42 CFR 483.102(b)(1)--"An individual is considered to have a serious mental illness (MI) if the individual meets the following requirements on diagnosis, level of impairment and duration of illness:"

Diagnosis: 42 CFR 483.102(b)(1)(i)--"A schizophrenic, mood, paranoid, panic or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or any other mental disorder that may lead to a chronic disability diagnosable under the DSM-III-R other than dementia unless the primary diagnosis is a major mental disorder."

Level of impairment: 42 CFR 483.102(b)(1)(ii)--"The disorder results in functional limitations in major life activities within the past 3 to 6 months that would be appropriate for the individual's developmental stage."

Duration: 42 CFR 483.102(b)(1)(iii)--"The individual experienced at least one of the following: psychiatric treatment more intensive than outpatient care more than once in the past 2 years; or... significant disruption to the normal living situation requiring supportive services to return home or... intervention by housing or law enforcement officials."

1919(e)(7)(B)--Resident reviews must be "based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority."

1919(e)(7)(B)(iii)--Prompt review is required upon significant change in resident's condition.

N/ A

42 CFR 483.106(d)--"The PASRR determination of N/A whether an individual requires NF services and whether specialized services are needed... must be made by the State mental health authority and be based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority."

42 CFR 483.106(d)--"(1) The State mental health...authority may delegate by subcontract or otherwise the evaluation and determination functions for which [it is] responsible to another entity only if--(i) The State mental health... authority retains ultimate control and responsibility for the performance of [its] statutory obligations; (ii) The two determinations as to the need for NF services and for specialized services are made, based on a consistent analysis of the data; and (iii) The entity to which the delegation is made is not an NF or an entity that has a direct or indirect affiliation or relationship with an NF. (2) The State mental retardation authority has responsibility for both the evaluation and determination functions for individuals with MR whereas the State mental health authority has responsibility only for the determination function. (3) The evaluation of individuals with MI cannot be delegated by the State mental health authority because it does not have responsibility for this function. The evaluation function must be performed by a person or entity other than the State mental health authority. In designating an independent person or entity to perform MI evaluations, the State must not use an NF or an entity that has a direct or indirect affiliation or relationship with an NF."

483-130 (b) (1) and C)

Level I identification of individuals with MI or MR

The State Medicaid PASRR program must identify all NF applicants and residents suspected of having MI or MR in order to conduct Level II evaluations and determinations.

The statute does not indicate how MI and MR individuals should be identified for PASRR.

42 CFR 483.128--"The State's PASRR program must identify all individuals who are suspected of having MI or MR... This identification function is termed Level I."

Level II preadmission screening

All applicants for new admission to an NF who are suspected of MI through a Level I screen must be referred for a Level II evaluation. A two- pronged determination must be made. The determinations are (1) whether the individual requires NF services and (2) whether the individual needs specialized services.

Regulations specify that SMHAs may develop categories for advance group determinations based on minimum evaluation based on minimum evaluation criteria when data are current, accurate, and sufficient, or they may make more extensive individualized determinations.

1919(e)(7)(A)(i)

42 CFR 483.112--"For each NF applicant with MI or MR, the State mental health or mental retardation authority (as appropriate) must determine... if the individual requires the level of services provided by an NF... If the individual with mental illness or mental retardation is determined to require an NF level of care, the State mental health or mental retardation authority (as appropriate) must also determine... whether the individual requires specialized services."

42 CFR 483.128(e)--"The State's PASRR program must use at least the evaluative criteria of Sec. 483.130 (if one or both determinations can easily be made categorically as described in Sec. 483.130) or of Secs. 483.132 and 483.134 or Sec. 483.136 (or, in the case of individuals with both MI and MR, Secs. 483.132, 483.134 and 483.136 if a more extensive individualized evaluation is required)."

42 CFR 483.130- No determination that specialized services are needed can be made categorically. In addition, categorical determinations that specialized services are not needed are limited to provisional, emergency, and respite categories. "Determinations made by the State mental health or mental retardation authority as to whether NF level of services and specialized services are needed must be based on an evaluation of data concerning the individual... Determinations may be (1) Advanced Group determinations, in accordance with this section, by category that take into account that certain diagnoses, levels of severity of illness, or need for a particular service clearly indicate that admission to or residence in an NF is normally needed, or that the provision of specialized services is not normally needed; or 2) Individualized determinations (based on more extensive individualized evaluations.)"

