This rule specifies Florida Medicaid’s process and forms required for Pre-Admission Screening and Resident Review (PASRR). The PASRR is a federally mandated process to help ensure individuals in need of long-term care services reside in the most ...

 

AGENCY FOR HEALTH CARE ADMINISTRATION
Medicaid

RULE NO.: RULE TITLE:
59G-1.040: Pre-Admission Screening and Resident Review
PURPOSE AND EFFECT: This rule specifies Florida Medicaid’s process and forms required for Pre-Admission Screening and Resident Review (PASRR). The PASRR is a federally mandated process to help ensure individuals in need of long-term care services reside in the most appropriate and least restrictive setting possible, are not inappropriately placed in nursing homes, and receive the services they need in that setting. The PASRR process is required for all applicants to Medicaid-certified nursing facilities, which include children under the age of 21 years, regardless of payor. The rule also ensures that every applicant receives a Level II evaluation and determination if indicated in the PASRR Level I. This rule supersedes the PASRR process and forms currently in the Florida Medicaid Nursing Facility Services Coverage and Limitations Handbook, incorporated by reference in Rule 59G-4.200, Florida Administrative Code.
SUBJECT AREA TO BE ADDRESSED: Pre-Admission Screening and Resident Review
An additional area to be addressed during the workshop will be the potential regulatory impact of Rule 59G-1.040 as provided for under sections 120.54 and 120.541, Florida Statutes.
RULEMAKING AUTHORITY: 409.919 FS.
LAW IMPLEMENTED: 409.902, 409.905(8), 409.912, 409.913 FS.
A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:
DATE AND TIME: Wednesday, February 27, 2013, 10:30 a.m. - 12:00 p.m.
PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room D, Tallahassee, Florida 32308-5407
Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 48 hours before the workshop/meeting by contacting: Susan Rinaldi at the Bureau of Medicaid Services, [phone]. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Susan Rinaldi, Medicaid Services, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail]

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

59G-1.040 Pre-Admission Screening and Resident Review

(1) Introduction.

(a) Pre-Admission Screening and Resident Review (PASRR) is a federal requirement mandated by the Nursing Home Reform Act, under the Omnibus Budget Reconciliation Act of 1987, amended in 1990 and 1996. The PASRR process is required for all applicants to Medicaid-certified nursing facilities, regardless of payor, and must be completed prior to admission. The program is intended to prevent the inappropriate placement and retention of individuals with serious mental illnesses or intellectual disabilities in need of long-term care services to allow them to reside in the most appropriate and “least restrictive setting” possible and receive the services they need to live in that setting.

(b) PASRR requires an individualized assessment and determination of the presence of serious mental illness (MI) or intellectual disabilities (ID) and related conditions, in accordance with Title 42, section 483.100, Code of Federal Regulations (CFR), through section 483.138, CFR. The purpose of PASRR is to ensure each person’s needs are met in a Medicaid certified nursing home, whether the person is seeking admission to a nursing facility or currently residing in a nursing facility.

(c) Florida’s PASRR process is designed to promote community-focused, patient centered care by assuring psychological, psychiatric, and functional needs are considered along with personal goals and preferences when planning long term care services. Multiple state agencies work together to ensure the individual’s long term care needs are met in the most appropriate and least restrictive setting possible.

(2) PASRR Evaluations.

(a) PASRR evaluations involve the following:

1. The individual being evaluated;

2. The individual's legal representative; and

3. The individual's family if available, in the event the individual or the legal representative agrees to family participation.

(3) Medicaid-certified nursing facilities must not admit applicants who have indications of serious mental illness or intellectual disability until the appropriate state agency or its designee has determined whether a) the individual needs the level of services that a nursing facility provides, and b) whether individuals who need nursing facility services also need “specialized services.” The intent of the PASRR process is to ensure that all nursing facility applicants are thoroughly screened, placed in nursing facilities only when appropriate, and receive all necessary services while there.

(4) PASRR Process. There are two parts to the PASRR process. They include Level I and Level II and are described as follows:

(a) Level I is a once in a lifetime screening performed prior to the first time an individual is admitted to the nursing facility setting. The purpose of PASRR is to “look behind” the diagnosis of record to identify any presenting evidence of MI or ID. If the finding of the Level I assessment indicates a serious MI or a ID, then a referral for a PASRR Level II Evaluation and Determination should be sent to the Comprehensive Assessment and Review for Long-Term Care Services (CARES) program, within the Department of Elder Affairs.

