Current through March 20, 2024
When an individual requests admission to or continuous
residence in a Medicaid-certified nursing facility (NF), the facility must
implement the preadmission screening and resident review (PASRR) as defined in
this chapter. An individual who has an indication or diagnosis of serious
mental illness, intellectual disability or a related condition, or a dual
diagnosis may be admitted to a nursing facility (NF) or continue to reside in a
nursing facility (NF) only when the individual is determined to be appropriate
for nursing facility (NF) services through the preadmission screening and
resident review (PASRR). The preadmission screening and resident review (PASRR)
provides the following to an individual with a diagnosis or indication of
serious mental illness, intellectual disability or a related condition, or a
dual diagnosis:
(A) A determination
whether the individual has serious mental illness, intellectual disability or a
related condition, or a dual diagnosis;
(B) A determination whether the level of
services provided by a nursing facility (NF) is appropriate to meet the
individual's needs; and
(C) A
recommendation for services that addresses the individual's needs in a nursing
facility (NF) or in an alternative placement.
006.01
PURPOSE OF THE
PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR). The purpose of
the preadmission screening and resident review (PASRR) is to:
(A) Determine the appropriateness of nursing
facility (NF) care for persons with serious mental illness, intellectual
disability or a related condition, or a dual diagnosis;
(B) Prevent the placement of individuals with
serious mental illness, intellectual disability or a related condition, or a
dual diagnosis in nursing facilities unless their medical needs clearly
indicate that they require the level of care (LOC) provided by a nursing
facility (NF);
(C) Coordinate
services needs among the health care industry and the mental health and
developmental disability systems;
(D) Comply with state and federal
requirements mandating an evaluation process that facilitates the nursing
facility's (NF) responsibility to provide services and activities to attain and
maintain the highest practical physical, mental, and psychosocial wellbeing of
each resident; and
(E) Assist with
the placement of persons found inappropriate for nursing facility (NF) care
into more appropriate, least restrictive services.
006.02
LEVEL I
SCREEN. A preadmission screening and resident review (PASRR) is
required to be submitted to the Department for:
(1) All persons who have requested admission
to a Medicaid certified nursing facility (NF);
(2) Any request for a first time admission or
readmission to a Medicaid certified nursing facility (NF) for a resident who
has been treated in an inpatient psychiatric setting or equally intensive
service, including the crisis unit, and when the Department contractor has
determined that the individual qualifies for such preadmission review per
criteria provided in this chapter;
(3) Was previously formally discharged from a
nursing facility (NF) and is applying for admission to the same or another
Medicaid certified nursing facility (NF);
(4) Was evaluated through the preadmission
screening and resident review (PASRR) Level II process more than 90 days before
admission to a Medicaid certified nursing facility (NF);
(5) Was screened as a negative Level I but
whose placement was delayed longer than 60 days from the previous Level I
screen; and
(6) When a status
change event occurs as specified below.
006.02(A)
STATUS
CHANGE. For the purpose of this chapter, the term "status change"
references the obligation to complete a new Level I preadmission screening and
resident review (PASRR) evaluation. The status change process is required for
all nursing facility (NF) residents who:
(i)
Have previously been screened with a negative outcome through the preadmission
screening and resident review (PASRR) process but have been determined to
exhibit signs, symptoms, or behaviors suggesting the presence of a diagnosis of
serious mental illness or intellectual disability or related
conditions;
(ii) Have demonstrated
an increase in symptoms or behaviors to the extent that there is a change in
mental health or intellectual disability treatment needs;
(iii) Have demonstrated a significant
physical status improvement such that they are more likely to respond to
special treatment for that condition or may be considered appropriate for a
less restrictive placement alternative;
(iv) Have required inpatient psychiatric
treatment. A Level II status change is required prior to the individual's
readmission to the facility;
(v)
Have been approved for nursing facility (NF) stay for a short term period and
the individual's stay is expected to exceed the approved time frame;
or
(vi) Current condition or
treatment is significantly different than described in the resident's current
Level I or Level II determination.
