1

PASRRPASRRPPrereAAdmission dmission SScreening & creening & RResident esident RRevieweview

Fall 2011Fall 2011

NJ Department of Health & Senior NJ Department of Health & Senior ServicesServices

2

Objectives for TrainingObjectives for Training Understand PASRR regulationsUnderstand PASRR regulations Identify PASRR responsibilities for Identify PASRR responsibilities for

state staff and providersstate staff and providers Explain PASRR requirementsExplain PASRR requirements Review and understand all elements Review and understand all elements

of the PASRR Level I Screening Form of the PASRR Level I Screening Form LTC-26LTC-26

Review and understand the Notice Review and understand the Notice of Referral for Level II Evaluation of Referral for Level II Evaluation Form LTC-29Form LTC-29

3

What is PASRR?What is PASRR? PPrereAAdmission dmission SScreening and creening and RResident esident RRevieweview Part of the Federal Nursing Home Reform Act of 1987 Part of the Federal Nursing Home Reform Act of 1987

(aka OBRA ’87)(aka OBRA ’87) Federal Requirement as set forth in 42 CFR 483 et seqFederal Requirement as set forth in 42 CFR 483 et seq Requires states to ensure that all individuals entering Requires states to ensure that all individuals entering

Medicaid-certified Nursing Facilities (NFs) are screened Medicaid-certified Nursing Facilities (NFs) are screened for Serious Mental Illness (SMI) and/or Intellectual for Serious Mental Illness (SMI) and/or Intellectual Disability (ID)/Related Condition (RC)Disability (ID)/Related Condition (RC)

RCs are severe and chronic Developmental Disabilities RCs are severe and chronic Developmental Disabilities (DDs) such as autism, seizure disorder, cerebral palsy, (DDs) such as autism, seizure disorder, cerebral palsy, spina bifida or head injury with spina bifida or head injury with date of onset prior date of onset prior to age 22to age 22

4

Purpose of PASRRPurpose of PASRREnsures that all NF applicants and Ensures that all NF applicants and

residentsresidents

with SMI and/or ID/DD are:with SMI and/or ID/DD are: IdentifiedIdentified Placed appropriately (least restrictive Placed appropriately (least restrictive

setting)setting) Provided with the MI/ID/DD services Provided with the MI/ID/DD services

they need including Specialized Servicesthey need including Specialized Services

55

PASRR ComponentsPASRR ComponentsThere are two components to PASRRThere are two components to PASRR Level I – Screening for indicators of Level I – Screening for indicators of

SMI and/or ID/DDSMI and/or ID/DD Level II – Evaluation and Level II – Evaluation and

DeterminationDetermination

6

PASRR ResponsibilitiesPASRR ResponsibilitiesLevel I ScreenLevel I Screen● NF professional staff complete for private pay NF professional staff complete for private pay

applicants from communityapplicants from community● NJ Department of Health’s Office of Community NJ Department of Health’s Office of Community

Choice Options (OCCO) staff complete clinical Choice Options (OCCO) staff complete clinical eligibility assessment (PAS/PreAdmission Screen) eligibility assessment (PAS/PreAdmission Screen) and the PASRR Level I Screen for community and the PASRR Level I Screen for community applicants who are currently Medicaid or applicants who are currently Medicaid or potentially Medicaid eligible within 6 months of potentially Medicaid eligible within 6 months of NF admissionNF admission

● Hospital – hospital discharge plannersHospital – hospital discharge planners

● APS, Hospice and Respite – care managersAPS, Hospice and Respite – care managers

PASRR ResponsibilitiesPASRR ResponsibilitiesLevel II Evaluation and DeterminationLevel II Evaluation and Determination● The Department of Human Services staff The Department of Human Services staff

administer the evaluation and administer the evaluation and determination processdetermination process

● The Division of Mental Health Services is The Division of Mental Health Services is responsible for individuals screening responsible for individuals screening positive for mental health indicators positive for mental health indicators while the Division of Developmental while the Division of Developmental Disabilities is responsible for individuals Disabilities is responsible for individuals screening positive for ID/DD indicatorsscreening positive for ID/DD indicators

77

8

Exceptions to PASRRExceptions to PASRRPASRR is not needed for entry into PASRR is not needed for entry into

thethe

following facilities:following facilities: Assisted LivingAssisted Living Fully private pay NFsFully private pay NFs Transitional Care Units in hospitalsTransitional Care Units in hospitals New Jersey Veteran HomesNew Jersey Veteran Homes

9

Who can complete a Level I?Who can complete a Level I?

