Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-503

Preadmission Screening and Resident Review

Notice of Proposed Rule

(Repeal and Reenact)

DAR File No.: 36187
Filed: 05/14/2012 04:30:28 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to update and clarify Medicaid policy for health care professionals who perform preadmission evaluations and screenings for nursing facility admission.

Summary of the rule or change:

All requirements of the repealed rule are reenacted in the proposed rule. In contrast to the repealed rule, this new rule updates and clarifies preadmission and screening policies, removes the administrative requirement for nursing facilities to perform an annual resident review, updates terminology to the more appropriate term of "intellectual disability" instead of "mental retardation," and removes other ambiguous language throughout the text.

State statutory or constitutional authorization for this rule:

• Section 26-1-5
• 42 U.S.C. 1396r
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this change only clarifies and updates preadmission and screening policies for health care professionals who evaluate and screen residents for nursing facility admission.

local governments:

There is no impact to local governments because they neither evaluate residents for nursing facility admission nor provide nursing facility services to Medicaid recipients.

small businesses:

There is no impact to small businesses because this change only clarifies and updates preadmission and screening policies for health care professionals who evaluate and screen residents for nursing facility admission.

persons other than small businesses, businesses, or local governmental entities:

There is no impact to nursing facilities, providers and residents because this change only clarifies and updates preadmission and screening policies for health care professionals who evaluate and screen residents for nursing facility admission.

Compliance costs for affected persons:

There is no impact to a single nursing facility, provider or resident because this change only clarifies and updates preadmission and screening policies for health care professionals who evaluate and screen residents for nursing facility admission.

Comments by the department head on the fiscal impact the rule may have on businesses:

Streamlining policy may have a positive fiscal impact on providers as reporting is simplified. Public comment will be carefully evaluated.

David Patton, PhD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

07/02/2012

This rule may become effective on:

07/09/2012

Authorized by:

David Patton, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

[ R414-503. Preadmission Screening and Annual Resident Review.

R414-503-1. Introduction and Authority.

This rule implements 42 USC 1396r(b)(3) and (e)(7) that require preadmission screening and annual review of nursing facility residents with serious mental illness or mental retardation.

 

R414-503-2. Definitions.

The definitions in Sections R414-1-1 and R414-501-2 apply to this rule.

 

R414-503-3. Preadmission Level I Screening for All Persons.

The purpose of the preadmission Level I screening is to determine if a person seeking admission to a nursing facility has serious mental illness or mental retardation and is therefore subject to a Level II evaluation.

(1) A nursing facility may not admit a person unless a health care professional has completed a Level I screening. The department shall deny reimbursement for a resident if a nursing facility fails to assure that the resident's Level I screening is completed as required.

(2) A health care professional shall complete a Level I screening on a form supplied by the department and shall include the date of the screening and the signature of the health care professional completing the screening.

(3) If the Level I screening identifies a positive response to all of the following three criteria, then the screening shall conclude that the person may have a serious mental illness. The Level I screening criteria for serious mental illness are whether the person has:

(a) A diagnosis falling within the diagnostic groupings of serious mental illness, as described in the Diagnostic and Statistical Manual of Mental Disorders IV, Revised, 1994;

(b) Experienced a functional limitation in a major life activity within the last six months in that the person has serious difficulty on a continuing or intermittent basis in interpersonal functioning, concentration and persistence and pace, or adaptation to change, and which is due to the serious mental illness diagnosis;

(c) A treatment history indicating psychiatric treatment more intensive than outpatient care occurring more than once within the last two years; or experienced, within the last two years, significant disruption to his normal living situation to the degree that he required supportive services to maintain his current level of functioning at home or in a residential treatment environment; or required intervention by housing or law enforcement officials.

(4) If the Level I screening identifies at least one positive response to any of the following criteria then the screening shall conclude that the person may have mental retardation. The Level I screening criteria for mental retardation is whether the person has:

(a) A diagnosis of mental retardation;

(b) A current prescription for anti-convulsant medications for epilepsy with an onset prior to age 22;

(c) A history of mental retardation, or cognitive or behavioral indicators that the person has mental retardation; or

(d) Been referred by any agency specializing in the care of persons with mental retardation;

(5) If the screening does not indicate the person may have serious mental illness or mental retardation, or if the screening determines the person has a diagnosis of dementia (including Alzheimer's disease or an organic mental disorder) based on criteria in the Diagnostic and Statistical Manual of Mental Disorders IV, Revised, 1994, then no further evaluation is necessary.