Exemptions to preadmission screening requirements

Exempted hospital discharge- Individuals admitted directly from a hospital for acute inpatient care are exempted from preadmission screening if they require NF services for the condition for which they were hospitalized, and if their attending physician certifies before admission to the facility that the likely NF stay is less than 30 days. If such individuals are later found to require more than 30 days of NF care, the SMHA must conduct a review within 40 days of admission.

Patients being readmitted to a NF or being transferred from another NF facility are not required to have a preadmission screening since they are not considered new admissions. However, they are subject to resident review requirements.

1919(e)(7)(A)(iii) "Exception For Certain Hospital Discharges.--The preadmission screening program under clause (i) shall not apply to the admission to a nursing facility of an individual--(I) who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital, (II) who requires nursing facility services for the condition for which the individual received care in the hospital, and (III) whose attending physician has certified, before admission to the facility, that the individual is likely to require less than 30 days of nursing facility services."

42 CFR 483.106(b)(2)--"(2) Exempted hospital discharge. (i) An exempted hospital discharge means an individual (A) Who is admitted to any NF directly from a hospital after receiving acute inpatient care at the hospital; (B) Who requires NF services for the condition for which he or she received care in the hospital; and (C) Whose attending physician has certified before admission to the facility that the individual is likely to require less than 30 days nursing facility services. (ii) If an individual who enters an NF as an exempted hospital discharge is later found to require more than 30 days of NF care, the State mental health or mental retardation authority must conduct an annual resident review within 40 calendar days of admission."

42 CFR 483.106(b)(3)--"Readmissions. An individual is a readmission if he or she was readmitted to a facility from a hospital to which he or she was transferred for the purpose of receiving care. Readmissions are subject to annual resident review rather than preadmission screening."

42 CFR 483.106(b)(4)--"Interfacility transfers. (i) An interfacility transfer occurs when an individual is transferred from one NF to another NF, with or without an intervening hospital stay. Interfacility transfers are subject to annual resident review rather than preadmission screening."

Level II resident review

All NF residents with MI must undergo evaluation and determinations of (1) whether NF services are required and (2) whether specialized services are needed

NFs must promptly report changes in a resident's physical or mental condition to the SMHA, which must then promptly conduct a review and determinations.

Congress repealed the Federal requirement for annual resident reviews in 1996, but did not change the required elements of those reviews. No regulations or SMM transmittals from CMS have been issued to reflect the 1996 changes. CMS provided guidance to States through letters and memorandums from regional offices.

1919(e)(7)(B)--Requires resident reviews of MI and MR residents in nursing homes. 1919(b)(3)(E)--"A nursing facility shall notify the State mental health authority... promptly after a significant change in the physical or mental condition of a resident who is mentally ill."

1919(e)(7)(B)(iii)--Requires SMHA to conduct a resident review promptly after an NF notifies the authority of significant change in an MI or MR resident's physical or mental condition.

The statute is silent on the frequency with which reviews must occur. But NFs are required to notify SMHAs of significant changes in the physical or mental functioning of MI or MR residents. And a review and determination must be conducted promptly by SMHAs after notification of a change in a president's physical or mental condition.

42 CFR 483.114--"For each resident of an NF who has mental illness, the State mental health authority must determine... whether, because of the resident's physical and mental condition, the resident requires (1) The level of services provided by (i) An NF; (ii) An inpatient psychiatric hospital for individuals under age 21...; or (iii) An institution for mental diseases providing medical assistance to individuals age 65 or older; and (2) Specialized services for mental illness."

Minimum evaluation criteria for the need for NF-level care

Regulations specify the evaluation criteria and minimum data requirements to evaluate the need for NF services and NF level of care.

1919(f)(8)(A)--Instructs the Secretary to develop minimum criteria for PASRR determinations.

42 CFR 483.132- The evaluator must determine (1) whether an individual's total needs can be met in an appropriate community setting; (2) whether the individual's total needs can only be met in an inpatient setting; (3) if inpatient care is needed and desired, whether the NF is an appropriate setting; (4) if inpatient care needed but the NF is inappropriate, whether an ICF/ MR, IMD, or psychiatric hospital would be appropriate. Evaluators must prioritize the physical and mental needs of the individual, taking into account the severity of each condition. The following data elements must be collected from the evaluation: physical status (diagnoses, date of onset, medical history, prognosis), mental status (diagnoses, date of onset, medical history, likelihood that the individual may be a danger to himself/ herself or others), and functional status (activities of daily living).