The minimum credentials for an screeningThe minimum credentials for an screening

professional completing a Level Screening professional completing a Level Screening

Tool are:Tool are: Certified Social Worker (CSW)Certified Social Worker (CSW) Registered Nurse (RN)Registered Nurse (RN) Physicians and Physician Assistants may Physicians and Physician Assistants may

also complete the Level I Screening Formalso complete the Level I Screening Form

10

Hospital Discharges to NFHospital Discharges to NF Hospital discharge planners complete a Level I Screening Hospital discharge planners complete a Level I Screening

Tool (LTC-26) on all discharges to a Medicaid-certified NFTool (LTC-26) on all discharges to a Medicaid-certified NF All Level I positive screens must be referred to DDD All Level I positive screens must be referred to DDD

and/or DMHS for a Level II Evaluation unless certified as and/or DMHS for a Level II Evaluation unless certified as Exempted Hospital DischargeExempted Hospital Discharge

CMS regulations allow for a suspension of the Level II for CMS regulations allow for a suspension of the Level II for short term (less than 30 days) rehab admissions with short term (less than 30 days) rehab admissions with physician’s certification – physician’s certification – Exempted Hospital Exempted Hospital DischargeDischarge

All positive screens for individuals who are currently All positive screens for individuals who are currently Medicaid or potentially Medicaid eligible within 6 months Medicaid or potentially Medicaid eligible within 6 months of NF admission must also have an EARC-PAS completed of NF admission must also have an EARC-PAS completed by a certified EARC-PAS hospital assessor or have an by a certified EARC-PAS hospital assessor or have an onsite hospital PAS (PreAdmission Screen) completed by onsite hospital PAS (PreAdmission Screen) completed by OCCO prior to discharge to the NF, per usual OCCO prior to discharge to the NF, per usual EARC-PAS/OCCO PAS procedureEARC-PAS/OCCO PAS procedure

Copies of Level I – and Level II documents if applicable – Copies of Level I – and Level II documents if applicable – must go with the individual to the NF for inclusion in must go with the individual to the NF for inclusion in active NF recordactive NF record

11

Community NF AdmissionsCommunity NF Admissions NF personnel must complete a Level I NF personnel must complete a Level I

Screening Tool on each private pay Screening Tool on each private pay admission from the communityadmission from the community

All positive screens must be referred All positive screens must be referred to DDD and/or DMHS for a Level II to DDD and/or DMHS for a Level II EvaluationEvaluation

Copies of the Level I – and Level II Copies of the Level I – and Level II documents if applicable – must be documents if applicable – must be placed on the active NF chartplaced on the active NF chart

1212

A new Level I Screen is required for each A new Level I Screen is required for each newnew NF NF admissionadmission Valid for entire period of Valid for entire period of continuouscontinuous NF NF

placementplacement Repeat Level I is not needed if NF resident is Repeat Level I is not needed if NF resident is

hospitalized then is readmitted to NF from hospitalhospitalized then is readmitted to NF from hospital Valid for NF-to-NF interfacility transfer Valid for NF-to-NF interfacility transfer

A new Level I Screen must be completed even when A new Level I Screen must be completed even when an individual discharges to the community from a an individual discharges to the community from a previous NF stay then requires subsequent NF previous NF stay then requires subsequent NF placementplacement

The Level I Screen is valid for one NF admission only The Level I Screen is valid for one NF admission only and can be completed up to 30 days prior to NF and can be completed up to 30 days prior to NF admissionadmission

Key Points about the Key Points about the PASRR Level I Screen PASRR Level I Screen

13

Level I Screening Forms: Level I Screening Forms: LTC-26 and LTC-29LTC-26 and LTC-29 LTC-26LTC-26 Level I Screening Form Level I Screening Form

