific recipient of emergency medical services or adult or pediatric trauma care shall include, but not be limited to, the recipient's social security number, date of birth, and name. (1) No records shall be provided in response to a public records request if the request asks for information sorted by, or if the request contains, information that identifies or would tend to identify a specific recipient of emergency medical services or adult or pediatric trauma care. (2) No records provided in response to a public records request shall contain any information that identifies or would tend to identify a specific recipient of emergency medical services or adult or pediatric trauma care. (B) Information that identifies or would tend to identify a specific provider of emergency medical services or adult or pediatric trauma care shall include, but not be limited to, the provider's hospital code, medical record number, and county. (1) Prior to the implementation of risk adjustment standards and procedures, no records shall be provided in response to a public records request if the request asks for information sorted by, or if the request contains, information that identifies or would tend to identify a specific provider of emergency medical services or adult or pediatric trauma care. (2) Prior to the implementation of risk adjustment standards and procedures, no records provided in response to a public records request shall contain any information that identifies or would tend to identify a specific provider of emergency medical services or adult or pediatric trauma care. (3) After risk adjustment standards and procedures are implemented, such records may be made public, but only on a risk adjusted basis. HISTORY: Eff Rule promulgated under: RC <JL:JUMP,"119.03","1_PORC" Rule authorized by: RC <JL:JUMP," ","1_PORC" Rule amplifies: RC <JL:JUMP," ","1_PORC" R.C. <JL:JUMP," ","1_PORC" review dates: 04/28/

78 <JD:" " Version 1.0 Effective January 1, Risk adjustment deliberations. (A) The department of public safety, division of EMS, may contract with individuals or organizations with specific expertise in risk adjustment and statistical analysis of medical data in order to perform risk adjustment of information received by the board under Chapter <JL:JUMP,"4765","1_PORC"4765. of the Revised Code. (B) Each person performing risk adjustment of Ohio trauma registry data has a fiduciary duty to maintain the confidentiality of such information. In the event a person performing risk adjustment under this chapter violates this duty, the department of public safety, division of EMS, may terminate such person and employ any other remedies, legal or equitable, available to it. (C) Each person performing risk adjustment of Ohio trauma registry data shall sign and adhere to a contract with the department of public safety, division of EMS, regarding the confidentiality of such information. In the event a person performing risk adjustment under this chapter violates any terms of this contract, the department of public safety, division of EMS, may terminate such person and employ any other remedies, legal or equitable, available to it. (D) All meetings in which persons are engaged in performing risk adjustment functions, including deliberations therein, shall not be open to the public. (E) All records of deliberations of persons performing risk adjustment functions shall be maintained in confidence. HISTORY: Eff Rule promulgated under: RC <JL:JUMP,"119.03","1_PORC" Rule authorized by: RC <JL:JUMP," ","1_PORC" Rule amplifies: RC <JL:JUMP," ","1_PORC" R.C. <JL:JUMP," ","1_PORC" review dates: 04/28/

79 APPENDIX 6 Trauma Registry Advisory Subcommittee Dr. James Begley M.D. Physical Medicine/Rehabilitation Physician Ms. Sally Betz, R.N., MSN Registered Nurse Ms. Margie Brunn, CSTR Trauma Registrar Ms. Paula Fowles, R.N. Rehab Representative Ms. Elizabeth Gash, RHIA Medical Records Professional Ms. Roxanna Giambri, RHIA Regional Trauma Registry Representative Ms. Vickie Graymire, R.N., MS Registered Nurse Mr Henry Kauffman, EMT-P, Fire Chief EMS Representative Dr. Barry Knotts, M.D., FACS, Ph.D Surgeon, level 1 Trauma Center Mr. Jon Konves, EMT-P Trauma Registrar Dr. Carl Parrott, M.D. County Coroner Dr. Douglas Paul, D.O. Hospital Representative Ms. Vicki Ruppert, R.N., BSN Hospital Representative Mr. Michael Smeltzer, MPH Consumer Dr. Richard Treat, M.D. Surgeon, non level 1Trauma Center Ms. Debbie Znosko, CCS Medical Records Professional 79

