Okla. Admin. Code § 317:35-19-9 - PASRR screening process
(a)
Level I screen for PASRR.
(1)
OHCA Form LTC-300R, Nursing Facility Level of Care Assessment, must be
completed by an authorized NF official or designee. An authorized NF official
or designee must consist of one of the following:
(A) The NF administrator or
co-administrator;
(B) A licensed
nurse, social service director, or social worker from the facility;or
(C) A licensed nurse, social
service director, or social worker from the hospital.
(2) Prior to admission, the authorized NF
official must evaluate the properly completed OHCA Form LTC-300R and the
Minimum Data Set (MDS), if available, as well as all other readily available
medical and social information, to determine if there currently exists any
indication of mental illness (MI), intellectual disability (ID), or other
related condition, or if such condition existed in the applicant's past
history. Form LTC-300R constitutes the Level I PASRR Screen and is utilized in
determining whether or not a Level II is necessary prior to allowing the member
to be admitted.
(3) The NF is
responsible for determining from the evaluation whether or not the member can
be admitted to the facility. A "yes" response to any question from Form
LTC-300R, Section E, will require the NF to contact the Level of Care
Evaluation Unit (LOCEU) for a consultation to determine if a Level II
assessment is needed. The facility is also responsible for consulting with the
LOCEU regarding any mental illness, an intellectual disability, or related
condition information that becomes known either from completion of the MDS or
throughout the resident's stay. The original Form LTC-300R must be submitted to
the LOCEU by mail within ten (10) days of the resident's admission. SoonerCare
payment may not be made for a resident whose LTC-300R requirements have not
been satisfied in a timely manner.
(4) Upon receipt and review of the PASRR
eligibility information packet, the LOCEU may, in coordination with the
Oklahoma Department of Human Services (OKHDS) area nurse, re-evaluate whether a
Level II PASRR assessment may be required. If a Level II assessment is not
required, as determined by the LOCEU, the area nurse, or nurse designee,
documents this and continues with the process of determining medical
eligibility. If a Level II is required, a medical decision is not made until
the area nurse is notified of the outcome of the Level II assessment. The
results of the Level II assessment are considered in the medical eligibility
decision. The area nurse, or nurse designee, makes the medical eligibility
decision within ten (10) working days of receipt of the medical information
when a Level II assessment is not required. If a Level II assessment is
required, the area nurse makes the decision within five working days if
appropriate.
(b)
Pre-admission Level II assessment for PASRR. The authorized
official is responsible for consulting with the OHCA LOCEU in determining
whether a Level II assessment is necessary. The decision for Level II
assessment is made by the LOCEU.
(1) Any one
of the following three (3) circumstances will allow a member to enter the NF
without being subjected to a Level II PASRR assessment:
(A) The member has no current indication of
mental illness or an intellectual disability or other related condition and
there is no history of such condition in the member's past;
(B) The member does not have a diagnosis of
an intellectual disability or related condition; or
(C) The member has indications of mental
illness or an intellectual disability or other related condition, but is not a
danger to self and/or others, and is being released from an acute care hospital
as part of a medically prescribed period of recovery (Exempted Hospital
Discharge). If an individual is admitted to an NF based on Exempted Hospital
Discharge, it is the responsibility of the NF to ensure that the individual is
either discharged by the 30th day or that a Level II has been requested and is
in process. Exempted Hospital Discharge is allowed only if all of the following
three (3) conditions are met:
(i) The
individual must be admitted to the NF directly from a hospital after receiving
acute inpatient care at the hospital (not including psychiatric
facilities);
(ii) The individual
must require NF services for the condition for which he/she received care in
the hospital; and
(iii) The
attending physician must certify before admission to the facility that the
individual is likely to require less than thirty (30) days of nursing facility
services. The NF will be required to furnish documentation to the OHCA upon
request.
(2)
If the member has current indications of mental illness or an intellectual
disability or other related condition, or if there is a history of such
condition in the member's past, the member cannot be admitted to the NF until
the LOCEU is contacted to determine if a Level II PASRR assessment must be
performed. Results of any Level II PASRR assessment ordered must indicate that
NF care is appropriate prior to allowing the member to be admitted.
(3) The OHCA Level of Care Evaluation Unit
authorizes Advance Group Determinations for the MI and ID Authorities in the
categories listed in the following categories listed in (A) through (C) of this
paragraph. Preliminary screening by the LOCEU should indicate eligibility for
NF level of care prior to consideration of the provisional admission.
(A)
Provisional admission in cases of
delirium. Any person with mental illness, an intellectual disability or
related condition who is not a danger to self and/or others, may be admitted to
a Title XIX certified NF if the individual is experiencing a condition that
precludes screening, i.e., effects of anesthesia, medication, unfamiliar
environment, severity of illness, or electrolyte imbalance.