Complete consumer’s identifying informationComplete consumer’s identifying information MI Screen: Answer questions 1-5 with available MI Screen: Answer questions 1-5 with available

informationinformation ID/DD Screen: Answer questions 6-10 with available ID/DD Screen: Answer questions 6-10 with available

informationinformation Scoring: positive or negative screen?Scoring: positive or negative screen? Does individual qualify for a Categorical Does individual qualify for a Categorical

Determination?Determination? Does hospitalized patient qualify for an Exempted Does hospitalized patient qualify for an Exempted

Hospital Discharge?Hospital Discharge? LTC-29LTC-29 Notice of Referral for Level II PASRR Evaluation Notice of Referral for Level II PASRR Evaluation

If Level I is positive, screener informs consumer of If Level I is positive, screener informs consumer of Level II referral and completes Form LTC-29 and gives Level II referral and completes Form LTC-29 and gives original to consumer, copy in consumer recordoriginal to consumer, copy in consumer record

Required for first-time identification of SMI/ID/DDRequired for first-time identification of SMI/ID/DD The LTC-26 and LTC-29 were revised March 2011The LTC-26 and LTC-29 were revised March 2011

14

Categorical DeterminationsCategorical DeterminationsThere are several populations that do There are several populations that do not require a full Level II Evaluation, whose not require a full Level II Evaluation, whose Level II may be abbreviated, if they fall into Level II may be abbreviated, if they fall into one of the following categories:one of the following categories:

Dementia with ID/DD (a DDD function, Dementia with ID/DD (a DDD function, category not listed on the LTC-26)category not listed on the LTC-26)

Terminal IllnessTerminal Illness Severe Physical IllnessSevere Physical Illness Respite CareRespite Care Protective ServicesProtective Services

Categorical Determinations -Categorical Determinations -Dementia with ID/DD and Dementia with ID/DD and Terminal IllnessTerminal IllnessDementia with ID/DDDementia with ID/DD: :

Diagnosis of MR and/or DD Diagnosis of MR and/or DD Documented diagnosis of dementia, including Alzheimer's Documented diagnosis of dementia, including Alzheimer's

Disease or related disorder, based on the most current Disease or related disorder, based on the most current Diagnostic Statistical Manual (DSM-IV) criteriaDiagnostic Statistical Manual (DSM-IV) criteria

Terminal IllnessTerminal Illness:: Diagnosis of serious mental illness, intellectual disability Diagnosis of serious mental illness, intellectual disability

and/or developmental disabilityand/or developmental disability Not a danger to self or othersNot a danger to self or others Certified by a physician and/or hospice care staff as Certified by a physician and/or hospice care staff as

having a life expectancy of six months or lesshaving a life expectancy of six months or less Requires continuous nursing care or medical Requires continuous nursing care or medical

supervision/treatment due to a physical condition supervision/treatment due to a physical condition 1515

Categorical Determinations - Categorical Determinations - Severe Physical IllnessSevere Physical Illness Applies to individuals with serious mental illness, Applies to individuals with serious mental illness,

intellectual disability and/or developmental intellectual disability and/or developmental disability who may not be expected to benefit from disability who may not be expected to benefit from specialized services due to impairment caused by a specialized services due to impairment caused by a severe medical illnesssevere medical illness

Examples of severe medical illnesses include:Examples of severe medical illnesses include: Amyotrophic lateral sclerosis, Huntington’s Amyotrophic lateral sclerosis, Huntington’s

disease, ventilator dependency, severe congestive disease, ventilator dependency, severe congestive heart failure, end-stage chronic obstructive heart failure, end-stage chronic obstructive pulmonary disease, end-stage Parkinson’s pulmonary disease, end-stage Parkinson’s disease, cerebellar degeneration, cerebrovascular disease, cerebellar degeneration, cerebrovascular accident, end-stage renal disease, severe diabetic accident, end-stage renal disease, severe diabetic neuropathies and refractoryneuropathies and refractory anemiaanemia

