Bureau of Long Term Care
Preadmission Screen and Resident Review
Background
The Omnibus Budget Reconciliation Act of 1984 (OBRA 87) and section, 1919 of the Social
Security Act (Part 2, Subtitle C of Title IV, Public Law 100-203), went into effect in 1987.
These laws require a preadmission screening and additional screening of individuals with
mental illness (MI) or intellectual disabilities (ID) who are applicants to or residents of Medicaid
certified nursing facilities (NF). The law requires States to:
•
•
•
Establish a preadmission screening program to prevent inappropriate admissions of
persons who are mentally ill, intellectually disabled or have conditions related to
Intellectual Disabilities;
Transfer inappropriately placed nursing facility residents with mental illness, intellectual
disabilities, or related conditions to alternate residential setting; and
Conduct additional resident reviews of residents identified with intellectual disabilities or
related conditions.
The Act prohibits a Medicaid certified NF from admitting any new resident, regardless of
payment source, after January 1, 1989, who is mentally ill, intellectually disabled or has a
related condition, unless the state mental health authority or the state intellectual disabilities
authority has determined, prior to admission, the individual requires level of services provided
by a nursing facility and whether such individual requires specialized services (OBRA ’90 PL
100-203 substituted “Specialized Services” for “Active Treatment”).
Minimum federal criteria for States to use in making determinations are categorized into two
screens, Level I and Level II.
Federal financial participation will not be provided for a resident’s stay in a NF if a Level I and,
if required, a Level II screening has not been completed accurately.
Idaho has complied with OBRA ’87 and technical corrections of OBRA ’90 with regulation
changes: IDAPA 16.03.10.227.1-4; Alternate Disposition Plan (ADP) submitted to the Health
Care Financing Administration (HCFA) in December 1988, approved by HCFA in March 1989;
and Identification and Evaluation guideline procedures developed in December 1988.
The Division of Behavioral Health, Medicaid Bureau of Long Term Care and the Division of
Family & Community Services are responsible for implementing the Division of Welfare’s
Preadmission screening and resident review (PASRR) responsibilities.
PASRR legislation is intended to prevent placement of individuals who are mentally ill and or
intellectually disabled in need of “specialized services” into a NF where these services are not
available. Legislation provided language which required states to review current nursing facility
residents to ensure they had been appropriately placed. When implemented, those residents
who had not been appropriately placed but met NF level of care and a resident of facility for
three (3) years or longer were given the choice of staying in the facility and receiving
specialized services or transferring to an Intermediate Care Facility for Persons with
Intellectual Disabilities (ICF/ID) to receive specialized services.
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Policy
The Department of Health and Welfare will ensure individuals who apply for admission to or
continue to reside in nursing facilities are:
• thoroughly evaluated,
• admitted to or continue to reside in a nursing facility only when appropriate
• receive all necessary services while there.
The PASRR process is used to make these assurances and implement OBRA ’87 and OBRA
’90, as well as decisions resulting from the 1999 Olmstead US Supreme Court case.
Procedure
Preadmission Screening
There are two screening processes: Level I and Level II.
Level I Screen
Prior to admission to a NF, ALL individuals, regardless of payment method, must be screened.
The Level I is used to identify whether applicants may have MI, ID, a related condition or be
dually diagnosed.
Responsibility for PASRR screening rests with discharging facility or home state. The receiving
facility is responsible for ensuring a Level I and, if necessary, a Level II has been completed
prior to admission. Medicaid reimbursement will only be authorized from date when Level I
and, if necessary, Level II is completed.
The State in which the individual is a State Resident must pay for
the PASRR and make the required determinations. 42 CFR
483.110
No retroactive payments are allowed prior to completion of the
PASRR.
PASRR Tables 1 and 2 outline guidelines to be used for the Preadmission Screening and
Resident Review (HW0087) and PASRR Screening for Nursing Facility Placement (HW0090).
