In the first part of our “Ftag of the Week” for F646, we reviewed important definitions related to this regulation – PASARR and Significant Change. As discussed in the last post, nursing facilities are required to notify the appropriate state authority when a resident with MI/ID experiences a significant change in his/her physical or mental condition. This notification must be independent of the SCSA findings. Different states require different referrals to determine if a Level II evaluation is required.
View all State Contacts on the PTAC website (current as of December 2023).
There are two important sets of guidance to understand for the referral process – individuals who were previously identified by PASRR and individuals who were not identified as having a PASRR condition at the time of admission. Let’s look at the differences and review some actual survey citations to understand appropriate notification. Don’t forget – even if you choose to notify the appropriate authority, the authority exercises its judgement as to whether a Level II evaluation is needed, which may not always be the case.
Residents Previously Identified by PASARR
Nursing home residents who have previously been identified through the PASARR process as having a mental disorder, intellectual disability or related condition who experience a significant change may warrant a referral for a Level II resident review evaluation when they experience certain significant changes.
The list provided below is directly from Appendix PP, and CMS indicates that the guidance is not an exhaustive list of examples of changes. It does provide a pretty good idea of what should be referred, so pay attention to the following examples.
For residents previously identified as having MD/ID/related condition through PASARR, the following changes may be provided as the reason for a referral for a resident:
- Who demonstrates increased behavioral, psychiatric or mood-related symptoms
- Who has behavioral, psychiatric, or mood-related symptoms that have not responded to on-going treatment
- Who experiences an improvement in their medical condition, such that the resident’s plan of care or placement recommendations may require modification.
- Who experiences a significant change that is physical, but with behavioral, psychiatric or mood-related symptoms, or cognitive abilities that may influence adjust to an altered pattern of daily living
- Whose condition or treatment is/will be significantly different than described in the resident’s most recent PASARR Level II evaluation and determination.
The Interpretive Guidance (IG) also reminds providers that referral for a possible new Level II evaluation is required whenever this type of disparity is identified, regardless of whether the individual is having a SCSA or not.
Let’s look at how failure to notify the appropriate state authority for a resident with a Level II evaluation can be cited on survey.
Recertification Survey – F646 S/S: D
A facility was cited for failure to ensure that the state mental health authority was notified of a significant change in a resident’s mental health status. During survey, it was identified that a resident who had diagnoses including diabetes, chronic kidney disease, cognitive communication deficit, unspecified psychosis, depression and dementia was seen by psychiatry for mood, behavior and psychosocial well-being. The resident had been observed walking through the facility with feces on him and becoming physically and verbally aggressive with staff when they attempted to provide care. The resident was ultimately transferred to the hospital for assessment and admitted to the hospital behavioral health unit. After he was subsequently readmitted to the nursing home, the facility did not notify the state mental health authority of his change in condition to the authority could determine if an assessment needed to be conducted for the resident.
Residents Not Previously Identified by PASARR
Nursing home residents who were not previously identified through PASARR to have a mental illness, intellectual disability/developmental disability, or a related condition may experience changes which could be a reason for referral to the appropriate state authority. Like the prior set of examples, this is not the only set of changes that could warrant a referral but gives you a good idea of what should be considered. Notification should be made for a resident:
- Whose primary diagnosis is not dementia and exhibits behavioral, psychiatric or mood-related symptoms which suggest the presence of a diagnosis of a mental illness
- Who has an intellectual disability or related condition which not previously identified and evaluated
- Who was transferred, admitted or readmitted to a nursing home after an inpatient psychiatric stay (or equally intensive treatment)
Here’s how F646 has been cited on survey for a resident not previously identified by PASARR:
Recertification Survey Citation – F646 S/S: D
Facility staff failed to request a new Level II evaluation after a resident demonstrated an increase in behavioral, psychiatric and mood-related symptoms which resulted in a change to the resident’s plan of care. The resident was initially admitted with diagnoses which included Wernicke’s Encephalopathy. His Level I Screen indicated that the resident has a history of alcohol abuse and did not meet the criteria for Serious Mental Illness, so a Level II was not needed. During survey, the surveyor reviewed the resident’s mental record and found a behavioral health note which indicated that the resident was anxious with concerns for depression and agitation and had diagnoses of MDD and Adjustment Disorder with Anxiety. He often had trouble completing thoughts and had excessive and repetitive speech. The note indicated that the resident would likely benefit from an increase in his SSRI. Upon further review, it was identified that a PASRR Level II screen request had not been submitted as required after the resident was diagnosed with a mental illness and had limitations in major life activities related to interpersonal functioning.
While F646 is not widely cited on surveys, this may be in part due to surveyors not being as familiar with the requirements as they could be. Review of survey citations from the past few years found many inappropriately identified areas cited under F646, including physician notifications of significant changes. This makes it even more important for providers to understand the nuances and ensure appropriate notifications are made per their particular states’ expectations.