006.03
LEVEL I IDENTIFICATION
SCREEN OUTCOMES. The Nebraska Level I Preadmission Screening and
Resident Review (PASRR) form must be submitted to the Department prior to an
individual's admission to a Medicaid certified nursing facility (NF) and under
those circumstances specified above. Outcomes are as follows:
(A) Negative screens - Negative Level I
screen means the results of a Level I screen that indicate the individual does
not require a Level II evaluation;
(B) Positive Level I screen means results of
a Level I screen which indicate that an individual falls within federal
requirements for a mandatory Level II evaluation;
(C) Questionable screens - In cases where
information suggests the possibility of a serious mental illness or
intellectual disability or related condition, the referral source must submit
medical records information with the Nebraska Level I Preadmission Screening
and Resident Review (PASRR) form, as applicable, to clarify the presence or
absence of the suspected disorder. When an individual's condition suggests that
some but not all criteria are met to qualify as mental illness or intellectual
disability or related condition under the criteria provided in this chapter,
the Department will exclude the individual from the preadmission screening and
resident review (PASRR) Level II process and will forward notification to the
referral source indicating that any later status change suggesting full
qualification for such a condition should be forwarded to the Department for
consideration of Level II need;
(D)
Exempted hospital discharges and categorical determination - Requests for
exemptions or categorical decisions must include supportive documentation. Both
the exempted hospital discharge provision and the categorical determination
options allow the individual to be admitted to a nursing facility (NF) without
requiring performance of an on-site Level II evaluation. The options are
indicated on the Nebraska Categorical Determinations and Exemptions form which
offer either short term or categorical approvals, based upon certain presenting
circumstances. Short term options allow for only brief admission, whereby
further contact must be made with the Department to initiate re-screening
through the Level I and arrangements for the Level II if the individual's stay
is expected to exceed the approved time frame; and
(E) Positive Level I Screen - The reviewing
agent will request medical records information which sufficiently supports that
the individual meets criteria for a preadmission screening and resident review
(PASRR) evaluation as indicated in this chapter. If the individual is
identified as potentially having an intellectual disability or related
condition, the Level I review agency will additionally request information
regarding whether the presence of intellectual disability has been clinically
diagnosed through psychological testing.
006.04
TRANSFERS. A
nursing facility (NF) to nursing facility (NF) transfer does not require the
completion of a new Nebraska Level I Preadmission Screening and Resident Review
(PASRR) form or the completion of a new Level II preadmission screening and
resident review (PASRR) evaluation if the transferring facility has completed
the appropriate preadmission screening and resident review (PASRR) screening.
The discharging facility must send a copy of the most recent Level I or II, as
applicable, screening information to the admitting facility at the time of
transfer. The Level II determination applies to nursing facility (NF) services
and is not facility-specific. The only exception is for a nursing facility (NF)
that is providing specialized services approved through a current Level II
determination. If the client transfers to another nursing facility (NF) and the
same specialized service cannot be provided, these determinations may not be
transferred from one facility to another.
006.05
IDENTIFICATION
CRITERIA.
006.05(A)
IDENTIFICATION CRITERIA FOR INDIVIDUALS WITH SERIOUS MENTAL
ILLNESS. An individual is considered to have a serious mental
illness (SMI) and requires a Level II preadmission screening and resident
review (PASRR) evaluation if the individual meets all three of the following
three indicators:
(1)
Diagnosis
indicator: The individual has a psychiatric diagnosis which, by
accepted clinical standards, is determined to be a serious and persistent
psychiatric condition, diagnosable under the current edition of the Diagnostic
and Statistical Manual of Mental Disorders. The mental disorder must be
characterized as likely to lead to a chronic disability but cannot be a primary
psychiatric diagnosis of dementia or a related disorder. For the purpose of
this definition, Alzheimer's and organic disorders are considered related
disorders to dementia. If dementia or a related disorder co-exists with a
serious and persistent serious mental illness which is not a dementia, the
dementia or related disorder must be predominant and progressive to exempt the
co-occurring psychiatric condition from this indicator;
(2)
Impairment and behavior
indicators: Within the past six months, the psychiatric disorder
has resulted in functional limitations in one or more of the following major
life activities on a continuing or intermittent basis:
(a) Serious difficulty interacting
appropriately and communicating effectively with other persons. Examples of
such difficulty may include but are not limited to, possible history of
altercations, evictions, firing, fear of strangers, avoidance of interpersonal
relationships, and social isolation;
(b) Serious difficulty in sustaining focused
attention for a sufficient period to complete tasks for which they should be
medically capable. Examples of such difficulty may include but are not limited
to concentration difficulties, inability to complete simple tasks within an
established time period, frequent errors related to task completion, or need
for assistance in completion of tasks; or
(c) Serious difficulty adapting to typical
changes in circumstances. Examples of such difficulty may include but are not
limited to agitation, exacerbated signs and symptoms of the psychiatric
condition, withdrawal from the situation, or need for intervention by the
mental health or judicial system.