(6) If the person is admitted to a nursing facility, the nursing facility shall submit a copy of the Level I screening to the department and shall retain a copy of the Level I screening in the resident's medical record.

(7) If the Level I screening indicates the person may have serious mental illness or mental retardation, then the Level I screener shall complete a notice of referral to the state authority that shall conduct the Level II evaluation. The notice shall be on a form provided by the department. The screener shall give the notice to the person, his legal representative, and the nursing facility.

 

R414-503-4. Preadmission Level II Evaluation.

(1) The purposes of the preadmission Level II evaluation are to determine whether a person with serious mental illness or mental retardation who seeks admission to a nursing facility requires the level of services provided by a nursing facility and whether the person requires specialized services.

(2) If a Level I screening indicates a Level II evaluation is required, then a nursing facility may not admit the person unless the Level II evaluation is completed and determines that it is appropriate to place the person in a nursing facility. The Level II evaluation is not required for a person who is any one of the following:

(a) A provisional admission in which the person has delirium where an accurate diagnosis cannot be made until the delirium clears, or in emergency situations where the nursing facility placement will not exceed seven days. However, if the placement exceeds seven days, the Level II evaluation shall be completed;

(b) Readmitted to a nursing facility after being transferred to a hospital, or for a person who is transferred from one nursing facility to another, with or without an intervening hospital stay; or

(c) Admitted to a nursing facility directly from a hospital where the person received acute inpatient care, and the person requires nursing facility services for the condition treated in the hospital, and the attending physician certifies before admission to the nursing facility that the person is likely to require a stay of less than 30 days. If a resident enters a nursing facility through such an exempted hospital discharge and then remains in the nursing facility for more than 30 days, then the resident shall be referred to the state mental health or mental retardation authority for an annual resident review within 40 calendar days of admission.

(3) The department shall deny reimbursement for a resident if the nursing facility fails to assure that the resident's Level II evaluation is completed as required.

(4) If the Level I screening indicates the person may have mental retardation, then the person shall be referred to the Department of Human Services Division of Services for People with Disabilities for the Level II determination. If the Level I screening indicates the person may have a serious mental illness, then the person shall be referred to the Department of Human Services Division of Mental Health for the Level II determination. If the Level I screening indicates the person may have both a serious mental illness and mental retardation, then the person shall be referred to both divisions.

(5) The Level II evaluation shall be based on the criteria established pursuant to 42 USC 1396r(f)(8), and addressing the level of nursing services, specialized services, and specialized rehabilitative services needed. Based on those criteria, the Level II evaluation shall make one of the following seven determinations:

(a) The person does not need nursing facility services. This determination disqualifies the person for placement in a nursing facility and Medicaid reimbursement;

(b) The person does not need nursing facility services but needs specialized services. This determination disqualifies the person for placement in a nursing facility and Medicaid reimbursement;

(c) The person needs nursing facility services but does not need specialized services. This determination qualifies the person for placement in a nursing facility and Medicaid reimbursement;

(d) The person is not a danger to himself or others and is being released from an acute care setting and requires a medically prescribed period of convalescent care in a nursing facility. This determination qualifies the person for placement in a nursing facility and Medicaid reimbursement for a period not to exceed 120 days with a categorical Level II evaluation. However, if the placement exceeds 120 days, the Level II evaluation shall be completed;

(e) The person is not a danger to himself or others and is certified by a physician to be terminally ill (a medical prognosis of a life expectancy of less than six months) and requires continuous nursing care or medical supervision or treatment due to a physical condition. The nature and extent of the person's need for nursing care, medical supervision, and medical treatment shall be the determining factors, and the existence of a chronic mental or physical disability shall be incidental considerations. This determination qualifies the person for placement in a nursing facility and Medicaid reimbursement with a categorical Level II evaluation; or

(f) The person has a severe physical illness that results in a level of impairment so severe that the recipient could not be expected to benefit from specialized services, like a categorical determination such as coma, ventilator dependence, or functioning at brain stem level, or a diagnosis such as chronic obstructive pulmonary disease, Parkinson's disease, Huntington's disease, amyotrophic lateral sclerosis, or congestive heart failure. This determination qualifies the person for placement in a nursing facility and Medicaid reimbursement with a categorical Level II evaluation.

(g) The person has a 14 day or less stay to provide respite to in-home care givers to whom the individual with MI or MR is expected to return following the brief Nursing Facility stay.

