DAR File No. 38141
This rule was published in the December 1, 2013, issue (Vol. 2013, No. 23) of the Utah State Bulletin.
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.: 38141
Filed: 11/15/2013 08:41:33 AM
RULE ANALYSIS
Purpose of the rule or reason for the change:
The purpose of this change is to update and clarify preadmission screening and resident review (PASRR) policy, and to implement the current policy by rule.
Summary of the rule or change:
All requirements of the repealed rule are reenacted in the proposed rule. The new rule also includes more detail on the eligibility requirements for "short-term stay" in a Medicare and Medicaid-certified nursing facility.
State statutory or constitutional authorization for this rule:
- Pub. L. No. 104-315
- Section 26-1-5
- Section 26-18-3
Anticipated cost or savings to:
the state budget:
There is no impact to the state budget because this change only updates ongoing PASRR policy for Medicaid recipients.
local governments:
There is no impact to local governments because they do not fund or provide Medicaid services to Medicaid recipients.
small businesses:
There is no impact to small businesses because this change only updates ongoing PASRR policy for Medicaid recipients.
persons other than small businesses, businesses, or local governmental entities:
There is no impact to Medicaid providers and to Medicaid recipients because this change only updates ongoing PASRR policy for Medicaid recipients.
Compliance costs for affected persons:
There is no impact to a single Medicaid provider or to a Medicaid recipient because this change only updates ongoing PASRR policy for Medicaid recipients.
Comments by the department head on the fiscal impact the rule may have on businesses:
This change simply codifies current practice so there will be no impact on business.
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:
HealthHealth 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 [email protected]
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:
12/31/2013
This rule may become effective on:
01/07/2014
Authorized by:
David Patton, Executive Director
RULE TEXT
R414. Health, Health Care Financing, Coverage and Reimbursement Policy.
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 if the nursing facility fails to comply with the
procedures and timelines set forth in Sections R414-503-3 through
R414-503-5.]
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/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 Section R414-1-2 and Section R414-501-2, the following definitions apply:
(1) "Break in Stay" occurs when a resident of a Medicare/Medicaid-certified nursing facility:
(a) voluntarily leaves against medical advice for more than two consecutive days;
(b) fails to return within two consecutive days after an authorized leave of absence;
(c) discharges into a community setting; or251658240
(d) is admitted to the Utah State Hospital, to a civil or forensic bed (not the Adult Recovery Treatment Center).
(2) "Intellectual Disability" is the equivalent term for "Mental Retardation" in federal law.
R414-503-3. PASRR Level I Screening for All Persons.
The purpose of a PASRR 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/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/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.
(4) The nursing facility shall revise the Level I Screening if there is a significant change in the person's condition.
(5) 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.
R414-503-4. PASRR Level II Evaluation Criteria.
The purpose of a Level II Evaluation is to avoid unnecessary or inappropriate nursing facility admission of persons with serious mental illness or intellectual disabilities or related conditions. The Level II evaluation ensures that persons with serious mental illness or intellectual disabilities or related conditions are recommended for specialized services when a health care professional determines there is a need for specialized services during the evaluation process. The Department bases Level II Evaluations on the criteria set forth in 42 CFR 483.130. Level II Evaluations must address the level of nursing services, specialized services, and specialized rehabilitative services needed for the patient.
(1) The health care professional who completes the Level I screening shall refer the person to a contracted mental health PASRR Evaluator for the Level II Evaluation if the Level I Screening indicates 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 Diagnostic and Statistical Manual; and
(c) In addition to the criteria listed in Subsection R414-503-4(1)(a)(b), 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 requires supportive services to maintain the current level of functioning at home or in a residential treatment center; or
(iii) The person requires intervention by housing or law enforcement officials.
(2) The health care professional who completes the Level I screening 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 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;
(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 health care professional who completes the Level I screening shall refer the person to both the contracted 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).
(4) The health care professional who completes the Level I screening shall provide written notice of a Level II Evaluation referral to the person, the person's legal representative, and the prospective nursing facility.
(5) If the person does not meet the criteria in Subsection R414-503-4(1) or (2), the Department may not require a further PASRR Evaluation unless there is a significant change in condition.
R414-503-5. PASRR Level II Exemptions.
The Department may not require a Level II Evaluation for any of the following reasons:
(1) The person does not meet the criteria listed in Subsection R414-503-4 (1) or (2);
(2) The nursing facility admits the person as a provisional admission due to delirium, an accurate diagnosis cannot be made until the delirium clears, and the nursing facility placement does not exceed seven days. The nursing facility shall refer the person for a Level II Evaluation before midnight on the seventh day if the placement will extend beyond the seventh day.