An individual who is comatose or in a persistent An individual who is comatose or in a persistent vegetative statevegetative state 16 16

Categorical Determinations -Categorical Determinations -Respite CareRespite Care11

An adult may be admitted to a NF from An adult may be admitted to a NF from home or an Adult Family Care home (a non-home or an Adult Family Care home (a non-institutional setting) for short-term respite institutional setting) for short-term respite care not to exceed thirty (30) days per state care not to exceed thirty (30) days per state or federal annual funding cycleor federal annual funding cycle

The maximum annual limit of up to 30 days The maximum annual limit of up to 30 days NF respite may be taken intermittently or NF respite may be taken intermittently or consecutively following prior approval by consecutively following prior approval by State-designated staff State-designated staff

Respite care is a temporary, finite service Respite care is a temporary, finite service provided to an individual with a cognitive provided to an individual with a cognitive impairment and/or self-care deficits in daily impairment and/or self-care deficits in daily living tasks, for the purpose of relieving the living tasks, for the purpose of relieving the caregiver in a non-institutional settingcaregiver in a non-institutional setting

1717

1818

Categorical Determinations Categorical Determinations Respite CareRespite Care22

At time of admission to a NF for respite At time of admission to a NF for respite care, there must be expressed intent by care, there must be expressed intent by the individual and/or their legal the individual and/or their legal representative to leave the NF and return representative to leave the NF and return to the home by the expiration of the to the home by the expiration of the respite approval periodrespite approval period

If the individual remains in the NF beyond If the individual remains in the NF beyond the pre-approved respite limit, the the pre-approved respite limit, the individual must undergo a complete PASRR individual must undergo a complete PASRR Level II evaluation coordinated through the Level II evaluation coordinated through the Division of Mental Health Services and/or Division of Mental Health Services and/or the Division of Developmental Disabilitiesthe Division of Developmental Disabilities

Categorical Determinations -Categorical Determinations -Protective ServicesProtective Services Adult may be admitted to NF from the community Adult may be admitted to NF from the community

for a period not to exceed 7 days while NF or for a period not to exceed 7 days while NF or alternative arrangements for longer care are madealternative arrangements for longer care are made

Emergency placement allowed only when a crisis Emergency placement allowed only when a crisis arises outside of normal state business hoursarises outside of normal state business hours

The individual must be in need of intensive The individual must be in need of intensive emergency intervention and in imminent danger emergency intervention and in imminent danger as certified in writing by the Adult Protective as certified in writing by the Adult Protective Services worker and/or supervisorServices worker and/or supervisor

NF placement must be the placement of last resort NF placement must be the placement of last resort

If the individual remains in the NF beyond the 7-If the individual remains in the NF beyond the 7-day limit, then the individual must undergo a day limit, then the individual must undergo a complete PASRR Level II evaluation coordinated complete PASRR Level II evaluation coordinated through the Division of Mental Health Services through the Division of Mental Health Services and/or the Division of Developmental Disabilitiesand/or the Division of Developmental Disabilities 19 19

20

Exempted Hospital DischargeExempted Hospital Discharge If a hospital patient screened positive If a hospital patient screened positive

on the Level I and is being on the Level I and is being discharged to a NF for subacute care, discharged to a NF for subacute care, and a physician certifies that the and a physician certifies that the individual is likely to require less individual is likely to require less than 30 days skilled nursing care, a than 30 days skilled nursing care, a Level II Evaluation can be suspendedLevel II Evaluation can be suspended

If the NF resident remains in the NF If the NF resident remains in the NF on or after the 30on or after the 30thth day, the Level II day, the Level II must be completed prior to day 40must be completed prior to day 40

21

Level IILevel II May block NF admission of individuals who May block NF admission of individuals who

might otherwise be admitted:might otherwise be admitted: May meet NF LOC but MI/ID/DD needs cannot be May meet NF LOC but MI/ID/DD needs cannot be

met in NFmet in NF Determination may be made that individual Determination may be made that individual

requires Specialized Services.requires Specialized Services.o SMI – inpatient psychiatric treatmentSMI – inpatient psychiatric treatmento ID/DD – Developmental Center (ICF-MR) or ID/DD – Developmental Center (ICF-MR) or

community-based setting meeting ICF-MR community-based setting meeting ICF-MR standards for skill deficits or other specialized standards for skill deficits or other specialized training requiring 24/7 coverage by trained training requiring 24/7 coverage by trained personnel to teach the individual functional personnel to teach the individual functional skills.skills.