(6) If at any time during the Level II evaluation the evaluator determines that the person does not have serious mental illness or mental retardation, or has a primary diagnosis of dementia without mental retardation, then the Level II evaluation may be stopped.

(7) The person or agency doing the evaluation shall provide a copy of the Level II determination and findings to the person evaluated, his legal representative, his attending physician, the discharging hospital, the nursing facility for retention in the person's medical record, if admitted, and to the department prior to Medicaid reimbursement.

 

R414-503-5. Annual Resident Review.

(1) As long as a resident who requires a preadmission Level II evaluation continues to reside in a nursing facility, he shall have an annual resident review subject to the same requirements as the preadmission Level II evaluation. The Level II evaluator shall establish the annual review date at the time the preadmission Level II evaluation is completed. For administrative purposes, the annual review shall be defined as occurring within every fourth quarter after the previous preadmission screen or annual resident review. In order to avoid duplicative testing and effort, the annual resident review shall be coordinated with the routine resident assessments that are otherwise required.

(2) If a Level II evaluation determines a resident is no longer qualified for continued placement in a nursing facility, the nursing facility, in consultation with the resident and his legal representative, shall arrange for the safe and orderly discharge of the resident from the nursing facility, and prepare and orient the resident for the discharge.

 

R414-503-6. Significant Change of Condition.

(1) The Nursing Facility shall notify the State mental health authority or mental retardation/developmental disability authority, as applicable, after a significant change in the physical or mental condition of a resident who is mentally ill or mentally retarded when there is a significant change in a resident's health status which has a bearing on his or her active treatment needs.

(2) The State mental health or mental retardation authorities must complete a review and determination after the notification by the Nursing facility of a significant change in the resident's physical or mental condition which has a bearing on his or her active treatment needs.

 

R414-503-7. Out-of-State Arrangements.

The state in which the person is a resident (or would be a resident at the time he becomes eligible for Medicaid), as defined in 42 CFR 435.403, shall pay for the Level II evaluation in accordance with 42 CFR 431.52(b).]

R414-503. Preadmission Screening and Resident Review.

R414-503-1. Introduction and Authority.

This rule implements 42 U.S.C. 1396r(b)(3) and (e)(7) and Pub. L. No. 104 315, which require preadmission screening and resident review (PASRR) of nursing facility residents with serious mental illness or intellectual disability. This rule applies to all Medicare and Medicaid-certified nursing facility admissions irrespective of the payment source of an individual's nursing facility services.

 

R414-503-2. Definitions.

In addition to the definitions in Sections R414-1-2 and R414-501-2, the following definitions apply:

(1) "Break in Stay" means an individual voluntarily leaves a Medicare and Medicaid-certified nursing facility or discharges from a hospital into a community placement.

(2) "Intellectual Disability" is the equivalent term for "Mental Retardation" in federal law.

 

R414-503-3. Preadmission Level I Screening for All Persons.

The purpose of a Preadmission Level I Screening is for a health care professional to identify any person with a serious mental illness, intellectual disability or other related condition so the professional may consider that person for admission to a Medicare and Medicaid-certified nursing facility. The health care professional who conducts the Level I Screening shall refer the person for a Level II Evaluation if the professional determines that the person has a serious mental illness, intellectual disability or other related condition.

(1) The health care professional shall complete a Level I Screening before any Medicare and Medicaid-certified nursing facility admission.

(2) The health care professional shall complete the Level I Screening on a form supplied by the Department.

(3) The health care professional shall sign and date the Level I Screening.

 

R414-503-4. Level II Evaluation Criteria.

(1) The Department requires a Level II Evaluation for serious mental illness if the person meets all of the following criteria:

(a) The person has a serious mental illness as defined by the State Mental Health Authority and identified by the Level I Screening;

(b) The diagnosis of mental illness falls within the diagnostic groupings as described in the current version of the Diagnostic and Statistical Manual;

(c) The person has experienced a functional limitation in a major life activity within the last six months that results in serious difficulty in interpersonal functioning, concentration or persistence, adaptation to change, and the serious mental illness is the cause of the limitation; and

(d) In addition to the criteria listed in Subsection R414-503-4(1)(a)(b)(c), the person meets any one of the following criteria:

(i) The person has undergone psychiatric treatment at least twice in the last two years that is more intensive than outpatient care;

(ii) Due to a significant disruption in the person's normal living situation, the person has required supportive services to maintain the current level of functioning at home or in a residential treatment center; or

(iii) The person has required intervention by housing or law enforcement officials.