80 APPENDIX 7 File Key Lay Out No. Field Name Length Type Start End Nullable Values Instructions 1 Rehabilitation Facility Code 2 Unique Patient Encounter/Admission Number 4 N 1 4 NO The facility code assigned by the Ohio Department of Public Safety.See Appendix 1 - ODPS Rehabilitation Facility Codes. 15 A 5 19 NO A number assigned by each facility to the patient at the time of admission. This number should be unique for each patient AND each visit. This number may be referred to as a patient account number. Medical record numbers are typically specific to each patient BUT are frequently the same for all rehabilitation facility visits by the same patient. 3 Date Exported 8 DATE NO Date (mmddyyyy) that this record was submitted to the Ohio Trauma Registry. 4 Zip Code of Residence 5 N NO The patient's five-digit zip code for place of residence, at the time of their injury. Enter "99999" for patients that reside outside of the USA. Must be present on all records submitted to the Ohio Department of Safety. A four-digit code assigned by the Ohio Department of Public Safety. This code needs to be entered initially. After initial entry it will automatically be entered for each record. Enter the rehabilitation facility's unique patient number for this patient. This record is for audit purposes only and will not be made public. This is a generated field and will be completed when the record is exported to Ohio Trauma Registry. Enter in the patients' zip code number of their residence at the time of their injury. If patient is homeless, enter the zip code of the location of injury. Enter "99999" for patients that reside outside of the USA. Do not enter the 4-digit extension. 5 Patient's Date of Birth 8 DATE NO mmddyyyy The patient's date of birth. Enter the month, day and year of the patient's Date of Birth. If the patients age is known, but the date of birth is not, enter 01/01/YYYY (YYYY appropriate to patients known age) Entire year must be used 6 Gender 1 N NO 1 - Male 2 - Female 3 - ND (Not Documented) 7 Race/Ethnicity 1 N NO 1 - American Indian or Alaskan Native 2 - Asian 3 - Black, not of Hispanic origin 4 - Hispanic or Latino 5 - Native Hawaiian or Other Pacific Islander 6 - White 7 - Other 8 - Multi-racial 9 - ND (Not Documented) 8 Date of Onset (Date Injury Occurred) Example: 1998 Enter in the patient's date of birth. Must use this format "01/01/1998". It is necessary to enter the year using the entire year. The patient's gender at the injury date. Enter the patient's gender using the options available from code table above. Use the pulldown menu to select this field. Select the most appropriate option. The patient's race/ethnic group. Enter the patient's race from the available options. Use the pulldown menu to select this field. Select the most appropriate option. If more than one race value #1 to #6 is selected then value number 8 - Multiracial must be selected. Note that pediatric facilities are limited to selection of only one value. Adult facilities can select multiple values, which will reported as 8 - multi-racial. 8 DATE NO mmddyyyy The date the injury occurred. Enter the month, day and year of the injury. The year must be 4-digits. Example: The date on which injury

81 9 Rehabilitation Admission From Version 1.0 Effective January 1, N NO 01 - Home 02 - Board and Care 03 - Transitional Living 04 - Intermediate care 05 - Skilled Nursing Facility 06 - Acute Unit of own facility 07 - Acute Unit another facility 08 - Chronic Hospital (LTAC) 09 - Rehabilitation facility 10 - Other 12 - Alternate Level of care 13 - Subacute setting 14 - Assisted Living Residence occurred must be the earliest date associated with the trauma event. All treatment dates must be equal to or after the date on which the injury occurred. Enter the patient's actual date of injury. If # 4, 5, 7, or 9 is selected, field # 10 Transferring Facility ID must be competed. Value number 11 is purposefully not utilized for this field.home: A private, community based dwelling (a house, apartment, mobile home, etc) that houses the patient, family, or friends. Board and Care: A community based setting where individuals have private space (either a room or apartment), or a structured retirement facility. The facility may provide transportation, laundry, and meals, but no nursing care. Transitional Living: A community based, supervised setting where individuals are taught skills so they can live independently in the community. Intermediate care (nursing home): A long term care setting that provides health related services but a registered nurse is not present 24 hours a day. Patients live by institutional rules; care is ordered by a physician, and a medical record is maintained. Patients in intermediate care are generally less disabled than those in skilled care facilities Skilled Nursing Facility (nursing home): A long term care setting that provides skilled nursing services. A registered nurse is present 24 hours a day. Patients live by institutional rules; care is ordered by a physician, and a medical record is maintained. Acute Unit of own Facility: An acute medical/surgical care unit in the same facility as the rehabilitation unit. Acute Unit another Facility: An acute medical/surgical care facility separate from the rehabilitation unit. Chronic Hospital (LTAC): A long-term care setting classified as a hospital, long term acute care. Rehabilitation facility: An inpatient setting that admits patients with specific disabilities and provides a team approach to comprehensive rehabilitation services, with a physiatrist (or physician of equivalent training/experience) as the physician of record. Other: Used only if no other code is appropriate Alternate Level of care: A physically and fiscally distinct unit that provides care to individuals who no longer meet acute care criteria Subacute setting: Subacute care is goal-oriented, comprehensive, 81

