PASRR PreAdmission Screening & Resident Review Fall 2011 NJ Department of Health & Senior Services

Objectives for Training Understand PASRR regulations Identify PASRR responsibilities for state staff and providers Explain PASRR requirements Review and understand all elements of the PASRR Level I Screening Form LTC-26 Review and understand the Notice of Referral for Level II Evaluation Form LTC-29

What is PASRR? PreAdmission Screening and Resident Review Part of the Federal Nursing Home Reform Act of 1987 (aka OBRA ’87) Federal Requirement as set forth in 42 CFR 483 et seq Requires states to ensure that all individuals entering Medicaid-certified Nursing Facilities (NFs) are screened for Serious Mental Illness (SMI) and/or Intellectual Disability (ID)/Related Condition (RC) RCs are severe and chronic Developmental Disabilities (DDs) such as autism, seizure disorder, cerebral palsy, spina bifida or head injury with date of onset prior to age 22

Purpose of PASRR Ensures that all NF applicants and residents with SMI and/or ID/DD are: Identified Placed appropriately (least restrictive setting) Provided with the MI/ID/DD services they need including Specialized Services

PASRR Components There are two components to PASRR Level I – Screening for indicators of SMI and/or ID/DD Level II – Evaluation and Determination

PASRR Responsibilities Level I Screen NF professional staff complete for private pay applicants from community NJ Department of Health’s Office of Community Choice Options (OCCO) staff complete clinical eligibility assessment (PAS/PreAdmission Screen) and the PASRR Level I Screen for community applicants who are currently Medicaid or potentially Medicaid eligible within 6 months of NF admission Hospital – hospital discharge planners APS, Hospice and Respite – care managers

PASRR Responsibilities Level II Evaluation and Determination The Department of Human Services staff administer the evaluation and determination process The Division of Mental Health Services is responsible for individuals screening positive for mental health indicators while the Division of Developmental Disabilities is responsible for individuals screening positive for ID/DD indicators 7

Exceptions to PASRR PASRR is not needed for entry into the following facilities: Assisted Living Fully private pay NFs Transitional Care Units in hospitals New Jersey Veteran Homes

Who can complete a Level I? The minimum credentials for an screening professional completing a Level Screening Tool are: Certified Social Worker (CSW) Registered Nurse (RN) Physicians and Physician Assistants may also complete the Level I Screening Form

Hospital Discharges to NF Hospital discharge planners complete a Level I Screening Tool (LTC-26) on all discharges to a Medicaid-certified NF All Level I positive screens must be referred to DDD and/or DMHS for a Level II Evaluation unless certified as Exempted Hospital Discharge CMS regulations allow for a suspension of the Level II for short term (less than 30 days) rehab admissions with physician’s certification – Exempted Hospital Discharge All positive screens for individuals who are currently Medicaid or potentially Medicaid eligible within 6 months of NF admission must also have an EARC-PAS completed by a certified EARC-PAS hospital assessor or have an onsite hospital PAS (PreAdmission Screen) completed by OCCO prior to discharge to the NF, per usual EARC-PAS/OCCO PAS procedure Copies of Level I – and Level II documents if applicable – must go with the individual to the NF for inclusion in active NF record

Community NF Admissions NF personnel must complete a Level I Screening Tool on each private pay admission from the community All positive screens must be referred to DDD and/or DMHS for a Level II Evaluation Copies of the Level I – and Level II documents if applicable – must be placed on the active NF chart

Key Points about the PASRR Level I Screen A new Level I Screen is required for each new NF admission Valid for entire period of continuous NF placement Repeat Level I is not needed if NF resident is hospitalized then is readmitted to NF from hospital Valid for NF-to-NF interfacility transfer A new Level I Screen must be completed even when an individual discharges to the community from a previous NF stay then requires subsequent NF placement The Level I Screen is valid for one NF admission only and can be completed up to 30 days prior to NF admission

Level I Screening Forms: LTC-26 and LTC-29 LTC-26 Level I Screening Form Complete consumer’s identifying information MI Screen: Answer questions 1-5 with available information ID/DD Screen: Answer questions 6-10 with available information Scoring: positive or negative screen? Does individual qualify for a Categorical Determination? Does hospitalized patient qualify for an Exempted Hospital Discharge? LTC-29 Notice of Referral for Level II PASRR Evaluation If Level I is positive, screener informs consumer of Level II referral and completes Form LTC-29 and gives original to consumer, copy in consumer record Required for first-time identification of SMI/ID/DD The LTC-26 and LTC-29 were revised March 2011

Categorical Determinations There are several populations that do not require a full Level II Evaluation, whose Level II may be abbreviated, if they fall into one of the following categories: Dementia with ID/DD (a DDD function, category not listed on the LTC-26) Terminal Illness Severe Physical Illness Respite Care Protective Services