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PASRR Table 1
Guidelines for Determining Serious Mental Illness
Preadmission Screens: Level I
Diagnosis
Mental disorder is a schizophrenic, mood, paranoid, panic, or other severe
anxiety disorder; a somatoform disorder; a personality disorder; other
psychotic disorder; or another mental disorder that may lead to a chronic
disability. NOT a primary diagnosis of dementia, including Alzheimer’s or a
related disorder.
Level of
Has functional limitation in major life activities within the past 3 to 6 months
Impairment
appropriate for individual’s development stage. Has at least one of the
following characteristics on a continuing or intermittent basis.
• Interpersonal functioning, i.e., serious difficulty interacting appropriately
and communicating effectively with others.
• Concentration, persistence and pace, i.e., serious difficulty in sustaining
focused attention for long enough periods to permit completion of tasks
commonly found in work, school, or home settings. Makes frequent
error, or requires assistance in completion of these tasks.
• Adaptation to change, i.e., serious difficulty adapting to typical changes
in work, school, family, or social interaction. Manifests aggression,
exacerbated signs and symptoms associated with illness, or withdrawal
from situation, or require intervention by mental health or judicial
system.
Duration of
Individual has experienced at least one of the following:
Illness
• Psychiatric treatment more intensive than outpatient care more than
once in past 2 years.
• Within last 2 years (due to mental disorder), experienced an episode of
significant disruption to normal living situation. Supportive services
required to maintain function at home or in a residential treatment
environment, or resulted in intervention by housing or law enforcement
officials.
Other
All individuals with diagnosis of schizophrenia, paranoia, mood disorder,
schizoaffective disorders, and atypical psychosis are included.
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PASRR Table 2
Guidelines for Determining Dementia, Intellectual Disabilities or Related Condition
Preadmission Screens: Level I
Dementia
Impairment in short and long term memory. This is associated with
impairment in abstract thinking, impaired judgment and other disturbances in
higher cortical function, or personality change. Disturbance is severe
enough to interfere significantly with work, usual social activities, or
relationships with others and does not occur exclusively during course of
delirium. “Reasonable measures” taken to assure accuracy of diagnosis
may not absolutely require mental or neurological exams (42 CFR 483.102,
b).
Mental
Significant sub average general intellectual functioning exists concurrently
Retardation with deficits in adaptive behavior and manifested during developmental
period (42 CFR 483.102, b).
Related
Severe, chronic disability attributable to cerebral palsy, epilepsy or other
Condition
condition related to intellectual disabilities. Results in impairment of general
intellectual functioning or adaptive behavior similar to that of persons with
Intellectual Disabilities and requires similar services. This condition is:
• Manifested before individual reaches age 22
• Likely to continue indefinitely
• Results in substantial functional limitations in three or more major life
activities (self care, language, learning, mobility, self direction, and
capacity for independent living or economic self-sufficiency. (42 CFR
483.102, b)
The Level I Preadmission Screening and Resident Review (HW0087) must be completed,
dated, and signed by a physician, physician extender or hospital discharge planner who is a
Registered Nurse (RN) or Licensed Social Worker (LSW) or both a Qualified Mental Health
Professional (QMHP) and a Qualified Intellectually Disabled Professional (QIDP) prior to an
individual’s admission to a NF. This screen is required only at first entry into the NF system, or
after having been out of NF with no intent to readmit, or if there is a change in participant
(and/or family or legal representative, as appropriate) (and/or family or legal representative, as
appropriate)’s mental status.
Prior to admission, the discharging facility or receiving NF sends a completed Preadmission
Screening and Resident Review (HW0087) to the regional Bureau of Long Term Care (BLTC)
and notifies them of:
• Any applicants with positive triggers on the Level I Screen Preadmission Screening and
Resident Review (HW0087) (answered YES to any question on the form except #12). If
#12 is marked with a “YES,” it indicates that individual has a primary diagnosis of
Alzheimer’s, or a related disorder or dementia based on neurological examination. A
diagnosis of dementia may or may not exempt an individual from the Level II Screen for
Mental Illness (MI).
“Primary” implies that the symptoms of dementia supersede
symptoms/behaviors of the MI/ID or related disorder. Persons with
dementia are not “exempted from PASRR Level I or II.