(3)
Duration of recent
treatment: The treatment history indicates that the individual has
experienced at least one of the following:
(a)
Psychiatric treatment more intensive than outpatient care once within the past
two years for a nursing facility (NF) resident or more than once in the past
two years for a nursing facility (NF) applicant;
(b) Within the last two years, due to the
mental disorder, experienced a major episode of significant disruption to the
normal living situation, for which supportive services were required to
maintain functioning at home or in a residential treatment environment, or
which resulted in intervention by housing or law enforcement officials. For the
purpose of this definition, major episodes of significant disruption may
include an involuntary psychiatric hospitalization, suicidal attempts or
gestures, 1:1 monitoring, or other issues which are safety-related or involved;
or
(c) Within the past two years,
residence in a psychiatric hospital which required a period of hospitalization
greater than that which is typically required for acute stabilization.
006.05(A)(i)
INDICATORS. In addition to the criteria listed in
above, the following indicators may be considered evidence of a serious mental
illness:
(1) The individual has a history of
a serious mental illness;
(2) There
is presenting evidence of a serious mental illness which includes possible
disturbances in orientation, affect, or mood, and the primary psychiatric
condition is not dementia, Alzheimer's disease or a related disorder. "Primary"
means that the symptoms of the dementia supersede symptoms of any co-occurring
psychiatric condition; and
(3) The
individual has been prescribed a psychoactive medication on a regular basis,
expressly for the indicators identified above.
006.05(A)(ii)
DEMENTIA,
ALZHEIMER'S DISEASE, OR RELATED DISORDER. An individual is
considered not to require a preadmission screening and resident review (PASRR)
Level II psychiatric evaluation if dementia or a related disorder can be ranked
as primary over any additional co-occurring psychiatric disorders, where
present, and the dementing condition meets established clinical standards
specified in the current edition of the Diagnostic and Statistical Manual. In
circumstances of dementia which co-occurs with other physical conditions but is
said to be the primary psychiatric disorder, the facility must make a
reasonable effort to provide documentation to the Department that the dementing
condition is primary. If one of two psychiatric disorders is dementia,
Alzheimer's disease, or a related disorder and the other psychiatric disorder
is a serious mental illness, the Level II evaluation will be required if the
facility cannot provide sufficient data to support a clear clinical ranking of
primary dementia. For purposes of preadmission screening and resident review
(PASRR), the neurological examination may be completed by a medical doctor. The
physician's findings must be clearly substantiated and must focus on a physical
examination and a psychological examination including mental status and
cognitive functioning. Although a neurological examination on its own may
corroborate a diagnosis of dementia, these examinations are not determinative
alone. Other factors may be considered.
006.05(B)
IDENTIFICATION CRITERIA
FOR INDIVIDUALS WITH INTELLECTUAL DISABILITY OR A RELATED
CONDITION. An individual is considered to have an intellectual
Disability or a related condition and requires a Level II evaluation if the
individual meets any of the following criteria:
(1)
Suspicion or diagnosis of
intellectual disability (ID): An individual is considered to have
intellectual disability if he or she has a level of intellectual disability as
described in the American Association on Mental Deficiency's Manual or
Classification in Mental Deficiency (1983). Intellectual Disability refers to
significantly sub-average general intellectual functioning existing
concurrently with deficits in adaptive behavior and manifested during the
developmental period; or
(2)
Suspicion or presence of a Related Condition or Developmental
Disability: Related condition is defined as a severe, chronic
disability whose condition is:
(a)
Attributable to cerebral palsy or epilepsy; or any other condition, other than
mental illness (MI), found to be closely related to intellectual disability
(ID) because the condition results in impairment of general intellectual
functioning or adaptive behavior similar to that of a person with intellectual
disability (ID) and requires treatment or services similar to those required
for such persons;
(b) Manifested
before the person reached age 22;
(c) Likely to continue
indefinitely;
(d) Results in
substantial functional limitations in three or more of the following areas of
major life activity:
(i) Self-care;
(ii) Understanding and use of
language;
(iii) Learning;
(iv) Mobility;
(v) Self-direction; or
(vi) Capacity for independent
living.