82 inpatient care designed for an individual who has an acute illness, injury or exacerbation of a disease process. It is rendered immediately after, or instead of, acute hospitalization to treat one or more specific active, complex medical conditions an overall situation. Generally the condition of an individual receiving subacute care is such that the care does not depend heavily on high technology monitoring or complex diagnostic procedures. Subacute care requires the coordinated services of an interdisciplinary team, including physicians, nurses, and other relevant professional disciplines whoa re knowledgeable and trained to assess and manage specific conditions and perform the necessary procedures. Subacute care is given as part of a specially designed program, regardless of the site. Subacute care is generally more intensive than traditional nursing home care, but less than acute inpatient care. It requires frequent (daily to weekly) patient assessment and review of the clinical course and treatment plan for a limited time period (several days to several months), until a condition is stabilized or a predetermined course is completed. 10 Pediatric Prehospital Setting 2 N YES 01 - Home 02 - Transitional living center 03 - Skilled nursing facility 05 - Other 06 - ND 11 Pediatric Living With 2 N YES 01 - Two parents 02 - One parent 03 - Relatives 04 - Foster care 05 - Shelter 06 - Other 07 - ND 12 Pediatric Education Category 13 Pediatric Educational Setting 2 N YES 01 - Not a student 02 - Early Intervention program 03 - Preschool 04 - Kindergarten through 12th 05 - Other 2 N YES 01 - Regular Class 02 - Special class (approx. 12:1) 03 - Special Class (approx. 6:1) 04 - Home-based 05 - Day Care/nursery school/center-based/community 06 - NA Assisted Living Residence: A community based setting that combines housing, private quarters, freedom of entry and exit, supportive services, personalized assistance, and healthcare designed to respond to individual needs of the those who need help with activities of daily living and instrumental activities of daily living. Supportive services are available 24 hours a day to meet scheduled and unscheduled needs in a way that promotes maximum dignity and independence for each resident. These services involve the resident's family, neighbors, and friends. Select the value that most accurately describes the patients living arrangements prior to their hospitalization. Note the value 04 is not used in this field. Select a value in this field ONLY if the value selected in field # 10 Pediatric Prehospital Setting is equal to "01-Home" Select the value If value 2, 3 or 4 is selected for the Pediatric Education Category, then an appropriate value for this field must be reported. If 01 or 05 is selected for Pediatric Education Category, then 06- NA must be selected. 82

