Summer’s over, so the CMSCG Team is back at its “Ftag of the Week” Blog series. While many people joke that the nursing home industry is more regulated than nuclear power, proof that this industry is highly regulated is the fact that CMSCG has been publishing our Ftag of the Week since 2017 – and we still haven’t covered every regulatory requirement!
Before we start our review of one of the regulations in the Resident Assessments regulatory group, F644 Coordination of PASRR and Assessments, let’s look at some important definitions included in SOM Appendix PP for this tag.
Definitions
Preadmission Screening and Resident Review (PASARR/PASRR) – This is a federal requirement which was implemented to ensure that individuals with intellectual disabilities or a mental disorder (ID/MD) are not inappropriately placed in a nursing home for long-term care.
Anyone who applies to a Medicaid-certified facility must be screened for serious mental disorder or intellectual disability and offered the appropriate care setting to meet their needs. Care settings include residing in the community, a nursing facility or acute care facility, and the care setting must be able to provide services the individual has been determined to need. PASARR is a federal requirement, but each State is responsible for conducting screens, preparing the associated report, and arranging for specialized services that are required as a result of the screen.
Specialized Services – These services are specified by the State when an individual’s PASARR Level II identifies the need for specialized services required. Related to the nursing facility setting, these services exceed the services that would typically be provided under the NF per diem rate. The State must provide or arrange for these services.
Intellectual Disability (ID) – Individuals who have a mild, moderate, severe or profound level of retardation or related condition, as defined by the 1983 edition of the American Association on Intellectual Disability Manual on Classification in Intellectual Disability. Related Conditions, as it pertains to ID, includes conditions which result in severe, chronic disability. The disability must meet specific criteria, including that it is attributable to cerebral palsy, epilepsy or another other condition (other than MI) which has been found to be closely related to ID. The condition must have manifested before age 22, is likely to continue indefinitely and results in substantial functional limitations. To qualify, there must be limitations in 3+ of the following areas of major life activities, including self-care, understanding/ use of language, learning, mobility, self-direction and/or capacity for independent living.
Mental Disorder (MD) – Per SOM Appendix PP, an individual is considered to have a serious mental illness (SMI) when he/she meets specific requirements related to diagnosis, level of impairment and illness duration. Major mental disorders diagnosable under DSM-3 (revised in 1987) are referenced in this definition and include “schizophrenic, mood, paranoid, panic or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that mean lead to a chronic disability.” The SMI cannot be a primary diagnosis of dementia, including Alzheimer’s disease or a related disorder or a non-primary diagnosis of dementia unless the individual’s primary diagnosis is one of the SMIs noted prior. The individual’s mental disorder must have caused functional limitations (as appropriate to the person’s developmental stage) in major life activities within the past 3-6 months to meet the criteria. Individuals who meet the criteria for level of impairment typically exhibit issues with interpersonal functioning, concentration, persistence and/or pace or issues with adapting to change on either an on-going or intermittent basis. The final criteria includes specific treatment history for the MD. The individual must have, within the past two years, experienced psychiatric treatment that was more intensive than outpatient care or experienced an episode of significant disruption to his/her normal living situation which required supportive services to maintain functioning or involvement of law enforcement or housing officials.
F644 – Regulatory Requirements
As mentioned in the definitions, while PASARR is a federal requirement, each State is really responsible for the PASARR program. The purpose of this regulation is to ensure coordination between the State and the nursing facility to ensure that individuals with MD/ID or a related condition receive care and services in the setting that is most appropriate to their needs.
Coordination
The primary requirement for F644 relates to the coordination of pre-admission screening and facility assessments of an individual to avoid duplicative testing and effort. The requirement for PASARR screening, as the name indicates, occurs prior to admission to a nursing home. All prospective residents must have a Level I pre-screening which determines if there is a possible serious mental disorder, intellectual disability and/or related condition. If the screen is negative, then the admission can proceed as usual. If the Level I is positive, then the individual must have a Level II screen, which is a more in-depth evaluation to determine the appropriate setting for that person, as well as the need for any specialized services.
Level II Determinations
A subset of the coordination requirement is to ensure that any recommendations from the Level II determination and evaluation report are incorporated into the resident’s assessment and plan of care. The information would also be used during transitions of care. If specialized services are needed, they may be provided or arranged by the State to either occur in the nursing facility or in an off-site setting that is coordinated by the facility.
Referrals
Another component of this regulation is ensuring that all residents with a Level II and any resident with a newly evident or possible MD/ID or related condition is reviewed whenever there is a Significant Change in Status (SCSA) assessment. The facility is required to contact the appropriate State authority whenever a resident with MD/ID experiences a significant change in either mental or physical status. Any resident who is observed to have a newly evident or possible SMI must also be referred to the appropriate State agency for review.
Something to Consider
In recent years, we have seen an increasing number of individuals with a Level II be admitted to a nursing facility for a temporary need who ultimately remain in the facility for years while an alternate care setting is being determined. States have limited options for alternate placement for individuals with complex needs and limited functional abilities, which has resulted in many residing in nursing homes for the long term. It’s important to note that residents with a Level II determination and evaluation report with recommendations for care may have unique needs that do not align with your facility’s predominant population, and thus, likely require different attention and even specific staff training.
Residents with a Level II will be included in your recertification survey sample – what will a surveyor find when he looks at the resident’s CCP? When was the last time your IDT checked to ensure that everything recommended in the Level II is being provided for that resident? More importantly, when is the last time you checked to see if your residents’ initial care plans indicating they were there for the short term remain active, despite years having passed? There may be more to look at than you think.
CMS Compliance Group, Inc. is a regulatory compliance and quality improvement consulting firm. We work with post-acute and long-term care providers to help them achieve and maintain the highest quality of care and services for their residents. Learn more about our consulting services or contact us to discuss how we can work together.