(b) Level II provides an in-depth evaluation of the individual which results in a determination of the need for continued long-term care services based on the need for specialized services to identify the most appropriate setting possible to meet their long term care needs; and to provide a set of recommendations for services if appropriate, to be incorporated in to the individual’s care plan. A Level II must be completed prior to admission to a Medicaid certified nursing facility when the Level I screening indicates a suspicion of serious MI or ID. A Level II must also be performed when there is a significant change in the nursing facility resident’s mental or physical condition.

(c) PASRR Level I and Level II forms are available on the Medicaid fiscal agent’s Web site at www.mymedicaid-florida.com. Select Public Information for Providers, then Provider Support, and then Forms.

(5) PASRR Level I Screenings.

(a) Appropriate hospital staff, nursing facility staff, or the Comprehensive Assessment and Review for Long-Term Care Services (CARES) program, within the Department of Elder Affairs (DOEA), shall perform Level I screenings on all applicants age 21 years or older, prior to admission to a Medicaid certified nursing facility, and if required, request and obtain the Level II Evaluation and Determination summary report. The CARES staff shall perform Level I screenings on all persons in community settings (other than hospitals) requesting admission under the Medicaid Institutional Care Program (ICP) in a Medicaid certified nursing facility.

(b) Individuals under the age of 21 years seeking admission to a Medicaid certified nursing facility must be referred to the Children’s Multidisciplinary Assessment Team (CMAT), within the Department of Health, prior to admission to a Medicaid certified nursing facility. CMAT shall perform PASRR Level I screenings and, if required, request and obtain the Level II Evaluation and Determination summary report.

(c) A PASRR Level I screening shall be used to determine whether the person seeking admission to a Medicaid certified nursing facility is suspected of having MI or ID, even if the individual has not been diagnosed with MI or ID.

(d) Prior to admission into a Medicaid certified nursing facility, both the PASRR Level I screening and, if required, the PASRR Level II Evaluation and Determination summary report, must be completed and maintained in the facility’s file for each resident.

(e) Provisional admission is allowed under the following circumstances:

1. Pending further assessment of delirium where an accurate diagnosis cannot be made until the delirium clears, not to exceed seven days.

2. Pending further assessment in emergency situations requiring protective services, with placement in a nursing facility, not to exceed seven days.

3. Brief respite care for in-home caregivers, with placement in a nursing facility twice a year not to exceed 14 days.

(f) A referral for a PASRR Level II is accomplished as follows:

1. The completed PASRR Level II form is sent to CARES, along with the following documentation. Contact information for the CARES program is available on the Department of Elder Affairs (DOEA) Web site at www.elderaffairs.state.fl.us. Select Programs & Services and then Comprehensive Assessment & Review for Long-Term Care Services (CARES).

a. When a PASRR Level II is requested as a result of a PASRR Level I screening, the Level II form must be sent to the CARES program along with following documentation:

i. PASRR Level I form (AHCA-MedServ Form 004, Part A);

ii. Informed Consent Form (AHCA-MedServ Form 2040, May 2008);

iii. Medical Certification for Nursing Facility/Home and Community Based Services Form (AHCA-MedServ 3008);

iv. Other medical documentation including relevant case notes or records of treatment/medication administration record (MAR);

v. Psychiatric Evaluation Forms (DOEA-MH Form 1911-A, Aug 01, and DOEA-MH Form 1911-B, Aug 01);

vi. DOEA Assessment Instrument (DOEA Form 701B, September 2008); and

vii. CMAT assessment, if the individual is under the age of 21 years.

b. When a PASRR Level II is requested as a result of a Resident Review (RR), when there is a significant change in the resident’s physical or medical condition, the Level II form must be sent to the CARES program along with the following documentation. Contact information for the CARES program is available on the Department of Elder Affairs (DOEA) Web site at www.elderaffairs.state.fl.us. Select Programs & Services and then Comprehensive Assessment & Review for Long-Term Care Services (CARES).

i. PASRR Level I form (AHCA-MedServ Form 004, Part A);

ii. Relevant Case Notes/Records of Treatment or Evaluations (including psychiatric)/Medication Administration Record (MAR); and Minimum Data Set (MDS).