Documented evidence of Primary dementia will yield a Level I
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conclusion that no MI is present for PASRR purposes and
screening may stop. Otherwise, the screening process continues
to look for the possibility of serious mental illness (SMI). If SMI is
documented or possible and there is no documented assessment
that dementia is primary, the individual is referred for Level II
evaluation of the co-morbidity.
Upon receipt of Preadmission Screening and Resident Review (HW0087) and supporting
records, BLTC determines:
• Level I Screen is accurate/substantiated in record
• Individual’s needs could be met in an alternate community setting (non-inpatient)
• Individual requires NF level of care
• Exemption criteria applies
• Categorical or Individualized Determinations apply.
• Participant (and/or family or legal representative, as appropriate) (and/or family or legal
representative, as appropriate) has been notified that medical information is being
forwarded for a PASRR evaluation via signature on the bottom section of the Level I
Preadmission and Resident Review (HW0087)
• Any Level I screen that might seem questionable or inaccurate based either on observation
or record review should be returned to the generating entity for accurate completion or
forwarded to Mental Health (MH) (Division of Behavioral Health) / Developmental
Disabilities Authority (DD) (Medicaid Bureau of Developmental Disabilities) to complete.
The decision whether a Level II is needed or exemption criteria exists should be made by
the Nurse Reviewer/MH/DD Authority within the same day the positive Level I is received.
If a Level II is needed it should be completed within 7-9 workings day from the date of
referral to MH/DD authority.
The Nurse Reviewer (NR) must request certain records for an individual with a positive Level I
Screen in need of further consideration for a Level II Screen prior to entering NF.
PASRR Table 3
Required Records for Individuals with Positive Level I Screen
• Physician’s history and physical (including evaluation of mental status) and progress
notes
• Physician’s Plan of Care, including prognosis
• Physician’s certification of level of care
• Social information
• Preadmission Screening and Resident Review Form (HW0087)
• Psychiatric or psychological evaluation, if available.
Note: All information must be current, accurate and reflect current functional
status.
Questionable diagnoses on Level I Preadmission Screening and Resident Review (HW0087)
may be referred at this point to MH/DD Authority for determination of need for Level II Screen.
NF Level of Care
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The NR determines the individual does not meet NF level of care. NR completes Part 1 and
#20 of PASRR Screening for NF Placement (HW0090) and sends copy to the individual,
physician and NF. Copies are also sent to the hospital and family or legal representative, as
appropriate if applicable. It is not necessary to refer this to MH Authority.
If applicant does not meet NF level of care, PASRR process stops and facility or applicant is
notified via PASRR Screening for NF Placement (HW0090) that participant/applicant (and/or
family or legal representative, as appropriate) does not meet criteria for admission to NF.
Exemption Criteria Present
If any exemption criteria in PASRR Table 4 are present, a Level II evaluation is not necessary.
PASRR Table 4
Exempt From Preadmission Level II Evaluation
Readmission
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 resident review (RR)
rather than preadmission screening. 42 CFR 483.106
Interfacility
An individual is transferred from one nursing facility to another with or
Transfer
without an intervening hospital stay. (Transferring facility is responsible
for sending copies of resident’s current Level I Screen and Level II
Determination and resident assessment reports with resident.).
42 CFR 483.106
Exempt
Individuals admitted to NF directly from a hospital after receiving acute
Convalescence inpatient care. NF services for the condition are required and an
attending physician certifies, before admission to NF, individual is likely
to require NF stay of less than 30 days.
Note: If it becomes apparent individual will stay longer, an additional
Resident Review (RR) must be completed within forty (40)
calendar days of admission (refer to table 8).
Swing Bed
Individuals admitted to a swing bed.
