PASRR-Preadmission Screening Resident Review & epasrr Application Training. Desiree Mizuno, Nurse Manager Health Service Advisory Group

Transcription

1 PASRR-Preadmission Screening Resident Review & epasrr Application Training Desiree Mizuno, Nurse Manager Health Service Advisory Group 1

2 Agenda PASRR history General regulations PASRR process Level 1 (1178) form Level 2 forms Resident Review process Quarterly PASRR compliance reviews (audits) Facilities responsibilities epasrr application 2

3 PASRR- History Due to the Institutional Mental Health Facility Closures or Downsizing in the 80 s: Individuals with a Serious Mental Illness (SMI) or/and Intellectual Disabilities or Developmental Disabilities or Related Condition (ID, DD, RC) were institutionalized in Nursing Facilities without adequate mental health services Omnibus Budget Reconciliation Act (OBRA) Congress created Preadmission Screening & Resident Review (PASRR) 3

4 General Regulations Preadmission Screening Requirements: Applies to all Medicaid Certified Nursing Facilities Applies to all individuals being admitted regardless of payor source Needs to be completed prior admission Purpose is to determine: If the individual is SMI, ID, DD, RC If the individual requires the level of services provided by NF If individual requires specialized psychiatric services Determination must be made by the State mental health authority: Department of Health (DOH) Adult Mental Health Division (AMHD) or Developmental Disabilities Division (DDD), unless the individual meets criteria for Categorical Determination 4

5 General Regulations Specialized Services: Specialized Services for SMI,ID, DD, RC Active treatment: Continuous and aggressive implementation of an individualized plan of care. Developed and supervised by interdisciplinary team. 5

6 General Regulations Resident Review for Nursing Facilities Required for significant change in an individual that result in a newly suspected diagnosis of SMI or ID/DD or change in the previous Level 2 determination concerning specialized services or NF care 6

7 PASRR Process 7

8 8 Level 1 (1178) Form

9 9

10 Completed by Physician, APRN, Hospital DC Planner RN 10

11 Level 1 Part A PART A: SERIOUS MENTAL ILLNESS (SMI): 1. The individual has symptom(s) and/or current diagnosis of a Major Mental disorder and/or a Substance Related disorder, which seriously affects interpersonal functioning (difficulty interacting with others; altercations, evictions, unstable employment, frequently isolated, avoids others), and/or completing tasks (difficulty completing tasks, required assistance with tasks, errors with tasks; concentration; persistence; pace), and/or adapting to change (self-injurious, self-mutilation, suicidal, physical violence or threats, appetite disturbance, hallucinations, delusions, serious loss of interest, tearfulness, irritability, withdrawal): a. A SCHIZOPHRENIC disorder, MOOD disorder, DELUSIONAL (PARANOID) disorder, PANIC OR OTHER SEVERE ANXIETY disorder, SOMATOFORM disorder, PERSONALITY disorder, SUBSTANCE RELATED disorder or PSYCHOTIC disorder not elsewhere classified that may lead to a chronic disability; BUT b. NOT a primary or secondary diagnosis of DEMENTIA, including ALZHEIMER S DISEASE OR A RELATED DISORDER. 11

12 Level 1 Part A PART A #1 KEY POINTS FOR POSITIVE ANSWER: Mental disorder and/or symptoms are current Mental disorder may lead to a chronic disability The level of impairment seriously affects the individual s interpersonal functioning Mental disorder is a stand alone diagnosis, behavior or mental health condition is not related to Dementia Level 2 evaluation is not required if individual has primary diagnosis of Dementia and secondary diagnosis of MI 12

13 Level 1 Part A PART A (continued) 2. Does the SMI individual have Dementia? If yes, include evidence/presence of workup, comprehensive mental status exam. If question 1 is a No, you do not need to answer question 2 3. Has psychoactive drug(s) been prescribed on a regular basis to treat behavioral/mental health symptom(s) for the individual within the last two (2) years with or without current diagnosis of SMI? 13

14 Level 1 Part A PART A #3 KEY POINTS FOR POSITIVE ANSWER: Psychoactive medication (i.e. antipsychotic, antidepressant and antianxiety drugs) Currently administered on a regular basis or was previously taking it on a regular basis within the past 2 years Prescribed to treat behavioral/mental health symptoms in the absence of a neurological disorder Do not mark positive when indications and use is for medical diagnosis or condition not in connection with a mental disorder, i.e. Valium for Seizures, Trazodone for Insomnia, Remeron for Appetite 14

15 Level 1 Part A Case Scenarios: Patient s primary diagnosis is Dementia, has a diagnosis of Depression, and taking Zoloft for Depression Answer: No for #1,2,3 Patient has a diagnosis of Schizophrenia and Dementia, taking Zyprexa for Schizophrenia Answer: Yes for #1,2,3 Patient has a history of Depression, taking Trazodone for Insomnia, no current symptoms of Depression or problems with interpersonal functioning Answer: No for #1,2,3 15