(2) The Department requires a Level II Evaluation for a person who meets at least one of the following criteria:

(a) The person has received a diagnosis of an intellectual disability or related condition;

(b) The person has received a diagnosis of epilepsy or seizure disorder with onset before 22 years of age, and has a current prescription for anti-seizure medication for epilepsy;

(c) The person has a history of intellectual disability or related condition, or an indication of cognitive or behavioral patterns that indicate the person has an intellectual disability or related condition; or

(d) The person is referred by any agency that specializes in the care of persons with intellectual disabilities or related conditions.

(3) The nursing facility shall refer the person to a local mental health PASRR Evaluator for the Level II Evaluation if the Level I Screening indicates the person meets any of the criteria listed in Subsection R414-503-4(1). The nursing facility shall also provide the notice of referral to the person, his legal representative, and the prospective nursing facility.

(4) The nursing facility shall refer the person to the Intellectual Disability or Related Condition Authority for the Level II Evaluation if the Level I Screening indicates the person meets any of the criteria listed in Subsection R414-503-4(2). The nursing facility shall also provide the notice of referral to the person, his legal representative, and the prospective nursing facility.

(5) The nursing facility shall refer the person to both the local mental health PASRR Evaluator and the Intellectual Disability or Related Condition Authority if the person meets the criteria for Subsection R414-503-4(1) and (2).

(6) If the person does not meet the criteria in Subsection 414-503-4(1) or (2), the Department may not require a further PASRR Evaluation unless there is a significant change in condition.

(a) The nursing facility shall submit a copy of the Level I Screening to the Department upon the person's admission. The nursing facility shall also retain a copy of the Level I Screening in the person's medical record.

(b) The nursing facility shall initiate a new or revised Level I Screening if there is a significant change in the person's condition.

(7) The Department may not require further PASRR Screening if the health care professional who conducts the Level I Screening determines that the person has a primary diagnosis of dementia that includes Alzheimer's disease.

(a) The nursing facility shall submit a copy of the Level I Screening to the Department upon the person's admission. The nursing facility shall also retain a copy of the Level I Screening in the person's medical record.

(8) The Department shall require Level I Screening for all persons even if a person cannot cooperate or participate in Level I Screening due to delirium or other emergency circumstances. The health care professional shall complete the Level I Screening by using available medical information or other outside information.

 

R414-503-5. Preadmission Level II Evaluation.

The Department shall base Level II Evaluations on the criteria set forth in 42 CFR 483.130 and shall address the level of nursing services, specialized services, and specialized rehabilitative services needed.

(1) The purpose of a Level II Evaluation is:

(a) to avoid unnecessary or inappropriate institutionalization of persons with serious mental illness or intellectual disabilities or related conditions; and

(2) to ensure that persons with serious mental illness or intellectual disabilities or related conditions receive mental health treatment or are referred for specialized services.

(a) Specialized services shall include:

(i) acute inpatient psychiatric care for persons with mental illness; and

(ii) the provision of additional services to persons with intellectual disabilities or related conditions who are admitted to nursing facilities.

(3) The Department shall require a referral for a Level II Evaluation if a Level I Screening indicates the person may have a serious mental illness or an intellectual disability or related condition.

(4) The Department may not require a Level II Evaluation if:

(a) the person does not meet the criteria listed in Subsection R414-503-4 (1) or (2);

(b) the nursing facility admits the person due to delirium or an emergency situation and an accurate diagnosis cannot be made until the delirium clears; and

(c) the nursing facility placement does not exceed seven days.

(i) The nursing facility shall refer the person for a Level II Evaluation before midnight on the seventh day if the placement exceeds seven days.

(d) The Department may not require a Level II Evaluation if the person has a previous Level II Evaluation and the nursing facility readmits the person to the same or a different nursing facility following hospitalization for medical care without a break in stay. This provision, however, does not apply if the person is hospitalized for psychiatric care.

(i) Following readmission, the nursing facility shall review and update the PASRR Level I Screening to determine whether there is a significant change in condition that requires a Level II Evaluation.

(e) The Department may not require a Level II Evaluation if the person has a previous Level II Evaluation and the nursing facility transfers the person to another nursing facility with or without intervening hospitalization and without a break in stay. This provision, however, does not apply if the person is hospitalized for psychiatric care.

(i) Following transfer, the nursing facility shall review and update the Level I Screening to determine whether there is a significant change in condition that requires a Level II Re-Evaluation.