Categorical or Individualized Determinations Apply
Categorical determinations permit states to omit the full Level II evaluation in certain
circumstances that are time-limited or where need is clear. While the evaluation process is
abbreviated, the function of the resulting determination is not different from individualized
determinations
There are two types of categorical determinations indicating either NF level of services
normally needed (see PASRR Table 5) or specialized services are not normally needed (see
PASRR Table 6). Categorical determinations are not automatic exemptions from Level II
evaluations 42 CFR 483.130 (d) (3-6). In absence of Categorical Determinations,
Individualized Determinations are required.
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PASRR Table 5 – NR makes this decision
Categorical Determinations
Evaluation for Specialized Services are Not Normally Needed
Delirium
Provisional admission pending further assessment when accurate
diagnosis cannot be made until delirium clears. Not to exceed 7 days.
Emergency
Provisional admission pending further assessment in situation requiring
Situation
protective services. Not to exceed 7 days.
Respite to
Very brief and finite stay of up to 30 consecutive days in one calendar
Home Care
year. The individual with MI or ID is expected to return home following
Givers
the brief NF stay.
If longer stays are required in any of the above cases, RR must be completed prior to the
last day. BLTC and NF are responsible to track stays exceeding the state limit.
PASRR Table 6 – Referred to MH/DD authority for decision
Categorical Determinations
Further Evaluation for Specialized Services Needed
Convalescence Care for an acute physical illness requiring hospitalization, but does not
meet all criteria for an exempt convalescence. (120 days)
Severity of
Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart
Illness
Failure (CHF), Parkinson’s Disease, Huntington’s Chorea in their acute
or severe stages; Coma, Amyotrophic Lateral Sclerosis, Ventilator
Dependency, and Brain Stem Level Functioning. Functioning which
results in a level so severe that individual cannot be expected to benefit
from specialized services. (annually)
Terminal Illness Has a medical prognosis life expectancy of six months or less. Must
be so stated by physician. (6 months)
Dementia/ID
Individuals with dementia which exists in combination with ID or related
condition. (May be permanent)
In the above cases, Convalescence, Severity of Illness and Terminal Illness, a record
review must be completed to determine need for specialized services by MH/DD Authority.
If Categorical Determinations in Table 6 applies:
 BLTC completes Part 1 Section VII #23 of PASRR Screening for NF Placement
(HW0090). This is sent with corresponding records to MH/DD Authority for review and
co-signature.
 Records are then returned to BLTC.
BLTC distributes copies as follows:
 Copy of PASRR Screening for NF Placement (HW0090) is sent to requesting party and
a copy with the right to appeal is sent to the individual, physician, NF, hospital and
family or legal representative, as appropriate.
 If need for Specialized Services is identified follow the process of Individualized
Determinations.
It is a dual responsibility of the NR and NF to ensure a Level II
evaluation is completed when stays exceed the state limit.
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Level II Individualized Determinations
In absence of Categorical Determination, an Individualized Determination is completed to
identify need for Specialized Services. The purpose of Level II evaluation is to determine
whether an individual requires level of care provided by a NF or another type of community
setting (non-inpatient) and whether individual requires specialized services or services of a
lesser intensity.
The first time an individual is referred for a Level II evaluation, the individual/legal
representative and NF are informed via the Notification of MH/DD review section of the Level I
Preadmission Screening and Resident Review (HW0087). This referral cannot be appealed.
The individual, or their legal representative, has the right to refuse a Level II evaluation.
However, it is important to advise them a refusal will result in refusal of admission to NF even
though applicant’s condition warrants nursing facility placement.
The process is to be completed in a maximum average time of 7-9 working days (from date of
referral to MH Authority and/or DD Authority to date of written determination).
The following are sent to the MH/DD authority:
• Part 1 of PASRR Screening for NF Placement (HW0090), completed by BLTC
• Medical records for evaluation and final determination of need for a full Level II
evaluation.
NR may discuss the need for a full Level II evaluation with MH/DD
authority on the phone to expedite the process.
Initially, MH and DD Authority may evaluate need for a Level II evaluation by phone or record
review.