(g) Within two days of completion of the PASRR Level I screening, if the individual is suspected of have MI or ID, written notice must be sent to the individual and their legal representative is suspected of an MI or ID diagnosis and is being referred for a more in-depth PASRR Level II evaluation shall be sent to the individual and his or her legal representative.

(h) A PASRR Level I must be performed when a person is considered for admission to a Medicaid certified nursing facility, unless otherwise exempted.

(6) PASRR Level II Evaluation and Determination.

(a) The Department of Children and Families (DCF), or state-designated contract provider, will perform the PASRR Level II evaluations for persons with a serious MI diagnosis or other indication of a serious MI; and

(b) The Agency for Persons with Disabilities (APD) will perform the PASRR Level II Evaluation and Determination for persons suspected of having an ID diagnosis or related conditions, through ID an diagnosis or other indications.

(c) Individuals who must be evaluated include:

1. Anyone determined to have an indication of a serious MI or ID diagnosis through a PASRR Level I screening;

2. A nursing facility resident that experiences a significant change in their mental or physical condition; or

3. An individual that entered a Medicaid certified nursing facility under the hospital discharge exemption, pursuant to 42 C.F.R. §483.106(b)(2), who is later found to require more than thirty (30) days of nursing facility care.

(d) The PASRR Level II evaluation shall be completed:

1. Within seven to ten working days of receipt of the Level II request with all of the appropriate paperwork;

2. Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purposes of the PASRR process, a “significant change” means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.);

3. Within 40 calendar days of admission, for an individual entering an nursing facility as an exempted hospital discharge pursuant to 42 C.F.R. §483.106(b)(2), who is later found to require more than 30 days of nursing facility care;

(e) PASRR Level II evaluations shall:

1. Confirm or rule out the presence of an MI or ID diagnosis;

2. Confirm the need for nursing facility services and the appropriate placement; and

3. Determine the need for specialized services; if specialized services can be provided in the nursing facility or the community; and whether or not nursing facility placement is appropriate if specialized services cannot be provided in the nursing facility.

(f) In determining appropriate placement, the PASRR Level II evaluation shall:

1. Prioritize the physical and mental needs of the individual being evaluated, taking into account the severity of each condition;

2. Assess whether:

a. The individual's total needs are such that their needs can be met in an appropriate community setting;

b. The individual's total needs are such that they can be met only on an inpatient basis, which may include the option of placement in a home and community-based services waiver program, but for which the inpatient care would be required;

c. If inpatient care is appropriate and desired, the nursing facility is an appropriate institutional setting for meeting those needs; or

d. If the inpatient care is appropriate and desired but the nursing facility is not the appropriate setting for meeting the individual's needs, another setting is an appropriate institutional setting for meeting those needs.

(g) At a minimum, the data relied on to make a nursing facility determination must include:

1. Evaluation of physical status (for example, diagnoses, date of onset, medical history, and prognosis);

2. Evaluation of mental status (for example, diagnoses, date of onset, medical history, likelihood that the individual may be a danger to themselves or others); and

3. Functional assessment (activities of daily living).

(h) All PASRR Level II evaluations must be individualized.

(i) Specialized services must be provided which are found to be necessary to improve the individual’s level of independence so that a reduction in intensity of services to below the level of specialized services can occur as soon as possible.

(j) The PASRR Level II evaluation shall be completed within seven to ten days of receipt of the PASRR Level II request and applicable paperwork.

(k) All PASRR Level II evaluation findings must be issued in the form of a written evaluative summary report which:

1. Identifies the name and professional title of person(s) who performed the evaluation(s) and the date on which each portion of the evaluation was administered;

2. Provides a summary of the medical and social history, including the positive traits or developmental strengths and weaknesses or developmental needs of the evaluated individual;

3. Identifies the specific services that are required to meet the evaluated individual's needs if nursing facility services are recommended;

4. Identifies any specific ID or MI services that are of a lesser intensity than specialized services that are required to meet the evaluated individual's needs if specialized services are not recommended;

5. Identifies the specific ID or MI services required to meet the evaluated individual's needs if specialized services are recommended; and

6. Includes the basis for the Level II Evaluation and Determination summary report's conclusions.

(l) DCF or state-designated contract provider, or APD, as appropriate, must send in writing the PASRR Level II Evaluation and Determination summary report to the following:

1. CMAT if the individual is under the age of 21 years or CARES if the individual is age 21 years or older;

2. The evaluated individual and their legal representative;

3. The admitting or retaining nursing facility;

4. The evaluated individual’s attending physician; and

5. The discharging hospital, if the individual is seeking admission to a Medicaid certified nursing facility from a hospital, and unless the individual is exempt from preadmission screening as provided for at 42 C.F.R. §483.106(b)(2).