Level II determination may also indicate that the Level II determination may also indicate that the individual’s needs could be better met in the individual’s needs could be better met in the communitycommunity

22

Specialized ServicesSpecialized Services Not permitted in NJ NFs as set forth in New Not permitted in NJ NFs as set forth in New

Jersey Administrative Code 8:85Jersey Administrative Code 8:85 No FFP (Federal Financial Participation) for No FFP (Federal Financial Participation) for

Specialized Services if provided to a NF Specialized Services if provided to a NF resident as NF servicesresident as NF services

States can provide Specialized Services as States can provide Specialized Services as services over and above NF services though services over and above NF services though NJ chose to provide Specialized Services NJ chose to provide Specialized Services outside of NF settingoutside of NF setting

The NF must provide mental health or The NF must provide mental health or intellectual disability/developmental intellectual disability/developmental disability services which are of a lesser disability services which are of a lesser intensity than Specialized Services to all intensity than Specialized Services to all residents who need such servicesresidents who need such services

23

Resident ReviewResident Review11

CMS no longer requires CMS no longer requires annualannual resident resident reviewsreviews

However, PASRR requires the resident However, PASRR requires the resident review evaluation process whenever review evaluation process whenever significant change in resident’s physical or significant change in resident’s physical or mental condition occurs:mental condition occurs: significant deteriorationsignificant deterioration significant improvement significant improvement when resident expresses a desire to when resident expresses a desire to

return to the communityreturn to the community NF must use the MDS 3.0 Significant NF must use the MDS 3.0 Significant

Change in Status Assessment to trigger Change in Status Assessment to trigger care planning and resident reviewcare planning and resident review

24

Resident Review Resident Review 22

NF must refer resident to Division of Mental NF must refer resident to Division of Mental Health Services and/or Division of Health Services and/or Division of Developmental Disabilities upon SCSA Developmental Disabilities upon SCSA (Significant Change in Status Assessment)(Significant Change in Status Assessment)

Resident Review by respective division will Resident Review by respective division will determine if resident needs additional or determine if resident needs additional or different services in the NF, or if Specialized different services in the NF, or if Specialized Services are required, and/or identify Services are required, and/or identify community supports and services for an community supports and services for an individual’s discharge to the communityindividual’s discharge to the community

2525

Department of Health & Senior Department of Health & Senior ServicesServices OCCO Contact Information OCCO Contact Information OCCO Northern Regional Office, Newark OCCO Northern Regional Office, Newark

Bergen, Essex, Hudson, Morris, Passaic, Sussex & Bergen, Essex, Hudson, Morris, Passaic, Sussex & Warren Counties Warren Counties Phone: (973) 648-4691; Fax: (973) Phone: (973) 648-4691; Fax: (973) 693-5046693-5046

OCCO Central Regional Office, EdisonOCCO Central Regional Office, EdisonHunterdon, Middlesex, Monmouth, Ocean, Somerset Hunterdon, Middlesex, Monmouth, Ocean, Somerset & Union Counties & Union Counties Phone: (732) 777-4650; Fax: (732) 777-4681Phone: (732) 777-4650; Fax: (732) 777-4681

OCCO Southern Regional Office, OCCO Southern Regional Office, HammontonHammontonAtlantic, Burlington, Camden, Cape May, Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Mercer & Salem Counties Cumberland, Gloucester, Mercer & Salem Counties Phone: (609) 704-6050; Fax: (609) 704-6055Phone: (609) 704-6050; Fax: (609) 704-6055

26

Questions?Questions?

PASRR resources and correspondence can PASRR resources and correspondence can be found on the DHSS website at be found on the DHSS website at http://nj.gov/health/senior/pasrr.shtmlhttp://nj.gov/health/senior/pasrr.shtml

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