If the individual has a mental health diagnoses, and the MH Authority determines a Level II
evaluation is needed, they make arrangements with the contracted MH Evaluator to review the
records and gather additional information in order to determine proper placement and
treatment. The DD Authority makes the Level II determination for those individuals who are
developmentally disabled by reviewing records and gathering additional information. Both the
MH Evaluator and DD Authority may see the individual in person. (See guidelines in PASRR
Table 7)
PASRR Table 7
Designated or Contract Evaluator
Mental
Independent evaluator completes PASRR–MI Evaluation (HW0088). All
Illness
supporting documentation is sent.
Intellectual
Evaluation team from regional Division of Medicaid Bureau of
Disabilities
Developmental Disabilities Services. A licensed psychologist must identify
the intellectual functioning measurement. A related condition i.e. cerebral
palsy, epilepsy may be determined by a physician. 42 CFR 483.136.15.C.
Developmental Disabilities Care manager completes a PASRR–ID
Evaluation (HW0089). All supporting documentation is sent.
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The State must ensure that a licensed psychologist identified the
intellectual functioning measurement of individuals with ID or a
related condition.
The MH or DD evaluator completes evaluation using PASRR–MI Evaluation (HW0088) or
PASRR—ID Evaluation (HW0089) and explains findings to individual and/or legal
representative, either in person, by phone or by letter.
The PASRR–MI Evaluation (HW0088) and PASRR–ID Evaluation (HW0089) are sent to
MH/DD Authority for final determination and completion.
Copies of PASRR-MI Evaluation (HW0088), PASRR—ID Evaluation (HW0089), and PASRR
Screening for Nursing Facility Placement (HW0090) that includes Appeal Rights are sent to
evaluated individual/legal representative, NF, attending physician and discharging hospital (if
applicable) by BLTC.
BLTC may not countermand decisions made by MH/DD Authority.
BLTC, MH/DD Authority, NF coordinate implementation of any specialized services required
for resident. It is the State’s responsibility to provide specialized services when needed.
MH Specialized Services are when individual requires continuous 24 hour supervision by a
professional with a mental health degree.
For an individual with mental illness whom it has been identified
they require specialized services, an alternate placement must be
considered. 42 CFR483.120a.i-ii
For ID individuals, Specialized Services are for those individuals who require active treatment.
The NF is responsible for providing any services below “specialized” level. These are referred
to as “services of a lesser intensity.” Refer to PASRR services Job Aid codes.
If need for specialized services is identified and NF placement is appropriate, BLTC may
preauthorize services by giving involved agency/center a prior authorization (PA) number for
billing.
The NR enters the PASRR information in the Assessment Section of the participant (and/or
family or legal representative, as appropriate) record in the RMS database, when the NR
receives information requiring action for PASRR:
• Enter type of assessment
• Reason (modifications)
• Date
• Facility
• Completed by
• Enter an action date as applies for re-review (RR date)
• Save.
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Transfers from Other States/Regions
The sending region or state is responsible for all determinations prior to transfer of an
individual. Individual’s Level I and Level II reports must indicate NF level of care.
The State in which the individual is a State Resident must pay for
the PASRR and make the required determinations. 42 CFR
483.110 Nursing Facility transfers who have had a prior Level I and
did not require a Level II evaluation do not require an update to the
Level I, unless there has been a significant change in status.
The State of Idaho will accept PASRR determinations from discharging States.
Resident Review (RR)
Effective October 30, 1996, Annual Resident Reviews are no longer required per passage of
H.R. 3632 but are still listed in 42 CFR 483.100-138.
Who is Reviewed?
NF residents who continue to meet NF level of care and meet at least one criterion in PASRR
Table 8.
PASRR Table 8
Resident Review (RR)
• Had status changes in their mental or physical condition/functioning.
• Met categorical determinations for convalescent care, terminal illness, or severity of
illness and need reevaluation to determine if categorical determination criteria are
still met.
• Met categorical determinations for delirium, emergency or respite placement and
will exceed stay limit.
• Been transferred from one NF to another with or without an intervening hospital
stay and have been identified as having MI or ID.