42 CFR 483.128(f)--The two determinations relating to the need for NF level of care and specialized services are interrelated and must be based upon a comprehensive analysis of all data.

No personnel qualifications are specified.

Minimum criteria for screening of persons with MI to determine need for specialized services

Regulations specify the criteria, minimum data, and personnel requirements for evaluating the need for specialized services.

1919(f)(8)(A)--Instructs the Secretary to develop minimum criteria for PASRR determinations.

42 CFR 483.134- Evaluation of person's need for specialized services for MI must include the following data: comprehensive history and physical (including complete medical history, review of all body systems, and neurological evaluation of motor and sensory function, gait, deep tendon reflexes, cranial nerves, and abnormal reflexes); comprehensive drug history, psychosocial evaluation, comprehensive psychiatric evaluation (including psychiatric history, intellectual and memory function and orientation, attitudes and overt behaviors, affect, suicidal or homicidal ideation, paranoia, degree of reality testing, and hallucinations); functional assessment of activities of daily living to determine level of support needed; functional assessments of self-monitoring of health and nutritional status; self-administration of medical treatment and medication compliance; and assessment of individual's ability to handle money, dress appropriately, and properly groom. Personnel requirements-If the history and physical examination are not performed by a physician, then a physician must review and concur with the examination. The State may designate the mental health professionals qualified to conduct the other parts of the evaluation.

A qualified mental health professional, as designated by the State, must validate the diagnosis of MI and determine whether specialized services are needed.

Definition: Specialized services

Regulations define specialized services that must be provided to MI and MR residents of NFs when necessary.

1919(e)(7)(G)--"The term 'specialized' services has the meaning given such term by the Secretary in regulations."

42 CFR 483.120(a)(1)--Specialized services are those specified by the State, which, when combined with NF services, result in the continuous and aggressive implementation of an individualized plan of care that is (1) developed under and supervised by a physician in conjunction with an interdisciplinary team of qualified health professionals; (2) prescribes specific therapies and activities for the treatment of persons experiencing an acute episode of severe MI that necessitates supervision by trained mental health personnel; and (3) is directed toward diagnosing and reducing the resident's behavioral symptoms that necessitated institutionalization, improving his or her level of independent functioning, and achieving a functioning level that permits reduction in the intensity of mental health services to below the specialized level of services at the earliest possible time.

Requirement to provide or arrange for specialized services

Specialized services must be provided or arranged for all MI residents in NFs who are determined by the SMHA to need such specialized services.

In addition, specialized services must be provided or arranged for all MI individuals needing such specialized services who resided in NFs but do not need NF services and were discharged or chose to leave because of PASRR.

The provision of specialized services is a required element of State Medicaid plans' PASRR program. State Medicaid agencies are responsible for administering and supervising State Medicaid plans. Thus, State Medicaid agencies bear overall responsibility for meeting PASRR obligations to provide or arrange for specialized services. However, the State Medicaid agency is not required to provide services directly and may delegate required activities unless specifically prohibited by statute.

1919(e)(7)(C)(i)(IV)--Long term NF residents not requiring NF services but requiring specialized services may choose to stay in the NF or be discharged to an alternative setting. "Regardless of the resident's choice, [the State must] provide for (or arrange for the provision of) such specialized services."

1919(e)(7)(C)(ii)(III)--Other residents not requiring NF services but requiring specialized services must be discharged and the State must "provide for (or arrange for the provision of) such specialized services."

42 CFR 483.120(b)--"The State must provide or arrange for the provision of specialized services, in accordance with this subpart, to all NF residents with MI or MR whose needs are such that continuous supervision, treatment and training by qualified mental health or mental retardation personnel is necessary, as identified by the screening provided in 483.130 or 483.134 and 483.136."

42 CFR 483.130(m)(1)--In the case of individuals with MI who require NF services, apply for admission to an NF and for whom NF placement is appropriate, "if specialized services are also needed, the State is responsible for providing or arranging for the provision of the specialized services."

42 CFR 483.130(m)(4)--In the case of long-term MI residents in NFs who do not require NF services but require specialized services and may choose to remain in the NF, "wherever the resident chooses to reside, the State must meet his or her specialized services needs."

42 CFR 483.130(m)(5)--Short- term MI residents in NFs who do not need NF services but require specialized services "must be discharged... to an appropriate setting where the State must provide specialized services."

42 CFR 483.130(n)--"If a determination is made to admit or allow to remain in a NF any individual who requires specialized services, the determination must be supported by assurances that the specialized services that are needed can and will be provided or arranged for by the State while the individual resides in the NF."