83 14 Adult Prehospital Living With 15 Adult Prehospital Vocational Category 16 Adult Prehospital Vocational Effort 2 N YES 01 - Alone 02 - Family/Relatives 03 - Friends 04 - Attendant 05 - Other 06 - ND 2 N YES 01 - Employed 02 - Sheltered 03 - Student 04 - Homemaker 05 - Not Working 06 - Retired for Age 07 - Retired for Disability 08 - ND 2 N YES 01 - Full-time 02 - Part-time 03 - Adjusted Work load 04 - NA 05 - ND Version 1.0 Effective January 1, 2005 Select the value that most accurately describes the patients living arrangements prior to their hospitalization. Select the value that most accurately describes the patients' vocation prior to their hospitalization.employed - The patient works for pay in a competitive environment or is self employed Sheltered - The patient works for pay in a non-competitive environment Student - the patient is enrolled in an accredited school (including trade school), college or university. Homemaker - The patient works at home, does not work outside the home, is not paid by an employer, and is not self employed Not Working - The patient is unemployed, but is not retired or receiving disability benefits Retired for Age - The patient is retired (usually 60 years of age or older) and is receiving retirement benefits Retired for Disability - The patient is receiving disability benefits and is less than 60 years of age. Select the value that most accurately describes the patients vocation prior to their hospitalization, if values 1-4 are selected in field # Prehospital Vocation Category, then are valid selections for this field. If are selected in field #, then 04 must be selected.full-time - The patient worked a full schedule (i.e or 40 hours per week) - which ever is normal where he/she works Part-time - The patient worked less than full time (i.e. less than 37.5 or 40 hours per week) depending on the norm where he/she works. Adjusted Workload - The patients workload was adjusted due to disability. The patient was not able to perform all the work duties of the position 17 Transferring Facility ID 4 N NO ODH or ODPS assigned number. If the patient is transferred from an Ohio hospital, enter the ODH assigned Ohio hospital code. See Appendix 1-A for the list of ODH assigned Ohio hospital codes If the patient is transferred from an out of state hospital, enter the ODPS assigned out of state hospital code. See Appendix 1-B for the list of ODPS assigned out of state hospital codes. If the patient is transferred from an Ohio Rehabilitation Facility, enter the ODPS assigned Ohio Rehabilitation Facility code. See Appendix 1-C for the list of ODPS assigned Ohio Rehabilitation Facility codes If the patient is transferred from an Ohio Nursing Facility, enter the ODH assigned Ohio Nursing Facility code. See Appendix 1-D for the list of ODH assigned Ohio Nursing Facility codes 18 Rehabilitation Facility 8 DATE NO mmddyyyy The arrival date that the patient actually arrived at the rehabilitation 83

84 Arrival Date 19 Etiologic Diagnosis (ICD- 9-CM Code) 20 Co-Morbid Conditions (ICD-9-CM Codes) 21 Complications during Rehabilitation Stay (ICD- 9-CM Codes) 22 Disability Assessment Tool Adult/Pediatric 23 Disability Assessment upon Admission Version 1.0 Effective January 1, 2005 facility. Enter the month, day and year. The actual date that the patient arrived at the rehabilitation facility. Date format: 01/29/1998. The year must be complete year (1998). 5 N YES Report the ICD-9-CM diagnosis codes Use an ICD-9-CM code to indicate the etiologic problem that led to the condition for which the patient is receiving rehabilitation. These should be diagnosis codes, not external cause of injury codes. When creating a data file the decimal point MUST be used. Example: = or 810 = Give the complete code not category codes. 50 N YES Report 10 additional ICD-9-CM codes of diagnoses The ICD-9-CM code for each injury diagnosis. List up to 10 codes. When creating a data file the decimal point MUST be used. Example: = or 810 = N YES Report up to 6 ICD-9-CM codes Enter an ICD-9-CM code for each complication that began with this rehabilitation stay. List up to 6 codes. When creating a data file the decimal point MUST be used. Example: = or 810 = N NO 1 - Adult 2 - Pediatric 18 N NO 0 - Activity Does Not Occur 1 - Total Assistance 2 - Maximum Assistance 3 - Moderate Assistance 4 - Minimal Assistance 5 - Supervision 6 - Modified Independence 7 - Complete independence Facilities using an adult assessment-scoring model (i.e. FIMTM) should select 1 - Adult. Facilities that use a pediatric scoring model, (i.e. WeeFIMTM) regardless of the patient's age should select 2 - Pediatric. Motor Subscore is a calculated field, the sum of fields #25 through #37 Cognitive Subscore is a calculated field; the sum of fields #38 through #42 Total Motor and Cognitive score is a calculated field, the sum of Motor subscore and Cognitive subscore Disability Assessment upon admission should be determined during the first three calander days of the patients admission 25 Self-Care: Eating 26 Self-Care: Grooming 27 Self-Care: Bathing 28 Self-Care: Dressing-Upper Body 29 Self Care: Dressing-Lower Body 30 Self-Care: Toileting 31 Sphincter Control: Bladder Management 32 Sphincter Control: Bowel Management 33 Transfers: Bed, Chair, Wheelchair 34 Transfers: Toilet 35 Transfers: Tub, Shower 36 Locomotion: Walk. Wheelchair 37 Locomotion: Stairs 38 Communication: Comprehension 39 Communication: Expression 40 Social Cognition: Social Interaction 41 Social Cognition: Problem Solving 42 Social Cognition: Memory Motor Subscore 84