• An exempt convalescent exemption exceeding 30 day limit
Participant (and/or family or legal representative, as appropriate)s who have been exempted
from Level II evaluation because of convalescence need to be evaluated if it becomes
apparent participant (and/or family or legal representative, as appropriate)s are likely to require
more than a 30 day stay. The RR must be completed within 40 calendar days of admission.
Provisional admissions, in cases of delirium or an emergency situation, exceeding seven (7)
day limit must have a Level II evaluation completed on sixth (6th) day.
If a respite stay is to exceed 30 day limit, an RR must be completed by the 29th day.
Individuals who have met categorical determinations for non-exempt convalescent care,
terminal illness, or severity of illness should have an RR completed by the identified review
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date, following admission to determine if categorical determination criteria are still met. Refer
to PASRR Table 5 & 6.
Individuals must be reviewed for a Level II evaluation need when NF notifies BLTC of a major
change in mental or physical condition.
It is a dual responsibility of the NR and NF to ensure Level II
evaluation is completed when stays exceed state limit.
How Resident Review is Completed
If it is determined client does not require NF services or specialized services, the State must, in
consultation with the resident’s family, legal representative and caregivers:
• Determine most appropriate least restrictive placement option
 Assist in safe and orderly discharge of participant (and/or family or legal
representative, as appropriate) and
 Prepare and orient participant (and/or family or legal representative, as appropriate)
for discharge in cooperation with NF.
If it is determined the resident who has resided in the facility more than 30 months, does not
require NF services but does require specialized services the State must, in consultation with
the resident’s family, legal representative and caregivers:
 Offer the resident the choice of remaining in the facility or of receiving services in
alternative appropriate setting
 Inform the resident of institutional non-institutional alternatives covered under State
Medicaid plan
 Clarify the effect on eligibility for Medicaid services if resident chooses to leave
facility, including effect on readmission
 Regardless of resident’s choice, provide or arrange for the provision of specialized
services for the mentally ill or intellectually disabled
If it is determined the resident who has not continuously resided in the facility more than 30
months, does not require NF services but does require specialized services the State, must in
consultation with the resident’s family, legal representative and caregivers:
 Arrange for safe, orderly discharge of the resident from the facility
 Prepare and orient the resident for discharge
 Provide or arrange for the provision of specialized services
Appeals will be governed by the provision of Idaho Department of Health and Welfare Rules
and Regulations, Sections 16.05.03.300 et seq. and Sections 16.05.03.331, Rules Governing
Contested Cases and Declaratory Rulings.” Right to appeal the determination is given to
individuals and/or legal representatives for reasons shown in PASRR Table 9 via the PASRR
Screening for NF Placement (HW0090):
PASRR Table 9
Right to Appeal
• It is proposed an individual be transferred or discharged from NF.
• An individual will be adversely affected by PASRR determinations. This includes an
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•
individual who does not meet NF level of care and who does not require specialized
services.
Federal financial participation is available for expenditures for services provided to
Medicaid clients during 28 day notice period and during period when appeal is in
progress.
PASRR Level II with Specialized Services & RMS database
In states that define specialized services as provided in acute
settings, not in a NF, in practice a determination that the person’s
total needs are such that SS are needed, will automatically
determine that NF is not needed at this time.
RMS Database Entry:
• Complete information on the Level of certification (HW0213), if not already in the database.
• Save
• Go into assessment, choose PASRR Level II
• Initial
• Date
• Go into program and open NF
• Click Edit
• Open the program
• Effective date is the date of admission
• NR
• Action item
• Drop down
• Choose 30 day, 7 day, respite
• For PASRR, refer to MH/DD authority, add date completed
• Click done. No further action is needed
• Application date when the initial PASRR completed NF level of care
• Save.
For tracking purposes, run an Action Report.
• When task is completed, click done.
• For any timelines less than 30 days track on Outlook Calendar.
For any category not listed in the drop down, use Custom Action:
• Reason for PASRR
• Exempt convalescence, enter due date
• Emergency, due date not to exceed 7 days
• Delirium, due date not to exceed 7 days
• Terminal illness, due date 6 months
• Specialized services.
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