(3) The nursing facility admits the person as a provisional admission due to an emergency situation requiring protective services, and the nursing facility placement does not exceed seven days. The nursing facility shall refer the person for a Level II Evaluation before midnight on the seventh day if the placement will extend beyond the seventh day.
(4) 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. The nursing facility shall refer the person for a Level II Evaluation before midnight on the 30th day if the placement will extend beyond the 30th day.
(5) The contracted mental health PASRR evaluator may terminate the Level II Evaluation at any time if the evaluator determines that the person does not have a serious mental illness. The Level II Evaluator shall document that the person does not have a serious mental illness.
(6) 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 does not apply if the person is hospitalized for acute psychiatric treatment. 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 Re-evaluation.
(7) 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 does not apply if the person is hospitalized for psychiatric treatment. 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.
R414-503-6. PASRR Level II Categorical Determinations.
The Level II Evaluator may make one of the following categorical determinations:
(1) Convalescent Care - The person is eligible for convalescent care for an acute physical illness that requires hospitalization and does not meet the criteria for an exempt hospital discharge, (which, as specified in 42 CFR 483.106(b)(2) is not subject to preadmission screening). The convalescent care determination only applies if the person is at a hospital for a medical condition and is going to the Medicare/Medicaid-certified nursing facility for the same medical condition. The Convalescent Care Categorical Determination is valid for up to 120 days. The nursing facility shall refer the person for a Level II Evaluation before midnight on the 120th day if the placement will extend beyond the 120th day.
(2) Short-term Stay - The person is eligible for a short-term stay for an acute physical illness in which the person is seeking admission to the nursing facility directly from a community setting. The Short-term Stay Categorical Determination is valid for a maximum of 120 days. The nursing facility shall refer the person for a Level II Evaluation before the end of the number of days specified if the placement will extend beyond the number of days specified by the State Mental Health Authority or Intellectual Disabilities Authority.
(3) Terminal Illness - The person is eligible for a stay related to a terminal illness when a physician provides a written statement that the person has a terminal illness. If the individual is not receiving hospice services at the time of the Level II Evaluation, an individualized Level II Evaluation is required.
(4) Severe Physical Illness - The person is eligible for a Severe Physical Illness Categorical Determination when the person has a level of impairment so severe that the individual cannot be expected to benefit from specialized services. This level of impairment includes conditions such as: (a) being in a coma;
(b) being ventilator dependent; or
(c) functioning at a brain stem level.
(5) Dementia and Intellectual Disability - The State Intellectual Disability Authority or delegated agency (not Level I screeners) may make categorical determinations that individuals with dementia, which exists in combination with intellectual disability or a related condition, do not need specialized services.
(6) Dementia and Mental Illness -The health care professional may terminate the PASRR Level II Evaluation if the health care professional discovers that the person has dementia and a serious mental illness during the evaluation process, and there is evidence that dementia is the primary condition. For example, the dementia has resulted in increased functional deficits and is the primary reason for requiring nursing facility services.
R414-503-7. Individualized Level II Determinations.
The Level II Evaluator may make one of the following individualized determinations:
(1) The person does not need nursing facility services. This determination disqualifies the person from admission to a Medicare/Medicaid-certified nursing facility.
(2) The person does not need nursing facility services but does need specialized services as defined by the State Mental Health Authority or Intellectual Disability or Related Condition Authority. This determination disqualifies the person from admission to a Medicare/Medicaid- certified nursing facility.
(3) The person needs nursing facility services but not specialized services. This determination qualifies the person for admission to a Medicare/Medicaid-certified nursing facility.
(4) The person needs nursing facility services and requires specialized services. The Level II Evaluation will specify the specialized services that are needed. This determination qualifies the person for admission to a Medicare/Medicaid-certified nursing facility. 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 person, the person's legal representative, the nursing facility, and the attending physician.
(5) Out-of-State Arrangement for Payment: The state in which the person is a resident (or would be a resident at the time the person 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).
(6) 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 if the person no longer meets the medical criteria for nursing facility services, or a Level II Evaluation disqualifies the person as no longer eligible for nursing facility placement.
R414-503-8. Penalties.
A nursing facility may not admit a patient until the health care professional completes the PASRR Level I Screening, and if necessary, the PASRR Level II Evaluation and Determination, finding that the patient is eligible for nursing facility services. The Department may not reimburse a nursing facility for any days in which the facility admits a patient before completion of the PASRR process.
KEY: Medicaid
Date of Enactment or Last Substantive Amendment: [July 18, 2012]2014
Notice of Continuation: August 20, 2009
Authorizing, and Implemented or Interpreted Law: 26-1-5;
26-18-3[; 63G-3-304
]
Additional Information
More information about a Notice of Proposed Rule is available online.
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For questions regarding the content or application of this rule, please contact Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [email protected].