006.05(B)(i)
NO KNOWN
DIAGNOSIS. In the absence of a known diagnosis of intellectual
disability or a related condition, a suspicion or history of treatment by an
agency serving individuals with such conditions should trigger the housing or
receiving facility to contact the Department for a determination of need for
Level II evaluation under the preadmission screening and resident review
(PASRR) program.
006.06
NEGATIVE
SCREENS. If a client does not require a Level II evaluation and is
admitted to the nursing facility (NF), the facility must retain a copy of the
Nebraska Level I Preadmission Screening and Resident Review (PASRR) form in the
resident's permanent nursing facility (NF) record.
006.06(A)
MEDICAID
PAYMENT. If a Medicaid-eligible client does not require a Level II
evaluation and is admitted to the nursing facility (NF), Medicaid payment for
nursing facility (NF) services can begin no earlier than the date of the Level
I preadmission screening and resident review (PASRR) screen is
completed.
006.07
CATEGORICAL DETERMINATIONS AND EXEMPTIONS. If the
results of a Level I screen, based on current medical documentation, indicate
that an individual has a diagnosis or an indication of serious mental illness,
intellectual disability or a related condition, and meets one of the following
conditions, the individual qualifies for a categorical determination, or an
exempted hospital stay and does not require an on-site Level II evaluation
prior to nursing facility (NF) admission. Admission to the nursing facility
(NF) for an individual qualifying under a categorical determination or extended
hospital stay may proceed only after approval is provided by Department.
Options include:
(1) Categorical emergency
seven day - The individual is being admitted pending further assessment in an
emergency situation requiring protective services for a period not to exceed
seven calendar days. Before admission can occur, documentation or verbal
description of emergency need must be provided to, and approval must be secured
by the Department. The Nebraska Level I Preadmission Screening and Resident
Review (PASRR) form and Categorical Determination and Exemptions form must be
submitted along with the above. If it is determined that the individual's stay
in the nursing facility (NF) will continue beyond the approved seven-day time
frame, the receiving facility must contact the Department as soon as the
determination is made that continued stay will be required and no later than
the seventh calendar day following admission, in order to arrange an on-site
Level II evaluation;
(2)
Categorical respite 30 day - The individual is being admitted to provide
respite care for a period not to exceed 30 calendar days for in-home caregivers
to whom the individual is expected to return. Before admission can occur,
documentation supporting the need for respite services placement must be
provided along with the Nebraska Level I Preadmission Screening and Resident
Review (PASRR) form and Categorical Determination and Exemptions form to the
Department. If it is determined that the individual's stay in the nursing
facility (NF) will continue beyond the approved 30-day time frame, the
receiving facility must contact the Department as soon as the determination is
made that continued stay will be required and no later than the 30th calendar
day following admission, in order to arrange an on-site Level II
evaluation;
(3) Categorical
progressed dementia with intellectual disability or related condition: The
individual has intellectual disability or a related condition along with a
co-occurring diagnosis of progressed dementia, Alzheimer's disease or related
disorder. Both of the following must also be present: The diagnosis of
dementia, Alzheimer's disease or related disorder must be considered the
primary diagnosis and the individual must be considered to be in the advanced
stages of this condition and no longer able to meaningfully participate in or
benefit from a program of specialized services. Before admission can occur,
medical records information which supports that the individual qualifies under
this criterion must be provided to the Department or contractor along with
Nebraska Level I Preadmission Screening and Resident Review (PASRR) form and
Categorical Determination and Exemptions form;
(4) Categorical serious medical - The
individual's medical condition renders him or her unable to benefit from a plan
of specialized services and clearly meets criteria for nursing facility (NF)
care. Applicable conditions include: coma, ventilator dependence, brain stem
injury, or end-stage medical condition. In order to qualify, medical records
information which support that the individual qualifies under this criterion
must be provided along with Nebraska Level I Preadmission Screening and
Resident Review (PASRR) form and the Categorical Determination and Exemptions
