Ftag of the Week – F645 PASARR Screening for Mental Disorder/ Intellectual Disability
This week’s “Ftag of the Week” is part of the Resident Assessments regulatory group, F645 PASARR Screening for Mental Disorder/Intellectual Disability. This Ftag outlines a nursing facility’s requirements for not admitting new residents with a mental disorder or intellectual disability except where certain criteria have been met.
What Conditions Meet the Criteria?
First, let’s look at some of the definitions:
- Mental Disorder (MD) – Per the ROPs, “An individual is considered to have a serious mental illness if the individual meets the following requirements on diagnosis, level of impairment and duration of illness.”
- The diagnosis must be a major mental disorder that is diagnosable under DSM-3. This includes: schizophrenic, mood, paranoid, panic/other severe anxiety disorder, somatoform disorder, personality disorder, or other psychotic disorder or another mental disorder that may lead to a chronic disability. This excludes a primary diagnosis of dementia or a non-primary diagnosis of dementia unless a major mental disorder is one of the primary mental disorders listed prior.
- The level of impairment requires that the mental disorder results in functional limitations in major life activities that are appropriate for the individual’s life stage for the past 3-6 months. This includes issues with interpersonal functioning, concentration/ persistence/ pace, and/or adaptation to change.
- The recent treatment requirement is based on a person’s treatment history that shows the person had at least one of the following occur: (a) psychiatric treatment more than once in the past 2 years that is more intensive than outpatient care, such as partial or inpatient hospitalization and/or (b) within the past 2 years, due to the mental disorder, the person has “experienced an episode of significant disruption to the normal living situation.” This disruption required support services to allow the individual to maintain functioning at home/residential treatment environment or resulted in “intervention by housing or law enforcement.”
- Intellectual Disability (ID) – Per the ROPs, “an individual is considered to have intellectual disability (ID) if he or she has (i) a level of retardation (mild, moderate, severe or profound) described in the American Association on Intellectual’s Disability Manual on Classification in Intellectual Disability (1983)” or a related condition.
- Persons with Related Conditions – Per the ROPs, persons with related conditions means individuals who have a severe, chronic disability that meets all of the following conditions: (a) is attributable to cerebral palsy, epilepsy or any other condition (other than mental illness) that is found to be closely related to ID, (b) manifested before the person reached age 22, (c) is likely to continue indefinitely, (d) results in substantial functional limitations in 3 or more areas of major life activity. These areas include self-care, understanding/use of language, learning, mobility, self-direction, and/or capacity for independent living.
All applicants for Medicaid-certified nursing facilities are required to be screened for possible serious mental disorders, intellectual disabilities and related conditions through the PASARR process. This is because the intent of F645 is to ensure that each resident in a nursing facility with one of these conditions is screened prior to admission and that those people who are identified to have MD/ID are evaluated and receive the care and services that they need in the most appropriate integrated setting. The initial screening is appropriately named “Level I Identification of individuals with MD or ID” and its purpose is to identify the individuals who would require a PASARR Level II evaluation and determination, which is an in-depth evaluation by a state-designated authority, which also occurs prior to admission.
The Level II assists with determining the appropriate setting for the person, as well as if any specialized services and/or rehabilitative services would be needed, so this cannot be conducted by the nursing facility. Each State Medicaid Agency has its own processes for Level I and Level 2 Screens, so it’s important to review your state-specific requirements if you have questions. The State is responsible for providing or arranging for specialized services for residents, and the facility is responsible for providing all the other care/services that are appropriate to the resident’s condition. Specialized services that the State could arrange for are those which would normally exceed the NF per diem rate, such as hiring additional staff that are qualified mental health/intellectual disability professionals. Rehabilitative services for MD/ID are those which nursing facility staff could provide and are considered necessary whether or not they are specified in the PASARR Level II or if the resident does or does not require additional services provided by the State. This means that your staff need to understand how to work with the residents that you admit to your building and have an understanding of their underlying conditions.
As with many cases, there are several exceptions to this requirement, including:
- Readmission to a nursing facility for a resident who was transferred to a hospital and then back to the nursing facility
- If a State chooses to not apply the preadmission screening process to an individual:
- Who is admitted to the facility directly from a hospital after receiving acute inpatient care there
- Who requires nursing facility services for the condition that the person was treated for in the hospital
- Whose attending physician has certified, before admission to the facility that the person is likely to require less than 30 days of nursing facility services. If this exception is permitted and the person remains in the facility longer than 30 days, the facility must screen the person using the State’s Level I screening process and refer the resident who may have MD/ID/related condition to the appropriate state-designated authority for a Level II screening.
PASAAR document review is an important part of a facility’s admission decision process and should not downplayed. If you choose to admit a person who required a Level II screen, remember you need to incorporate the evaluation letter’s recommendations into the plan of care.