Current through September 21, 2024
(a) Purpose. The
Level I screening is performed by qualified staff of a nursing facility or
hospital to determine whether an individual seeking admission to or residing in
a facility needs further evaluation because of suspected mental illness, an
intellectual disability or a related condition.
(b) Applicability. All individuals,
regardless of payment source, who apply for admission to a facility on or after
January 1, 1989, or who were clients in a facility on January 1, 1989, are
subject to the requirements of this Section.
(c) Frequency of screening.
(i) Any individual who was a client in a
facility before January 1, 1989, must be screened on or before April 1,
1990.
(ii) Any individual seeking
admission to a facility as a new admission on or after January 1, 1989, must be
screened before admission.
(iii) If
the screening does not result in a referral to Level II, the individual need
not be screened again unless there is a significant change in the individual's
condition that indicates that a Level II screening is advisable.
(d) Screening. All screening shall
be performed by a qualified staff member of the facility. A qualified staff
member is a member of a nursing facility's or hospital's staff that is
qualified, by education, professional status or administrative authority, to
discern the possibility or probability of mental illness, intellectual
disability, or related condition by reviewing medical records, observation of
presenting evidence, or other sources. The screener uses the following
criteria:
(i) Mental illness. The screener
shall consider whether:
(A) The individual is
diagnosed with a serious mental illness, as defined by
42 C.F.R. §
483.102. This diagnosis shall not include
individuals experiencing temporary anxiety or depressive reactions to a
terminal or chronic debilitating condition for which specialized services would
not be appropriate, but for which mental health services of a lesser intensity
than specialized services may be required based on evaluation and
recommendation by a physician or a qualified mental health
professional;
(B) The individual
has a history of mental illness requiring treatment more intensive than out
treatment; or
(C) There is
presenting evidence of a serious mental illness, including possible
disturbances in orientation, affect or mood that is not attributable to
dementia or other medical diagnosis or treatment.
(ii) Intellectual Disability. The screener
shall consider whether:
(A) A physician or
qualified intellectual disability professional has given the individual a
primary or secondary diagnosis of mental retardation or related
condition;
(B) The individual has a
history of an intellectual disability or related condition;
(C) There are cognition or behavior deficits
indicating an intellectual disability or related condition; or
(D) The individual was referred by an agency
that serves persons with an intellectual disability or related condition, and
the individual was eligible for that agency's services.
(e) Recommendation. Upon
completion of the Level I screening, the screener shall make a recommendation
as to whether the individual should be referred for a Level II screening:
(i) If the recommendation is that a Level II
screening is not necessary, the individual may be admitted to the facility;
or
(ii) If the recommendation is
that a Level II screening is necessary, the provisions of Section 7 of this
Chapter apply.
(f)
Notice. The nursing facility must provide written notice to the individual or
client, or his or her legal representative, if the individual is suspected of
having mental illness, an intellectual disability or related condition, and is
being referred to the SMHA or SIDA for Level II screening. This notice is
required for first time Level II identifications only.
(g) Documentation requirements. The facility
shall complete documentation in the format specified by the
Department.