form to the Department before the individual's admission can occur;
or
(5) Exempted hospital discharge
- Federal regulations also offer an exemption from the Level II preadmission
screening and resident review (PASRR) process for individuals with serious
mental illness or intellectual disability or related conditions who are being
discharged from the hospital to the nursing facility (NF) for a nursing
facility (NF) stay which is expected to not exceed 30 calendar days. The
hospital must complete the Categorical Determinations and Exemptions form with
a physician's certification to indicate necessity. Qualifying criteria for the
exempted hospital discharge exemption are as follows:
(a) The individual meets criteria for serious
mental illness or intellectual disability or a related condition as described
in this chapter;
(b) The individual
is being admitted to a nursing facility (NF) directly from a hospital after
receiving acute inpatient medical care at the hospital, excluding inpatient
psychiatric care;
(c) The
individual requires nursing facility (NF) services for the condition for which
they received care; and
(d) The
individual's attending physician has certified on the hospital discharge orders
or the nursing facility (NF) admission orders that admission to the nursing
facility (NF) is likely to require less than 30 days of nursing facility (NF)
services.
(6) 60 day
convalescent option: The 60 day convalescent option is an allowable categorical
exemption for an individual with a serious mental illness or intellectual
disability or related condition. To qualify, the individual must require
nursing facility level of care (NF LOC) following hospitalization from an acute
physical illness and does not meet all of the criteria for an exempted hospital
discharge exemption as defined above.
006.07(A)
DOCUMENTATION OF
CATEGORICAL DETERMINATIONS AND EXEMPTED HOSPITAL DISCHARGE. The
facility must submit the Nebraska Level I Preadmission Screening and Resident
Review (PASRR) form and Categorical Determination and Exemptions form with
documentation supporting the request to the Department before admission for an
individual with serious mental illness, intellectual disability, or a related
condition may occur.
006.07(B)
STAY BEYOND SPECIFIED LIMITS. If the individual with
serious mental illness, intellectual disability, or a related condition
qualified for a categorical determination or an exempted hospital discharge
which involved a time limited admission, the Department must be contacted if
the stay is expected to exceed the approved time frame and no later than the
conclusion of the approved time frame in order to arrange an on-site subsequent
Level II evaluation. The facility must coordinate such a contact through
submission of an updated Level I preadmission screening and resident review
(PASRR) to the Department. The on-site Level II evaluation will be completed by
the fifth business day from the Level II referral date. Medicaid payment is not
allowed beyond the specified time limits if a Level I status change is not
completed and sent to the Department prior to the conclusion of the time
frame.
006.07(C)
MEDICAID PAYMENT. If the documentation supports the
categorical determination or exemption, Medicaid payment can begin no earlier
than the date the Nebraska Level I Preadmission Screening and Resident Review
(PASRR) is completed. If the documentation does not support the categorical
determination, a Level II evaluation must be initiated immediately. Medicaid
payment can begin no earlier than the date of the Level II
determination.
006.08
INDIVIDUALS WHO REQUIRE A
LEVEL II EVALUATION. Following the first time identification when
an individual requires a Level II evaluation, the Department will notify the
individual or their legal representative that they have an indication or
diagnosis of serious mental illness or intellectual disability or related
condition and are being referred for a Level II evaluation. The nursing
facility (NF), hospital, or other party must submit the signed release of
information to the Department prior to conducting the Level II evaluation. If
the Department determines that additional information is required to determine
whether the individual has a condition warranting a Level II preadmission
screening and resident review (PASRR) evaluation, the referring source must
submit requested information to the Department by the request deadline. Failure
to provide requested information by the request deadline may result in a
cancelled preadmission screening and resident review (PASRR) determination
review. Subsequently, a new Level I preadmission screening and resident review
will be required to be submitted for review. The nursing facility (NF) retains
a copy of the Preadmission Screening and Resident Review (PASRR) Level I form
and the Release of Information form in the resident's permanent file.