Categorical Determinations - Dementia with ID/DD and Terminal Illness Diagnosis of MR and/or DD Documented diagnosis of dementia, including Alzheimer's Disease or related disorder, based on the most current Diagnostic Statistical Manual (DSM-IV) criteria Terminal Illness: Diagnosis of serious mental illness, intellectual disability and/or developmental disability Not a danger to self or others Certified by a physician and/or hospice care staff as having a life expectancy of six months or less Requires continuous nursing care or medical supervision/treatment due to a physical condition 15

Categorical Determinations - Severe Physical Illness Applies to individuals with serious mental illness, intellectual disability and/or developmental disability who may not be expected to benefit from specialized services due to impairment caused by a severe medical illness Examples of severe medical illnesses include: Amyotrophic lateral sclerosis, Huntington’s disease, ventilator dependency, severe congestive heart failure, end-stage chronic obstructive pulmonary disease, end-stage Parkinson’s disease, cerebellar degeneration, cerebrovascular accident, end-stage renal disease, severe diabetic neuropathies and refractory anemia An individual who is comatose or in a persistent vegetative state 16

Categorical Determinations - Respite Care1 An adult may be admitted to a NF from home or an Adult Family Care home (a non-institutional setting) for short-term respite care not to exceed thirty (30) days per state or federal annual funding cycle The maximum annual limit of up to 30 days NF respite may be taken intermittently or consecutively following prior approval by State-designated staff Respite care is a temporary, finite service provided to an individual with a cognitive impairment and/or self-care deficits in daily living tasks, for the purpose of relieving the caregiver in a non-institutional setting 17

Categorical Determinations Respite Care2 At time of admission to a NF for respite care, there must be expressed intent by the individual and/or their legal representative to leave the NF and return to the home by the expiration of the respite approval period If the individual remains in the NF beyond the pre-approved respite limit, the individual must undergo a complete PASRR Level II evaluation coordinated through the Division of Mental Health Services and/or the Division of Developmental Disabilities

Categorical Determinations - Protective Services Adult may be admitted to NF from the community for a period not to exceed 7 days while NF or alternative arrangements for longer care are made Emergency placement allowed only when a crisis arises outside of normal state business hours The individual must be in need of intensive emergency intervention and in imminent danger as certified in writing by the Adult Protective Services worker and/or supervisor NF placement must be the placement of last resort If the individual remains in the NF beyond the 7-day limit, then the individual must undergo a complete PASRR Level II evaluation coordinated through the Division of Mental Health Services and/or the Division of Developmental Disabilities 19

Exempted Hospital Discharge If a hospital patient screened positive on the Level I and is being discharged to a NF for subacute care, and a physician certifies that the individual is likely to require less than 30 days skilled nursing care, a Level II Evaluation can be suspended If the NF resident remains in the NF on or after the 30th day, the Level II must be completed prior to day 40

Level II May block NF admission of individuals who might otherwise be admitted: May meet NF LOC but MI/ID/DD needs cannot be met in NF Determination may be made that individual requires Specialized Services. SMI – inpatient psychiatric treatment ID/DD – Developmental Center (ICF-MR) or community-based setting meeting ICF-MR standards for skill deficits or other specialized training requiring 24/7 coverage by trained personnel to teach the individual functional skills. Level II determination may also indicate that the individual’s needs could be better met in the community

Specialized Services Not permitted in NJ NFs as set forth in New Jersey Administrative Code 8:85 No FFP (Federal Financial Participation) for Specialized Services if provided to a NF resident as NF services States can provide Specialized Services as services over and above NF services though NJ chose to provide Specialized Services outside of NF setting The NF must provide mental health or intellectual disability/developmental disability services which are of a lesser intensity than Specialized Services to all residents who need such services

Resident Review1 CMS no longer requires annual resident reviews However, PASRR requires the resident review evaluation process whenever significant change in resident’s physical or mental condition occurs: significant deterioration significant improvement when resident expresses a desire to return to the community NF must use the MDS 3.0 Significant Change in Status Assessment to trigger care planning and resident review

Resident Review 2 NF must refer resident to Division of Mental Health Services and/or Division of Developmental Disabilities upon SCSA (Significant Change in Status Assessment) Resident Review by respective division will determine if resident needs additional or different services in the NF, or if Specialized Services are required, and/or identify community supports and services for an individual’s discharge to the community

Department of Health & Senior Services OCCO Contact Information OCCO Northern Regional Office, Newark Bergen, Essex, Hudson, Morris, Passaic, Sussex & Warren Counties Phone: (973) 648-4691; Fax: (973) 693-5046 OCCO Central Regional Office, Edison Hunterdon, Middlesex, Monmouth, Ocean, Somerset & Union Counties Phone: (732) 777-4650; Fax: (732) 777-4681 OCCO Southern Regional Office, Hammonton Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Mercer & Salem Counties Phone: (609) 704-6050; Fax: (609) 704-6055

Questions? PASRR resources and correspondence can be found on the DHSS website at http://nj.gov/health/senior/pasrr.shtml The LTC-26 Level I Screening Form and LTC-29 Notice of Referral for Level II PASRR Evaluation can be found on the DHSS website at http://web.doh.state.nj.us/apps2/forms/