PASRR Preadmission Screening Resident Review and epasrr Common Questions Desiree Mizuno, BSN, RN, Nurse Manager Health Service Advisory Group (HSAG) January 23, 2019 1
Objectives To have a better understanding of the following: 1 PASRR history, requirements, and overall process 2 PASRR Level 1 and categorical determinations 3 PASRR Level 2 4 Resident review process 5 Compliance reviews 6 Responsibilities of facilities Address common questions regarding epasrr 2
PASRR History Due to the institutional mental health facility closures or downsizing in the 80s: 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 (NF) without adequate mental health services Omnibus Budget Reconciliation Act (OBRA) 1987 Congress created Preadmission Screening & Resident Review (PASRR) 3
General Regulations PASRR 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 to admission 4
General Regulations (cont.) 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 5
General Regulations (cont.) 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. 6
General Regulations (cont.) PASRR Resident Review while in nursing facilities Required for significant change in an individual May require a Level 2 to be completed 7
PASRR Process 8
Referring Entity: Completes 1178 Level 1 Negative Level 1 Part A/B Admit to NF OR Referring Entity: Completes 1178 Level 1 Positive Level 1 Part A/B Complete Part C 9 PASRR Process
Complete Part C- Categorical Determination Part C All No s Complete Level 2 If Needs Determination -> AMHD or DDD OR Part C 1 Yes Admit to NF 10 PASRR Process
PASRR Process Determination by AMHD and/or DDD Determination by AMHD and/or DDD In need of NF services and not in need of specialized services OR Not in need of NF service and/or is in need of specialized services Admit to NF Do not admit to NF 11
While in the Nursing Facility Significant change Resident Review May require Level 2 Exemption expires Level 2 is required 12
13 Level 1 (1178) Form
14 Level 1 (1178) Form Part A and B
Completed by physician, Advanced Practice Registered Nurse (APRN), hospital discharge (DC) planner registered nurse (RN) 15 Level 1 (1178) Form Part C
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. 16
Level 1 Part A (cont.) 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 Excluded from Level 2: Individuals with a primary or secondary diagnosis of SMI (ONLY) under Dementia as defined in the DSM-III-R (including Alzheimer s disease or a related condition) 17
Level 1 Part A (cont.) PART A (cont.) 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? 18
Level 1 Part A (cont.) 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 19
Level 1 Part A (cont.) Case Scenarios #1 Patient s primary diagnosis is Dementia Has a diagnosis of depression and it s related to the Dementia Taking Zoloft for depression 20
Case Scenarios #1 Answer No for 1, 2, 3 21
Level 1 Part A (cont.) Case Scenarios #2: Patient has a diagnosis of bipolar disorder and Dementia Patient currently has symptoms for both conditions The patient s bipolar symptoms are not related to patient s Dementia Taking Zyprexa for bipolar 22
Case Scenarios #2 Answer Yes for 1, 2, 3 23
Level 1 Part A (cont.) Case Scenarios #3 Patient has a history of depression Taking Trazodone for Insomnia No current symptoms of depression 24
Case Scenarios #3 Answer No for 1, 2, 3 25
Level 1 Part A (cont.) Case Scenarios #4 Patient has no current behavioral/mental health symptoms No current mental health diagnoses Previously took Xanax for anxiety daily but was discontinued 2 weeks ago 26
Case Scenarios #4 Answer No for 1 and 2 and Yes for 3 27
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 18. 2. 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: 28
Level 1 Part B (cont.) PART B #1 and #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, self-care/direction, learning, understanding/use of language, capacity for living independently) 29
Level 1 Part B (cont.) PART B (cont.) 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. 4. The individual has functional limitations relating to ID/DD (mobility, selfcare/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 30
Level 1: Negative vs. Positive Screening All NO s Part A and B Considered Negative PASRR OK to admit to NF If YES in Part A and/or B Considered Positive PASRR Continue to Part C 31
Level 1 Part C: Categorical Determinations PART C 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? 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? 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? 32
Level 1 Part C: Categorical Determinations (cont.) PART C (cont.) Does this individual require provisional admission pending further assessment in cases of delirium where an accurate diagnosis cannot be made until the delirium clears? Does this individual require provisional admission which is not to exceed 7 days, for further assessment in emergency situations that require protective services? 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. 33
Level 1 Part C: Categorical Determinations (cont.) Part C: Categorical Determination Part C 1 Yes OK to admit to NF Ensure only one selected Ensure that the definition meets the individual s current status Monitor expiration dates Level 2 is required on or before the expiration date or after rehabilitation (exemption #1) 34
Level 1 Part C: Categorical Determinations (cont.) Part C- Categorical Determination Part C All No s Complete Level 2 If Needs Determination -> AMHD or DDD 35
36 Level 2 Forms
Level 2 Evaluations SMI 37
Level 2 Evaluations ID/DD/RC Upload forms and be sure to click Complete Form 38
39 SMI Form 2 Medical Evaluation
40 SMI Form 3 Psychiatric Evaluation, Part I
If found NOT SMI on form 4, determination from AMHD is NOT required 41 SMI Form 4 Psychiatric Evaluation, Part II
42 DDD PASRR for ID/DD form
43 AMHD Determination Form
44 AMHD Determination Letter
45 DDD Determination Form
46 DDD Determination Letter
47 Resident Review Process
Resident Review Process Resident Review Required for Significant Change Shows major change in behavioral/psychiatric condition or Affects individual s MI/ID/DD/RC needs or Results in a newly suspected diagnosis of SMI, ID, or DD or Affects individual s need for specialized services 48
Resident Review Process Resident Review Requirements Care Plan reassessment by seventh day Comprehensive assessment by fourteenth day Complete a Level 2 by twenty-first day if individual s condition warrants review for specialized services 49
Quarterly PASRR Compliance Reviews (Audits) 50
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 51
52 Responsibilities of Facilities
Responsibilities of Facilities (cont.) 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 53
Responsibilities of Facilities (cont.) Nursing Facilities (NFs): 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. 54
NFs Responsibilities of Facilities (cont.) 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 55
56 epasrr
epasrr Basics Registration Login Creating/copying Level 1 Completing Level 2 Assigning placement Community admission Transfers to another NF Refer to document: epasrr Frequently Asked Questions (FAQs) Step-by-step instructions found on HSAG website: www.myhawaiieqro.com 57
epasrr Common Questions Question 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. 58
Question 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 59
Question 2 (cont.): 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, then Pending Placement or Level 2 will come up 60
Question 3 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 61
Question 3 (cont.): 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 62
Question 4 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 63
Question 4 (cont.) 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 64
epasrr Reports Hospitals/Referring Entities: 65
epasrr Reports (cont.) Nursing Facilities 66
HSAG Contacts Health Service Advisory Group (HSAG) Desire Mizuno, Nurse Reviewer/Manager 808.941.1444 or dmizuno@hsag.com Website: www.myhawaiieqro.com PASRR forms, training resources, epasrr link Technical assistance: Email: epasrrsupport@hsag.com HSAG Help Desk: 1.866.316.6974 HSAG Hawaii Office: 808.941.1444 (office hours 7:45 A.M. 4:30 P.M. HST) 67
Questions? 68
69 Thank you!
Please complete the evaluation at: https://goo.gl/xgmvno If you registered online for this event, you will also receive the link via email. 70