006.08(A)
MEDICAID
PAYMENT. If a Medicaid-eligible client requires a Level II
evaluation and is admitted to the nursing facility (NF), Medicaid payment for
nursing facility (NF) services can begin no earlier than the date of the
preadmission screening and resident review (PASRR) final determination. If the
initial Level II determination approval was time limited, continued payment
will be allowed provided that a status change preadmission screening and
resident review (PASRR) is submitted to the Department or its agent and the
individual is determined to meet nursing facility (NF) preadmission screening
and resident review (PASRR) placement criteria no later than the expiration
date of the initial Level II evaluation.
006.08(B)
ADMISSION TO A NEBRASKA
FACILITY FROM ANOTHER STATE. The nursing facility (NF) must notify
the Department of potential admissions and must complete the Nebraska Level I
Preadmission Screening and Resident Review (PASRR) form and, as applicable, the
Categorical Determinations and Exemptions form prior to the individual's
admission to a Nebraska Medicaid-certified nursing facility (NF). If the
individual is determined by the Department to require a Level II evaluation,
the Level II determination must be completed before the applicant may be
transferred to the Nebraska facility. In circumstances where the Department is
unable to arrange an on-site evaluation in the transferring individual's home
state, the Department must request medical records information to make
document-based determination of need for nursing facility (NF) and need for
specialized services, if indicated. If unable to make a determination of
nursing facility (NF) need based upon Medicaid nursing facility level of care
(NF LOC) criteria, Medicaid coverage for nursing facility (NF) services for the
individual will be denied.
006.08(C)
ADMISSION OF NEBRASKA
RESIDENTS TO OUT-OF-STATE FACILITIES. If an individual is
transferring from the State of Nebraska to an out-of-state Medicaid-certified
nursing facility (NF), the preadmission process including the Level II
evaluation, if required, must be completed before the individual leaves the
state.
006.09
LEVEL II EVALUATION. The Level II evaluation process
determines:
(1) Whether the individual has
serious mental illness or intellectual disability or related condition as
defined by federal regulations and as defined within this chapter;
(2) Whether the level of services provided by
a nursing facility (NF) or another institutional placement is appropriate to
meet the individual's needs; and
(3) For applicants determined to require
nursing facility (NF) placement and for all evaluated nursing facility (NF)
residents services which are required to meet the evaluated individual's needs
are the responsibility of the receiving or retaining facility, except for
specialized services, which are the responsibility of the State.
006.09(A)
RETURNING FROM
RECEIVING INTENSIVE TREATMENT SERVICES FOR SERIOUS MENTAL ILLNESS.
If an individual is returning to a nursing facility (NF) from receiving
intensive treatment services for serious mental illness, a new Level I screen
is required to determine further screening requirements. If the Level I screen
indicates that the individual meets serious mental illness criteria as
indicated in this chapter, a Level II summary of findings report must be
issued. The summary may be based upon a document-based review of the
psychiatric facility's medical records, if an on-site Level II assessment was
performed within the 90-day period and current documentation supports that the
individual is sufficiently stable. An on-site evaluation is required if an
on-site Level II has not been performed within the prior 90-day period or if
the documentation does not sufficiently indicate adequate psychiatric
stabilization.
006.09(B)
FACILITY ACTION. For each individual who requires a
Level II evaluation, the nursing facility (NF), hospital, or other party must
obtain medical records information. The referring source must submit the
information to the Department so that a determination of Level II need can be
made.
006.09(C)
MENTAL
HEALTH EVALUATOR ACTION. For each individual with an indication or
diagnosis of serious mental illness, the evaluator must complete a
comprehensive review, which contains medical, functional, and psychosocial
information. The on-site evaluation and the final validation and Summary of
Findings Report must be completed by the third business day of the referral for
an evaluation by the Level I screening agency to the on-site evaluator.
Following completion of the on-site evaluation, evaluative data will be
reviewed and countersigned by a board-eligible or board-certified psychiatrist
who will validate whether the individual has a serious mental illness,
summarize the medical and social history, provide recommendations to meet the
service needs, and provide recommendations regarding placement needs. The final
Level II determination must be completed by the fifth business day from the
date of the Level II referral.