Timeliness of preadmission screenings

Preadmission screening determinations must be made within an annual average 7 to 9 working days after patients are identified as suspected of having an MI and referred to the SMHA. The Secretary may grant exceptions to this standard.

There is no timeliness standard for identification and referral of NF applicants with suspected MI.

1919(b)(3)(F)--Requires PASRR determination before admission.

42 CFR 483.112(c)--"... a preadmission screening determination must be made in writing within an annual average of 7 to 9 working days of referral of the individual with MI or MR by whatever agent performs the Level I identification."

42 CFR 483.122(b)--"FFP for late reviews. When a preadmission screening has not been performed prior to admission or an annual review is not performed timely, in accordance with Sec. 483.114(c), but either is performed at a later date, FFP is available only for services furnished after the screening or review has been performed, subject to the provisions of paragraph (a) of this section."

Individualized determinations

Individualized determinations of the need for NF services and the need for specialized services must meet the minimum evaluation criteria specified in regulations (see above).

Regulations specify content of evaluation reports for individualized determinations.

All positive determinations of the need for specialized services must be made through individualized evaluations.

1919(f)(8)(A)--Instructs the Secretary to develop minimum criteria for PASRR determinations (see above)

42 CFR 483.130(b)(2)--"Determinations may be... individualized determinations based on more extensive individualized evaluations as required in Sec. 483.132, Sec. 483.134, or Sec. 483.136 (or, in the case of an individual having both MR and MI, Secs. 483.134 and 483.136)."

42 CFR 483.128(i)--"For individualized PASRR determinations, findings must be issued in the form of a written evaluative 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) If NF services are recommended, identifies the specific services which are required to meet the evaluated individual's needs, including services required in paragraph (i)(5) of this section; (4) If specialized services are not recommended, identifies any specific mental retardation or mental health services which are of a lesser intensity than specialized services that are required to meet the evaluated individual's needs; (5) If specialized services are recommended, identifies the specific mental retardation or mental health services required to meet the evaluated individual's needs; and (6) Includes the bases for the report's conclusions."

42 CFR 483.130(g)--"The State mental health and mental retardation authorities must not make categorical determinations that specialized services are needed. Such a determination must be based on a more extensive individualized evaluation under Sec. 483.134 or Sec. 483.136 to determine the exact nature of the specialized services that are needed."

Categorical determinations

SMHAs may establish categories to make advance group determinations that NF services are needed. Categories must be approved by CMS and included in the State plan.

Time limits may be established for NF service need. Time limits are required for provisional and respite care admissions. Residents who will exceed time limits must have a resident review.

SMHAs may also make categorical determinations on whether specialized treatment is not needed only in the provisional, emergency, and respite categories and when a person has both MR and dementia. When specialized services are needed, individualized evaluations are required.

Categorical determinations of NF need do not eliminate the requirement for the SMHA to determine the individual's need for specialized services.

Regulations specify content of evaluation reports for categorical determinations.

1919(f)(8)(A)--Instructs the Secretary to develop minimum criteria for PASRR determinations (see above).

42 CFR 483.130(b)(1)--"Determinations may be (1) Advance group determinations, in accordance with this section, by category that take into account that certain diagnoses, levels of severity of illness, or need for a particular service clearly indicate that admission to or residence in an NF is normally needed, or that the provision of specialized services is not normally needed."

42 CFR 483.130(c)--"Advance group determinations by category developed by the State mental health or mental retardation authorities may be made applicable to individuals by the NF or other evaluator following Level I review only if existing data on the individual appear to be current and accurate and are sufficient to allow the evaluator readily to determine that the individual fits into the category established by the State authorities (see Sec. 483.132(c)). Sources of existing data on the individual that could form the basis for applying a categorical determination by the State authorities would be hospital records, physician's evaluations, election of hospice status, records of community mental health centers or community mental retardation or developmental disability providers."

42 CFR 483.130(e)--"The State may specify time limits for categorical determinations that NF services are needed and in the case of paragraphs (d)(4), (5) and (6) of this section, must specify a time limit which is appropriate for provisional admissions pending further assessment for emergency situations and respite care. If an individual is later determined to need a longer stay than the State's limit allows, the individual must be subjected to an annual resident review before continuation of the stay may be permitted and payment made for days of NF care beyond the State's time limit."