85 24 Disability Assessment Score upon Discharge Version 1.0 Effective January 1, 2005 Cognitive subscore Total Motor and Cognitive score 18 N NO 1 - Complete Dependence 2 - Maximum assistance 3 - Moderate Assistance 4 - Minimal Assistance 5 - Supervision 6 - Modified Independence 7 - Complete independence Motor Subscore is a calculated field, the sum of fields #25 through #37 Cognitive Subscore is a calculated field; the sum of fields #38 through #42 Total Motor and cognitive score is a calculated field, the sum of Motor subscore and cognitive subscore 25 Date of Discharge or Death 25 Self-Care: Eating 26 Self-Care: Grooming 27 Self-Care: Bathing 28 Self-Care: Dressing-Upper Body 29 Self Care: Dressing-Lower Body 30 Self-Care: Toileting 31 Sphincter Control: Bladder Management 32 Sphincter Control: Bowel Management 33 Transfers: Bed, Chair, Wheelchair 34 Transfers: Toilet 35 Transfers: Tub, Shower 36 Locomotion: Walk. Wheelchair 37 Locomotion: Stairs 38 Communication: Comprehension 39 Communication: Expression 40 Social Cognition: Social Interaction 41 Social Cognition: Problem Solving 42 Social Cognition: Memory Motor Subscore Cognitive subscore Total Motor and Cognitive score 8 DATE NO mmddyyyy Enter the date of the patient's discharge, transfer or death from the rehabilitation facility. The actual date that the patient was discharged from the rehabilitation facility or date that the patient was pronounced dead. Date format: 01/29/1998. The year must be complete year (1998). 26 Discharge Status 1 N NO 1 - Alive 2 - Dead 27 Adult Discharge Disposition 2 N YES 01 - Home 02 - Board and Care 03 - Transitional Living 04 - Intermediate care 05 - Skilled Nursing Facility 06 - Acute Unit of own facility 07 - Acute Unit another facility 08 - Chronic Hospital (LTAC) 09 - Rehabilitation facility 10 - Other Enter the status of the patient upon discharge from the rehabilitation facility. The patient was alive or dead when they left the rehabilitation facility. The patient's disposition upon discharge from the rehabilitation facility. If #01 is selected you must make an entry in Field # XX Discharge Living With. If #04, 05, 07, or 09 is selected you must enter an ODPS or ODH Assigned facility code in field # XX-Transfer to Other Rehabilitation Facility. 85