006.09(D)
INTELLECTUAL DISABILITY
OR RELATED CONDITION EVALUATOR ACTION. For each individual with an
indication of intellectual disability or a related condition, the evaluator
will complete the on-site evaluation. The on-site evaluation and the final
determination and Summary of Findings Report will be completed by the fifth
business day of the referral. Intellectual testing will be administered to
establish a diagnosis if:
(1) Lack of
social-historical information from a third party knowledgeable of the
individual;
(2) The individual is
not currently or has not received services from a community-based developmental
disability (DD) provider;
(3) The
individual is not currently or was not placed in an intermediate care facility
for individuals with developmental disabilities (ICF/DD); or
(4) No indication of previous intelligence
quotient (IQ) testing is available.
006.09(D)(i)
INTELLIGENCE
QUOTIENT (IQ) TESTING. Intelligence quotient (IQ) testing will
only be performed as a last resort to substantiate an intellectual disability
or related condition diagnosis.
006.09(D)(ii)
ADAPTIVE
BEHAVIOR. Adaptive behavior will always be assessed.
006.09(D)(iii)
PSYCHOLOGICAL
EVALUATION REPORT. The psychological evaluation report must
include the following information:
(1) Type
of tests administered to determine intelligence quotient (IQ) score and
adaptive behavior functioning;
(2)
Test scores;
(3) Interpretation of
the findings;
(4)
Recommendation;
(5)
Diagnosis;
(6) Discussion of any
other diagnosis and tests used to substantiate these findings; and
(7) Summary of adaptive and functional
levels.
006.09(D)(iv)
PSYCHOLOGICAL EVALUATION PROFESSIONALS. The
psychological evaluation must be completed by licensed or certified
professionals who meet one of the following criteria:
(a) A licensed psychologist;
(b) A licensed and certified clinical
psychologist;
(c) A certified
psychologist (Master of Science) in a clinical setting - a psychological
evaluation completed by certified psychologist must be countersigned by a
licensed and certified clinical psychologist;
(d) A certified counselor (Master of Arts) -
a certified counselor can only complete psychological evaluations as specified
by the Department of Health and Human Services Division of Public Health's
Bureau of Examining Board.
006.09(D)(iv)(1)
LICENSE AND
CERTIFICATION. All licensure and certifications must be current
and approved according to the Department of Health and Human Services Division
of Public Health requirements.
006.09(D)(iv)(2)
QUALIFIED
INTELLECTUAL DISABILITY PROFESSIONAL. Medical, functionality and
psychosocial information will be obtained by a qualified intellectual
disability professional (QIDP). This protocol identifies the extent to which
the individual's status compares with each of the following skill deficits
typically associated with individuals with intellectual disability or related
conditions:
(a) Ability to accomplish most
self-care needs;
(b) Ability to
comprehend simple commands;
(c)
Ability to communicate most needs and wants;
(d) Ability to perform a task without
systematic long term supervision or support;
(e) Ability to learn new skills without
intensive, consistent training;
(f)
Ability to apply skills learned in a training situation to other settings
without intensive, consistent training;
(g) Ability to demonstrate behavior
appropriate to the time, situation, or place without direct
supervision;
(h) Demonstration of
severe maladaptive behaviors which place the individual or others in jeopardy
to health and safety;
(i) Ability
or extreme difficulty in making decisions requiring informed consent;
(j) Other skill deficits or specialized
training needs which necessitate the availability of trained intellectual
disability (ID) personnel, 24 hours per day, to teach the individual functional
skills; and
(k) Ability to commute
independently.
006.09(E)
PARTICIPATION IN THE
LEVEL II EVALUATION. The mental health or qualified intellectual
disability professional (QIDP) evaluator must contact the retaining facility to
coordinate the time and date of the on-site evaluation and to assure that the
release of information form has been completed and signed as required. If the
individual has a legal representative, the facility must notify the legal
representative of the scheduled assessment time and date and invite him or her
to participate. The family also must receive notification from the facility of
the pending evaluation and be allowed to participate, if available, with
consent from the individual or their legal representative.
006.09(F)
PRE-EXISTING
DATA. Relevant evaluative data collected prior to the Level II
evaluation may be used if the data is considered accurate and reflects the
current functional status of the individual. To supplement existing data, the
mental health reviewer or qualified intellectual disability professional (QIDP)
must gather additional information necessary to assess proper placement and
treatment.