(m) Each notice of a PASRR Level II determination made by DCF or a state-designated contract provider, or APD must include documentation that specifies:

1. Whether a nursing facility level of services is needed;

2. Whether specialized services are needed;

3. The placement options that are available to the individual consistent with these determinations; and

4. The rights of the individual to appeal the determination.

(n) The PASRR Level II findings must be interpreted and explained to the individual and, where applicable, to and their legal representative or the legal representative.

(7) MI PASRR Level II Evaluation and Determination.

(a) The PASRR Level II evaluation for MI will be performed by DCF, or a state-designated contract provider, and must be based on an independent physical and mental evaluation performed by a person or entity other than DCF. A qualified mental health professional outside of DCF must validate the diagnosis.

(b) The specialized services must be designed to result in the continuous and aggressive implementation of an individualized plan of care that:

1. Is developed and supervised by an interdisciplinary team including the attending physician, qualified mental health professionals and other professionals as appropriate;

2. Prescribes specific therapies and activities for the treatment of persons experiencing an acute episode of serious MI, which necessitates supervision by trained mental health personnel; and

3. Is directed toward diagnosing and reducing the individual’s behavioral symptoms that necessitated institutionalization, improving their level of independent functions, and achieving a functioning level that permits a reduction in the intensity of mental health services to below the level of specialized services at the earliest possible time.

(c) MI Diagnosis. A qualified mental health professional outside of DCF must validate the diagnosis of serious MI. A comprehensive history and physical examination of the person must be provided, including:

1. Complete medical history;

2. Review of all body systems;

3. Specific evaluation of the person's neurological system in the areas of motor functioning, sensory functioning, gait, deep tendon reflexes, cranial nerves, and abnormal reflexes; and

4. In case of abnormal findings which are the basis for a nursing facility placement, additional evaluations conducted by appropriate specialists;

a. A comprehensive drug history including current or immediate past use of medications that could mask symptoms or mimic MI;

b. A psychosocial evaluation of the person, including current living arrangements and medical and support systems;

c. A comprehensive psychiatric evaluation including a complete psychiatric history, evaluation of intellectual functioning, memory functioning, and orientation, description of current attitudes and overt behaviors, affect, suicidal or homicidal ideation, paranoia, and degree of reality testing (presence and content of delusions) and hallucinations; and

d. A functional assessment of the individual's ability to engage in activities of daily living and the level of support that would be needed to assist the individual to perform these activities while living in the community. The assessment must determine whether this level of support can be provided to the individual in an alternative community setting or whether the level of support needed is such that nursing facility placement is required. The functional assessment must address the following areas:

i. Self-monitoring of health status;

ii. Self-administering and scheduling of medical treatment, including medication compliance, or both; and

iii. Self-monitoring of nutritional status, handling money, dressing appropriately, and grooming.

(d) A qualified mental health professional must determine whether a program of psychiatric specialized services is needed.

(e) When the Level II indicates both MI and ID, DCF or state designated provider will coordinate with APD to complete the evaluation and determination.

(8) ID PASRR Level II Evaluation and Determination.

(a) The PASRR Level II Evaluation and Determination will be performed by APD.

(b) An ID diagnosis, confirmed by a licensed psychologist, must be utilized to identify the intellectual functioning measurement of individuals with ID or a related condition.

(c) Specialized services are to be directed toward the acquisition of the behaviors necessary for the individual to function with as much self-determination and independence as possible; and the prevention or deceleration of regression or loss of current optimal functional status.