(f) The Department may not require a Level II Evaluation if the person is admitted to a nursing facility directly from a hospital and requires nursing facility services for the condition treated in the hospital (not psychiatric treatment), and the attending physician certifies in writing before the admission that the person is likely to be discharged in less than 30 days.

(i) The nursing facility shall refer the person for a Level II Evaluation before midnight on the 30th day.

(g) The Department may not require a Level II Evaluation if the person is admitted to a nursing facility for no more than 14 days to provide respite to in-home care givers and the person is expected to return to the in-home care givers after the respite period.

(i) The nursing facility shall refer the person for a Level II Evaluation before midnight on the fourteenth day if the placement exceeds 14 days.

(5) The Level II Evaluator shall evaluate the person and make one of the following determinations:

(a) The Level II Evaluator shall determine whether the person does not need nursing facility services. This determination disqualifies the person from nursing facility placement and the Department shall deny reimbursement from the date of the evaluator's finding.

(b) The Level II Evaluator shall determine whether the person does not need nursing facility services but does need specialized services as defined by the State Mental Health or Intellectual Disability or Related Condition Authority. This determination disqualifies the person from nursing facility placement, and the Department shall deny reimbursement from the date of the evaluator's finding.

(c) The Level II Evaluator shall determine whether the person needs nursing facility services but not specialized services. This determination qualifies the person nursing facility placement.

(d) The Level II Evaluator shall determine whether the person should be released from a hospital setting for a medically prescribed period of convalescent care in a nursing facility. This determination qualifies the person for nursing facility placement for a maximum period of 120 days.

(i) If the person is expected to remain in a nursing facility for more than 120 days, the nursing facility shall refer the person for another Level II Evaluation before midnight on the 120 ^th day.

(e) The Level II Evaluator shall determine whether the person requires short-term, medically prescribed care in a nursing facility. This determination qualifies the person for nursing facility placement for the number of days specified by the State Mental Health Authority and cannot exceed 120 days.

(i) The nursing facility shall refer the person for another Level II Evaluation before the end of the number of days specified if the person is expected to remain in a nursing facility for more than the number of days specified by the State Mental Health Authority.

(f) The Level II Evaluator shall determine whether the person is certified by a physician to be terminally ill with a medical prognosis of less than six months to live, and shall also determine whether the person requires continuous nursing care or medical supervision or treatment due to a physical condition. The nature and extent of the person's need for nursing care, medical supervision, or treatment shall be the primary consideration. This determination qualifies the person for nursing facility placement and no further Level II Evaluation is needed unless there is a significant change of condition.

(g) The Level II Evaluator shall determine whether the person has a severe physical illness and as a result of the severe physical illness is not expected to benefit from mental health or intellectual disability or related condition services. This determination qualifies the person for nursing facility placement and no further Level II Evaluation is needed unless there is a significant change of condition.

(6) If at any time during the Level II Evaluation, the local PASRR Evaluator or the Intellectual Disability of Related Condition Authority determines that the person does not have a serious mental illness, an intellectual disability or related condition, or dementia the evaluator may terminate the evaluation. The evaluator shall document that the person does not have a serious mental illness, an intellectual disability or related condition, or dementia in accordance with State Mental Health and Intellectual Disabilities or Related Conditions Authority.

(7) The State Mental Health Authority or the Intellectual Disabilities or Related Conditions Authority shall provide a copy of the Level II Evaluation and findings to the following:

(a) The person evaluated;

(b) The person's legal representative, if any; and

(c) The nursing facility for retention in the person's medical record, if the person is admitted.

(8) Out-of-State Arrangement for Payment: The state in which the person is a resident (or would be a resident at the time he becomes eligible for Medicaid) as defined in 42 CFR 435.403 shall pay for the Level II Evaluation in accordance with 42 CFR 431.52(b).

(9) The nursing facility, in consultation with the person and his legal representative, shall arrange for a safe and orderly discharge from the nursing facility, and shall assist with linking the person to supportive services and preparing the person for discharge when a Level II Evaluation disqualifies a person or concludes that a person is no longer eligible for nursing facility placement.

 

R414-503-6. Penalties.

The Department shall deny reimbursement for each day that a person remains admitted in a nursing facility past the specified dates and times i f the nursing facility fails to comply with the procedures and timelines set forth in Sections R414-503-3 through R414-503-5.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [July 18, 2001]2012

Notice of Continuation: August 20, 2009

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3; 63G-3-304