006.10
HALTING THE LEVEL II EVALUATION. If, at any time
during the Level II evaluation, it is found that the individual does not meet
criteria for serious mental illness or intellectual disability or a related
condition, the Level II evaluation must be halted and admission to the nursing
facility (NF) can proceed according to standard procedures for admission. A
halted Level II preadmission screening and resident review (PASRR) evaluation
means that a nursing facility level of care (NF LOC) was not determined. If the
individual's status changes, later suggesting the presence of serious mental
illness or intellectual disability or a related condition, the Level I must be
resubmitted to the Department as a status change.
006.11
FINAL DETERMINATION
CRITERIA. The Department or contractor must use the following
criteria to make the final determination for each individual who requires a
Level II evaluation.
006.11(A)
APPROPRIATE FOR NURSING FACILITY (NF) SERVICES. An
individual with serious mental illness, intellectual disability or a related
condition, is considered appropriate for Nursing Facility services if it is
determined through a Level II evaluation that:
(i) Nursing needs are primary and may include
treatment and monitoring of the individual's medical needs, a protective
structured environment, assistance with activities of daily living (ADL),
nursing supervision, and monitoring to avoid further deterioration or
complications;
(ii) Nursing needs
outweigh the individual's capacity for living in a less restrictive setting and
require technical or professional nursing supervision on a 24-hour
basis;
(iii) Mental health needs do
not require specialized services but may require mental health services as part
of the overall plan of care, to include but not limited to services such as
medication monitoring, counseling and therapy, consultations with a
psychiatrist; or
(iv) Intellectual
disability or related condition needs do not require intensive treatment
services but may require intellectual disability or related condition services
as part of the overall plan of care, to include but not limited to services
such as physical therapy, occupational therapy, speech, and social or
recreational activities.
006.11(B)
INAPPROPRIATE FOR
NURSING FACILITY (NF) SERVICES. An individual with serious mental
illness, intellectual disability or a related condition, is considered
inappropriate for nursing facility (NF) services if it is determined through a
Level II evaluation that they do not require nursing facility (NF) services but
do require:
(i) Inpatient psychiatric
treatment or equally intensive services;
(ii) Mental health, intellectual disability
or developmentally disabled services at a level which is defined in this
chapter as intensive treatment services; or
(iii) Alternative services.
006.12
NOTIFICATION OF FINAL DETERMINATION. The Department or
its agent must make a final determination after reviewing the information
obtained from the Level II evaluation and provide a Summary of Findings report
indicating the results of the Level II evaluation. The nursing facility (NF)
must incorporate all recommendations included in the Summary of Findings into
the resident's plan of care and update facility records with current diagnosis
and other information resulting from the evaluation.
006.13
CHOICE.
Individuals who have resided in a nursing facility (NF) for 30 continuous
months may elect continued nursing facility (NF) residence if the preadmission
screening and resident review (PASRR) evaluation determines that nursing
facility (NF) care is inappropriate but specialized services, which can be
provided by the State in the nursing facility (NF), as needed. The 30 months of
continuous residence is calculated back from the first preadmission screening
and resident review (PASRR) determination which found that the individual was
not in need of nursing facility (NF) care. The initial choice provision and
alternative placement options must be explained as appropriate. If the
individual chooses to remain in the nursing facility (NF) under the choice
provision, the nursing facility (NF) is required to incorporate the care
recommendations into the overall plan of care as with any other individual who
requires the Level II evaluation. Subsequent decisions of the choice option
will be explained in written form to the individual or legal representative and
will include a toll-free number if further explanation is needed or if the
individual or legal representative chooses to reevaluate that option. Inquiries
for further placement option discussion will be referred to the community-based
developmental disability service provider (CBDDSP) or the behavioral health
regions (BHR) by the Department or its agent for an on-site discussion. The
choice stays with the individual until their status changes, including a change
in determination from inappropriate for nursing facility (NF) care to
appropriate for nursing facility (NF) care, a denial of specialized services,
or if the individual leaves the nursing facility (NF). When a new admission
occurs, a new Level II determination will be made.