(d) The data collected for an evaluation of the need for specialized services for an ID individual must include the individual's comprehensive history and physical examination results to identify the following information or, in the absence of data, must include information that permits a reviewer specifically to assess:

1. The individual's medical problems;

2. The level of impact these problems have on the individual's independent functioning;

3. All current medications used by the individual and the current response of the individual to any prescribed medications must be evaluated in the following drug groups:

a. Hypnotics;

b. Antipsychotics (neuroleptics);

c. Mood stabilizers and antidepressants;

d. Antianxiety-sedative agents; and

e. Anti-Parkinson agents.

4. Self-monitoring of health status;

5. Self-administering and scheduling of medical treatments;

6. Self-monitoring of nutritional status;

7. Self-help development such as toileting, dressing, grooming, and eating;

8. Sensorimotor development, such as ambulation, positioning, transfer skills, gross motor dexterity, visual motor perception, fine motor dexterity, eye-hand coordination, and extent to which prosthetic, orthotic, corrective or mechanical supportive devices can improve the individual's functional capacity;

9. Speech and language (communication) development, such as expressive language (verbal and nonverbal), receptive language (verbal and nonverbal), extent to which non-oral communication systems can improve the individual's function capacity, auditory functioning, and extent to which amplification devices (for example, hearing aid) or a program of amplification can improve the individual's functional capacity;

10. Social development, such as interpersonal skills, recreation-leisure skills, and relationships with others.

11. Academic/educational development, including functional learning skills;

12. Independent living development such as meal preparation, budgeting and personal finances, survival skills, mobility skills (orientation to the neighborhood, town, city), laundry, housekeeping, shopping, bed making, care of clothing, and orientation skills (for individuals with visual impairments);

13. Vocational development, including present vocational skills;

14. Affective development such as interests, and skills involved with expressing emotions, making judgments, and making independent decisions; and

15. The presence of identifiable maladaptive or inappropriate behaviors of the individual based on systematic observation (including, but not limited to, the frequency and intensity of identified maladaptive or inappropriate behaviors).

(e) In making the determination of special needs for an individual with ID, APD must also make a qualitative judgment on the extent to which the person's status reflects, singly and collectively, the characteristics commonly associated with the need for specialized services, including:

1. The inability to:

a. Take care of the most personal care needs;

b. Understand simple commands;

c. Communicate basic needs and wants;

d. Be employed at a productive wage level without systematic long term supervision or support;

e. Learn new skills without aggressive and consistent training;

f. Apply skills learned in a training situation to other environments or settings without aggressive and consistent training;

g. Demonstrate behavior appropriate to the time, situation or place without direct supervision; and

h. Make decisions requiring informed consent without extreme difficulty.

2. Demonstration of severe maladaptive behaviors that place the person or others in jeopardy to health and safety; and

3. Presence of other skill deficits or specialized training needs that necessitate the availability of personnel trained in ID, 24 hours per day, to teach the person functional skills.

(f) When the Level II indicates both MI and ID, APD shall coordinate with the DCF or state designated provider, to complete the evaluation and determination.

(9) Nursing facility Resident Review. A Resident Review is required when there is a significant change in the resident’s condition. The procedures for completing the Level II requests is the same for Resident Reviews (RR) and Level I screening, as specified in this rule.

(10) Records.

(a) Nursing facilities are required to maintain copies of all PASRR screenings, evaluations and re-evaluations in the resident’s file, even after the resident has been discharged or has been transferred from another facility.

(b) Original PASRR Level I screenings shall be retained by the entity completing the Level I screen and a copy submitted to CARES for repository. Level II Evaluations and Determinations shall be maintained with CARES. The original Level II Resident Review (RR) completed by nursing facilities through DCF or a state-designated contract provider, or APD shall be kept by the initiating facility and also a copy will be sent to CARES.

(11) Oversight of PASRR. Agency for Health Care Administration (AHCA), Agency for Persons with Disabilities (APD), Department of Children and Families (DCF), Department of Elder Affairs (DOEA), and Department of Health (DOH) shall enter into a memorandum of understanding outlining each respective agency’s role in the PASRR process. AHCA shall review a sample of PASRR Level I screenings and PASRR Level II evaluations and determinations on an annual basis, to determine compliance with the requirements outlined in this rule, federal regulations, state law, and the executed memorandum of understanding.

Rulemaking Authority 409.919 FS. Law Implemented: 409.902, 409.905(8), 409.912, 409.913 FS. History–New ______________.