42 CFR 483.128(j)--"For categorical PASRR determinations, findings must be issued in the form of an abbreviated written evaluative report which (1) Identifies the name and professional title of the person applying the categorical determination and the data on which the application was made; (2) Explains the categorical determination(s) that has (have) been made and, if only one of the two required determinations can be made categorically, describes the nature of any further screening which is required; (3) Identifies, to the extent possible, based on the available data, NF services, including any mental health or specialized psychiatric rehabilitative services, that may be needed; and (4) Includes the bases for the report's conclusions."

Placement options

Regulations specify 6 possible options for individuals with MI or MR, as determined under PASRR.

1919(e)(7)(C)

42 CFR 483.130(m)--The options for placement are as follows:

"(1) Can be admitted to an NF. Any applicant for admission to an NF who has MI or MR and who requires the level of services provided by an NF, regardless of whether specialized services are also needed, may be admitted to an NF, if the placement is appropriate, as determined in Sec. 483.126. If specialized services are also needed, the State is responsible for providing or arranging for the provision of the specialized services.

(2) Cannot be admitted to an NF. Any applicant for admission to an NF who has MI or MR and who does not require the level of services provided by a NF, regardless of whether specialized services are also needed, is inappropriate for NF placement and must not be admitted.

(3) Can be considered appropriate for continued placement in an NF. Any NF resident with MI or MR who requires the level of services provided by an NF, regardless of the length of his or her stay or the need for specialized services, can continue to reside in the NF, if the placement is appropriate, as determined in Sec. 483.126.

(4) May choose to remain in the NF even though the placement would otherwise be inappropriate. Any NF resident with MI or MR who does not require the level of services provided by an NF but does require specialized services and who has continuously resided in an NF for at least 30 consecutive months before the date of determination may choose to continue to reside in the facility or to receive covered services in an alternative appropriate institutional or noninstitutional setting. Wherever the resident chooses to reside, the State must meet his or her specialized services needs. The notice must provide information concerning how, when, and by whom the various placement options available to the resident will be fully explained to the resident.

(5) Cannot be considered appropriate for continued placement in an NF and must be discharged (short- term residents). Any NF resident with MI or MR who does not require the level of services provided by an NF but does require specialized services and who has resided in an NF for less than 30 consecutive months must be discharged in accordance with Sec. 483.12(a) to an appropriate setting where the State must provide specialized services. The determination notice must provide information on how, when, and by whom the resident will be advised of discharge arrangements and of his/ her appeal rights under both PASRR and discharge provisions.

(6) Cannot be considered appropriate for continued placement in an NF and must be discharged (short or long- term residents). Any NF resident with MI or MR who does not require the level of services provided by an NF and does not require specialized services regardless of his or her length of stay, must be discharged in accordance with Sec. 483.12(a). The determination notice must provide information on how, when, and by whom the resident will be advised of discharge arrangements and of his or her appeal rights under both PASRR and discharge provisions."

Adaptation to culture, language, ethnic origin

Evaluations and notices must be adapted to the cultural background, language, ethnic origin, and means of communication used by the individual being evaluated.

1919(c)

42 CFR 128(b)

Participation by individual and family

Evaluations must involve the individual, his or her legal representatives, and the individual's family if family members are available and their participation is agreed to by the individual.

1919(c)

42 CFR 483.128(c)

Record retention

The State PASRR system must maintain records of evaluations and determinations, regardless of whether they are performed categorically or individually.

1919(e)(7)(C)(iv)

42 CFR 483.130(o)

Tracking system

The State PASRR system must establish and maintain a tracking system for all individuals with MI or MR in NFs to ensure that appeals and future reviews are performed.

1919(e)(7)(F)

42 CFR 483.130(p)

Appeals

Each State must provide a system of appeals for individuals adversely affected by any PASRR preadmission screening or resident review determination.

1919(e)(7)(F)

42 CFR 483.204

FFP for PASRR activities

States receive 75% FFP under administrative costs for PASRR activities.

To prevent duplicative payment, FFP is not available for specialized services furnished to NF residents as NF services.

1903(a)(20)(C) --Provides 75% FFP for PASRR activities.

42 CFR 433.15(b)(9) --Provides 75% FFP for PASRR activities.

42 CFR 483.124 - "FFP is not available for specialized services furnished to NF residents as NF services."

Enforcement

CMS may deny FFP if the State Medicaid plan fails to meet federal requirements or the or the State does not comply in practice with Federal requirements.

1902(a), 1904

42 CFR 430.35