16 Level 1 Part B PART B: INTELLECTUAL DISABILITY/DEVELOPMENTAL DISABILITIES (ID/DD): 1. The individual has a diagnosis of ID or has a history indicating the presence of ID prior to age The individual has a diagnosis of DD/related condition (evidence/affects intellectual functioning, adaptive functioning; autism, epilepsy, blindness, cerebral palsy, closed head injury, deaf) or has a (history indicating the presence of DD prior to age 22. Age of diagnosis/presence: 16

17 Level 1 Part B PART B #1 & #2 KEY POINTS FOR POSITIVE ANSWER: Likely to continue indefinitely Results in substantial functional limitations in three or more areas of major life activities (mobility, selfcare/direction, learning, understanding/use of language, capacity for living independently) 17

18 Level 1 Part B PART B (continued) 3. Does the ID/DD individual have a primary diagnosis or presence of Dementia? If yes, include evidence/presence of Dementia work-up, comprehensive mental status exam, if available. There should be collaborative evidence if an ID/DD individual has or have presence of Dementia (including Alzheimer s disease or a related condition) as these individuals are NOT excluded from PASRR. 4. The individual has functional limitations relating to ID/DD (mobility, self-care/direction, learning, understanding/use of language, capacity for living independently). 5. The individual received/receives ID/DD services from an agency serving individuals with ID/DD past and/or present; referred/referrals). Describe past AND present receipt of services and referrals made from agencies that serve individuals with ID/DD: If questions 1 and 2 are No, you do not need to answer questions 3,4, and 5 18

19 Level 1: Negative vs. Positive Screening All NOs in part A and B = a NEGATIVE screening Ok to admit individual if meets NF institutional level of care If YES in part A or B = a POSITIVE screening If individual is POSITIVE, must proceed to Part C (Categorical Determinations) 19

20 Level 1 Part C: Categorical Determinations: PART C 1. Is this individual being discharged from an acute care hospital and admitted to the NF for recovery from an illness or surgery not to exceed 120 days and is not considered a danger to self and/or others? 2. Is this individual certified by his physician to be terminally ill prognosis of a life expectancy of 6 months or less) and is not considered a danger to self and/or others? 3. Is this individual comatose, ventilator dependent, functioning at the brain stem level or diagnosed as having a severe physical illness, such as, COPD, Parkinson s Disease, Huntington s Chorea, or amyotrophic lateral sclerosis; which result in a level of impairment so severe that the person cannot be expected to benefit from specialized services? 20

21 Level 1 Part C: Categorical Determinations: PART C (continued) 4. Does this individual require provisional admission pending further assessment in cases of delirium where an accurate diagnosis cannot be made until the delirium clears? 5. Does this individual require provisional admission which is not to exceed 7 days, for further assessment in emergency situations that require protective services? 6. Does this individual require admission for a brief stay of 30 days for respite care? The individual is expected to return to the same caregivers following this brief NF stay. 21

22 Level 1: Part C Categorical Determinations Only one Categorical Determination can be selected If yes on one of Categorical Determination, a Level 2 evaluation an/or determination is not required Ensure that the definition meets the individual s current status Monitor Categorical Determinations that have expiration dates Level 2 is required on or before the Categorical Determination expiration date or after rehabilitation (exemption #1) if individual continues institutional NF stay If all NOs on Part C A Level 2 Evaluation and/or Determination is REQUIRED before admission into the NF 22

23 23 Level 2 Forms

24 Level 2 SMI Condition Adult Mental Health Division (AMHD) Forms Completed by Attending Physician and a Psychologist or Psychiatrist No affiliation with NF or AMHD Form 2 Medical Evaluation (H & P can be utilized) Form 3 Psychiatric Evaluation, Part I (psychiatric consultation report can be utilized) Form 4 Psychiatric Evaluation, Part II: 1147 optional DD/ID/RC Developmental Disabilities Division (DDD) Form Completed by Attending Physician and a Psychologist or Psychiatrist (QMRP) DDD PASRR for ID/DD form Social Summary: For example, documentation explaining patient s living situation, any community services being provided, any guardianship Cognitive/IQ Test - optional optional 24

25 25 SMI Form 2 Medical Evaluation

26 26 SMI Form 3 Psychiatric Evaluation, Part I

27 If found NOT SMI on form 4, determination from AMHD is NOT required 27 SMI Form 4 Psychiatric Evaluation, Part II

28 28 DDD PASRR for ID/DD form

29 29 Resident Review Process

30 Resident Review Process Resident Review Required for Significant Change: Results in a new suspected diagnosis of SMI, ID, or DD or Affects individual s MI/ID/DD/RC needs or Affects individual s need for specialized services Care Plan reassessment by 7 th day Comprehensive Assessment by 14 th day Complete a Level 2 by 21 st day if individual s condition warrants review for specialized services 30

31 Quarterly PASRR Compliance Reviews (Audits) 31

32 Compliance Reviews HSAG performs compliance reviews every quarter Sample is generated from nursing facilities census reports submitted in epasrr Nursing facilities provide medical records in epasrr for their sample PASRR Non-Compliance: Med-QUEST is notified Corrective Action Plans will be required by the NF Potential recoupment for all daily per diem if Medicaid is the primary payor 32