86 28 Adult Discharge Living With 29 Pediatric Discharge Disposition 30 Pediatric Discharge Living With Version 1.0 Effective January 1, Died 12 - Alternate Level of care 13 - Subacute setting 14 - Assisted Living Residence 2 N YES 01 - Alone 02 - Family/Relatives 03 - Friends 04 - Attendant 05 - Other 06 - NA 2 N YES 01 - Home 02 - Transitional living center 03 - Skilled nursing facility 05 - Other 06 - ND 2 N YES 01 - Two parents 02 - One parent 03 - Relatives 04 - Foster care 05 - Shelter 06 - Other 07 - ND 31 Discharge Referrals 10 N NO 01 - Referral to Bureau of Vocational Rehabilitation 02 - Referral to Bureau of Visual Impairment 03 - Outpatient therapy 04 - Home Health Services 05 - Other (examples - homeless or women's shelters, protective services, etc.) 09 - No Referals Made 32 Transfer to Other Hospital/Facility 33 Billed Rehabilitation Facility Charges 4 N YES/NO ODH assigned # for in-state hospitals ODPS assigned # for out of state hospitals ODPS assigned # for rehabilitation facilities ODH assigned # for licensed nursing homemay be BLANK if Field Number #27 is NOT = 5, 6, 7, 8, 9 (adult) or if Field Number #29 is NOT = N YES Whole Dollar amount of total rehabilitation facility charges rounded off to the nearest dollar Blank* - Not Documented It is acceptable to leave this field blank. Calculations that will be performed on this field (addition, averages, means, etc.) require either a whole dollar amount or a blank field. DO NOT use "ND" or "9999" in this field. If values1, 2, 3 or 14 are selected in field #27 - Adult Discharge Disposition, then values 01 through 05 are valid for this field, otherwise 06- NA must be selected. Select the value that most accurately describes the patients living arrangements prior to their hospitalization. Note that the value "04" is not used in this field. Select a value in this field ONLY if the value selected in field # 29 Pediatric Prehospital Setting is equal to "01-Home" More than one value may be selected. Enter the location of the patient disposition from the hospital. If the patient is transferred to another Ohio hospital, enter the ODH assigned Ohio hospital code. See Appendix 1-A for the list of ODH assigned Ohio hospital codes. If the patient is transferred to an out of state hospital, enter the ODPS assigned out of state hospital code. See Appendix 1-B for the list of ODPS assigned out of state hospital codes. If the patient is transferred to a rehabilitation facility, enter the ODPS assigned rehabilitation facility code. See Appendix 1-C for the list of ODPS assigned rehabilitation facilities codes. If the patient is transferred to a licensed nursing home, enter the ODH assigned nursing home facility code. See Appendix 1-D for the list of ODH assigned nursing home facilities codes. The final billed amount charged for this admission, excluding professional fees, at the rehabilitation facility, expressed in a whole dollar figure. Total amount charged to the patient for treatment received at the rehabilitation facility expressed in a whole dollar amount. *If the information is not documented leave this field blank. 86

87 34 Payment Source 4 N NO 1 - Primary Source 2 - Secondary Source 35 Adult Length of Stay in Rehabilitation Facility Version 1.0 Effective January 1, 2005 Code each source with one of the following values 01 - Blue Cross 02 - Medicare non-mco 03 - Medicaid non-mco 04 - Commercial Insurance 05 - MCO HMO 06 - Workers' Compensation 07 - Crippled Children's Services / Bureau of Children with Medical Handicaps 08 - Developmental Disabilities Services 09 - State Vocational Rehabilitation 10 - Private Pay 11 - Employee Courtesy 12 - Unreimbursed 13 - CHAMPUS 14 - Other 15 - None 16 - No-Fault Auto Insurance 51 - Medicare MCO 52 - Medicaid MCO 48 DATE YES mm/dd/yyyy Interruptions in care #1 1st Interruption date mm/dd/yyyy 1st Return date mm/dd/yyyy The entity that is expected to be responsible for the largest percentage of the patient's bill for the current encounter, both as a primary payor source as well as a secondary payor source. Values are not utilized. Select from the pulldown menu the appropriate final payment source responsible for the outstanding charges incurred. Enter the dates of up to three interruptions in care. The length of stay in the rehabilitation facility will be calculated by subtracting the total number of days of interrupted care from the total number of days from admission to discharge. Using this process will allow the LOS to be calculated 36 Pediatric Length of Stay in Rehabilitation Facility Interruptions in care #2 2nd Interruption date mm/dd/yyyy 2nd Return date mm/dd/yyyy Interruptions in care #3 3rd Interruption date mm/dd/yyyy 3rd Return date mm/dd/yyyy 48 DATE YES mm/dd/yyyy Interruptions in care #1 1st Interruption date mm/dd/yyyy 1st Return date mm/dd/yyyy Interruptions in care #2 2nd Interruption date mm/dd/yyyy 2nd Return date mm/dd/yyyy Interruptions in care #3 3rd Interruption date mm/dd/yyyy 3rd Return date mm/dd/yyyy An interruption in care is defined as a discharge from the rehabilitation center and returns to the same facility within three consecutive days. Enter the dates of up to three interruptions in care. The length of stay in the rehabilitation facility will be calculated by subtracting the total number of days of interrupted care from the total number of days from admission to discharge. Using this process will allow the LOS to be calculated. 87

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