(i) A Level II evaluation is completed
immediately after the delirium clears. LOCEU must be provided with written
documentation by a physician that supports the individual's condition which
allows provisional admission as defined in (i) of this subparagraph.
(ii) Payment for NF services will not be made
after the provisional admission ending date. If an individual is determined to
need a longer stay, the individual must receive a Level II evaluation before
continuation of the stay may be permitted and payment made for days beyond the
ending date.
(B)
Provisional admission in emergency situations. Any person with a
mental illness, an intellectual disability or related condition, who is not a
danger to self and/or others, may be admitted to a Title XIX certified NF for a
period not to exceed seven days pending further assessment in emergency
situations requiring protective services. The request for Level II evaluation
must be made immediately upon admission to the NF if a longer stay is
anticipated. LOCEU must be provided with written documentation from Adult
Protective Services or the facility which supports the individual's emergency
admission. Payment for NF services will not be made beyond the emergency
admission ending date.
(C)
Respite care admission. Any person with mental illness, an
intellectual disability or related condition, who is not a danger to self
and/or others, may be admitted to a Title XIX certified NF to provide respite
to in-home caregivers to whom the individual is expected to return following
the brief NF stay. Respite care may be granted up to fifteen (15) consecutive
days per stay, not to exceed thirty (30) days per calendar year.
(i) In rare instances, such as illness of the
caregiver, an exception may be granted to allow thirty (30) consecutive days of
respite care. However, in no instance can respite care exceed thirty (30) days
per calendar year.
(ii) Respite
care must be approved by LOCEU staff prior to the individual's admission to the
NF. The NF provides the LOCEU with written documentation concerning
circumstances surrounding the need for respite care, the date the individual
wishes to be admitted to the facility, and the date the individual is expected
to return to the caregiver. Payment for NF services will not be made after the
respite care ending date.
(c)
PASRR Level II resident
review. The resident review is used primarily as a follow-up to the
pre-admission assessment.
(1) The facility's
routine resident assessment will identify those individuals previously
undiagnosed as intellectually disabled or mentally ill . A new condition of
intellectual disabilities or mental illness must be referred to LOCEU by the NF
for determination of the need for the Level II. The facility's failure to refer
such individuals for a Level II assessment may result in recoupment of funds
and/or penalties from CMS.
(2) A
Level II resident review may be conducted the following year for each resident
of a NF who was found to experience a serious mental illness with no primary
diagnosis of dementia on his or her pre-admission Level II to determine
whether, because of the resident's physical and mental condition, the resident
requires specialized services.
(3)
A Level II resident review may be conducted for each resident of a NF who has
mental illness or an intellectual disability or other related condition when
there is a significant change in the resident's mental condition. If such a
change should occur in a resident's condition, it is the responsibility of the
facility to have a consultation with the LOCEU concerning the need to conduct a
resident review.
(4) Individuals
who were determined to have a serious mental illness on their last PASRR Level
II evaluation will receive a resident review at least within one year of the
previous evaluation.
(d)
Results of pre-admission Level II
assessment and Resident Review. Through contractual arrangements between
the OHCA and the Mental Illness/Intellectual Disabilities Authorities/
Community Mental Health Centers , individualized assessments are conducted and
findings presented in written evaluative reports. The reports recommend if NF
services are needed, if specialized services or less than specialized services
are needed, and if the individual meets the federal PASRR definition of mental
illness or intellectual disability or related conditions. Evaluative reports
are delivered to the OHCA's LOCEU within federal regulatory and state
contractual timelines to allow the LOCEU to process formal, written
notification to member , guardian, NF and significant others.
(e)
Evaluation of pre-admission Level
II or Resident Review assessment to determine Medicaid medical eligibility for
long term care. The determination of medical eligibility for care in a
NF is made by the area nurse (or nurse designee) unless the individual has an
intellectual disability or related condition or a serious mental illness. The
procedures for obtaining and submitting information required for a decision are
outlined in this subsection. When an active long term care member enters the
facility and nursing care is being requested:
(1) The pre-admission screening process must
be performed and must allow the member to be admitted.
(2) The facility will notify the local county
office by the OKDHS Form 08MA083E, Notification Regarding Patient in a Nursing
Facility, Intermediate Care Facility for the Mentally Retarded or Hospice and
Form 08MA084E, Management of Recipient's Funds, of the member's admission.
(3) The local county office will
send the NF the OKDHS Form 08MA038E, Notice Regarding Financial Eligibility,
indicating actions that are needed or have been taken regarding the member.
Notes
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