33 33 Responsibilities of Facilities

34 Responsibilities of Facilities Hospital Facilities/Referring Entities: Ensure Level 1 is completed accurately according to the patients condition, past medical history, and medications Complete Level 2 when required Obtain AMHD and/or DDD determination when required Provide the determination letter to the patient and physician Assign the PASRR packet to the nursing facility and complete the packet 34

35 Responsibilities of Facilities Nursing Facilities: Ensure PASRR is done prior all admissions Review PASRR for accuracy. Have hospital/referring entities make corrections before accepting the patient. Ensure determination is completed by AMHD and/or DDD prior admission, if applicable Ensure your nursing facility is selected as placement Keep track of Categorical Determinations expiration date. Do Level 2 prior expiration date or when rehab is completed. Enter PASRR packets for community admissions Complete Resident Review for appropriate significant change in condition Complete monthly census report in epasrr Upload medical records for sample pulled for compliance reviews 35

36 36 epasrr

37 epasrr - Basics Registration Login Creating/Copying Level 1 Completing Level 2 Assigning Placement Community Admission Transfers to Another Nursing Facility Refer to document: epasrr Frequently Asked Questions (FAQ) Step by step instructions found on HSAG website: 37

38 epasrr- Common Questions 1. What do I do if I need to change my Level 1 and the packet is in complete status? The patient must still be in the hospital in order to change the Level 1. If so, call HSAG and HSAG will change the packet status back to Level 1 in Progress so you can edit the Level 1. 38

39 2) Why can t I assign my placement or proceed to Level 2? a) After you are done entering in information on the Level 1 form, you must click on Complete Form 39

40 2. Continued b) Upload supporting documentation or mark the check box if the nursing facility has access to the referring entity s EMR c) Click on Finalize L1 Process 40

41 2. Continued d) Patient Placement Determination will come up e) Check the nursing facility, click on Save NF, click on Select, f) Click on "Complete Packet 41

42 3. How do I complete a Level 2? a) For hospitals/referring entity: Select Create New Level 2 Packet and then click on Save Packet Options For nursing facilities: Select SMI, ID/DD, or both then click on Begin Level 2 Entry; then same as the above 42

43 3) Continued AMHD Level 2 DDD Level 2 b) Click on Edit Form or Upload There is no upload feature for Psych 2, you will have to enter that form in. 43

44 3) Continued c) All the required forms must be in Complete status d) Be sure to click on Complete Form for each Level 2 form 44

45 3) Continued f) Add notes/comments about patient (optional) by typing in the section and then click on Add Note g) For AMHD Level 2- Depending on how the Psych Eval Part 2 is answered: If it says "yes," then the PASRR Packet Status will change to "Pending Level 2 Determination and the packet will be referred to AMHD for determination. Check the PASRR status just in case AMHD defers for more information, packet status will be Level 2 Deferred After you address the deferral, click on Complete Level 2 and it will go back to AMHD and/or DDD for determination 45

46 3) Continued h) If AMHD Determination is not required and you feel that the patient s case is a special situation that may benefit from further review by AMHD, click on Send to AMHD i) Be sure to enter a note describing why you want the case reviewed by AMHD although it s not required j) Otherwise, click on Complete Level 2 46

47 3) Continued k) When all the steps are complete, the hospitals/referring entities can proceed with assigning placement. For NF, your packet status will switch to Packet Complete and your NF name will populate under Placement. If NF entered the Level 2, their name will populate as Referring Entity too 47

48 4. What do I do if I have a hard copy of a previous or old Determination letter and this is the first Level 2 being done in epasrr? a) Be sure the previous or old Determination letter still applies to the patient s current condition b) Select Use Existing Level 2 Determination, then click Save Packet Option c) Unable to find a valid AMHD Packet to copy will pop up, click on Upload Existing Determination 48

49 4. Continued d) Select Yes under Do you have an existing determination to upload? Enter the determination date in the box and click on Save e) Upload the Determination letter and Determination Form and click on Complete Form f) Once all required Level 2 documents are entered or uploaded, and are in complete status, click on Complete Level 2 button g) The hospitals/referring entities can proceed with assigning placement. For NF, your PASRR packet status will switch to Packet Complete 49

50 5. What if the patient needs a Level 2 and there is a previous Level 2 packet entered in epasrr? a) Be sure the previous Level 2 evaluations (and Determination letter, if there is one) are still applicable to the patient s current condition. b) Select Use Existing Level 2 Determination, then click Save Packet Option 50

51 5. Continued d) The Level 2 forms (and Determination letter, if there is one) will copy over e) Click on Confirm Existing L2 Determination f) The hospitals/referring entity can proceed with assigning placement. For NF, your PASRR packet status will switch to Packet Complete If there was a Determination letter, that would copy over too 51

52 epasrr- Reports Hospitals/Referring Entities: 52

53 epasrr- Reports Nursing Facilities 53

54 HSAG Contacts Health Service Advisory Group (HSAG) Desire Mizuno, Nurse Reviewer/Manager , or Website: PASRR forms, training resources, epasrr link Technical assistance: HSAG Help Desk: HSAG Hawaii Office: (office hours 7:45 AM 4:30 PM HST) 54

55 Thank you Questions? 55